The patient may have had chronic mild hyponatraemia and had been asymptomatic with it, but has only recently worsened. A derangement in peripheral volume receptors in paraplegic patients has been proposed as the mechanism behind reset osmostat. So I suppose it is uncommon for reset osmostat to have happened just now in this case.
Best wishes
Mohammad
Dr. M A Al-Jubouri
Consultant Chemical Pathologist
----- Original Message ----
From: TICKNER TREVOR (RM1) Norfolk and Norwich University Hospital <[log in to unmask]>
To: [log in to unmask]
Sent: Friday, 26 January, 2007 3:54:32 PM
Subject: Re: A case of hyopnatraemia
Thanks.
Is it common for this to happen randomly (in this case after 40 or so years)? Are there any known precipitating factors?
Trevor
-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Mohammad Al-Jubouri
Sent: 26 January 2007 15:45
To: [log in to unmask]
Subject: Re: A case of hyopnatraemia
Hi,
The history and clinical/laboratory findings are consistent with reset osmostat that is common in paraplegic patients.
Best wishes
Mohammad
Dr. M A Al-Jubouri
Consultant Chemical Pathologist
----- Original Message ----
From: TICKNER TREVOR (RM1) Norfolk and Norwich University Hospital <[log in to unmask]>
To: [log in to unmask]
Sent: Friday, 26 January, 2007 12:17:09 PM
Subject: A case of hyopnatraemia
Below is the clinical summary of a patient who has had recurrent episodes of hyponatraemia that was attributed to inappropriate ADH but I am unconvinced by that explanation. Urea and creatinine concentrations have remained very constant from before the first episode of hyponatraemia in June 06 since when there have been two other episodes.
Given the recent low urine sodium despite diuretics (for oliguria) and urine osmolality < serum osmolality what do members share my concern over fluid restriction?
Any comments/thoughts appreciated.
Trevor Tickner,
Norwich
A brief summary.
66 year old female
Traumatic spinal cord injury in a RTA in 1961 ( 45yrs ago)- resultant T2 paraplegia with left sided sympathetic chain damage causing a left horners syndrome. Injury was a C6/7 fracture dislocation- managed conservatively. No head injury documented
Other medical History:
1. Neurogenic bladder on long term suprapubic catheter (>20 yrs)- with shrunken bladder and detrusor hyperactivity. No kidney damage on ultrasound.
2. Type 2 DM on Metformin 1gm bd and Gliclazide 80mg od
3. Hypercholesterolaemia on Atorvastatin
4. Osteoporosis with lower limb fractures. Intolerant of Bisphosphonates
Mobile using electric wheelchair. Active in art and gardening. Well until June 06
Current Medication:
Demeclocycline 300mg bd
Atorvastatin 10 mg on
Tinzaparin 0.7ml od (Therapeutic heparin as warfarin caused INR 0f 14)
Multivitamin
OHA’s stopped on 17/1/06 because of anorexia & low BM’s
Domperidone 10mgs tds for persistent nausea
Time line Symptoms Signs Investigations Mx
13/6/06 Nausea for 1 week.
Nil- no evidence of fluid retention Na 113
Normal Renal & Liver function (RFT& LFT). Ultrasound kidneys normal. Short Synacthen test (SST) negative, Thyroid(TFT) Function Normal
Urine osmolality 494
Serum osmolality 241
Urine Sodium 55/44 Dothiepin stopped (Been on this for > 10yrs)
Fluid restriction + Demeclocycline
14/6/06 Short synacthen cortisol 30 min sample 1269 nmol/l
Serum osmo 241
Na 115 K 4.5 Alb 32
Urine osmo 494
5/8/06 Coughing epidode with O2 desaturation to 89%, Tachypnoea B/L chest crackles, respiratory distress. CXR Rx for chest infection with Amoxicillin
8/8/06 Persistent SOB on lying down Persistent B/L crackes Echo : Severe Pulmonary Hypertension. PA pressure 77mmhg + ® Atrial pressure, Dilated impaired ® ventricle. Good LV function Had a CTPA- no evidence of thromboembolic disease. Referred to Respiratory team by Cardiologist.
August 06 Persistent nausea Nil new Na continues to fall off Demeclocycline
23/8/06 Na is 124 Demeclocycline restarted
1/9/06 Weight loss of 8kgs since June Overnight oximetry- overnight hypoxaemia with O2 saturation <90, 30% of the night. Referred to specialist hosp for respiratory Inv:
1. Overnight sleep studies mildly suggetsive of central sleep apnoea but no indication for ventilation
October- November 2006 Occasional episodic SOB V/Q: Suggestive of distal thromboembolic disease- ventilation part could not be done as pt unable to do
December 06
Tiredness
Nil new
Na 130 on 12/12/06. K 5.2
Normal RFT, LFT, CRP and ESR 19
22/12/06 Specialist hosp adv anticoagulation
Warfarin started
January 07 Episodic SOB, General decline.
Cognitive decline- MMSE 16/30 Na 129, K 5.2 on 2/1/07
Short Synacthen Negative
9/1/07 Continues to be confused, anorexic , tired Na 121
15/1/07 Tachypnoea, confused, oliguric . Urine output < 100ml
Persistent B/L crackles- except right apex Na 120, K 5.8, Bicarb 32
Normal RFT
INR 13.18. Rechecked INR 14.78. Mild LFT derangement with ALT -76, GGT 23 Had had one dose of 100mg of spirinolactone on 14/1/07
RX . Vitamin K
Frusemide to cause diuresis- 40mg
Stop sprinolactone
16/1/07 Still confused Urine output 500-600ml last 24 hrs.
Now again low
Persistent B/L crackles Na 119, K 5.3
Normal RFT
Serum osmolality 245
Urine osmolality 225
Urine Na < 5 Frusemide 40mg repeated
17/1/07 Still confused, SOB Persistent crackles
Urine output post frusemide 1L INR post Vitamin k 1.39
Bm’s low
Urgent echo: As before, good LV function
CXR: No consolidation Oral hypoglycaemics stopped
ABG: ype 2 respiratory failure
Fluid restriction 750ml + Demeclocycline
22/1/07 Still SOB and confused Improving B/L crackeles
Improving Urine output- 1L over 24 hrs Na 128, K 4.5
23/1: Na 130, K 4.5 MRI: No brain lesion.
Small 7mm cyst in posterior pituitary likely aracnoid or Rathke’s cleft cyst displacing anterior pituitary forward
23/1/07 Continues on 24% oxygen Anterior pituitary funcion: WNL
LH: 2.6
FSH 45
TSH 1.29
Posterior function:
Prolactin 1621 Continues on Demeclocycline
24/1/07 Na 132, K 4.1 Bicarb 33. Normal RFT, LFT
Chol 2.6, TG 0.58, Urate 220 (0-450)
serum osmolality 264
urine osmolality 236
Na 18 K 18 Continues on Demeclocycline
Other avenues pursued:
CT abo/pelvis request to r/o malignancy denied
Not fit for investigation of persistent nausea by endoscopy
Not fit for cystoscopic inv of bladder
No evidence of pulmonary malignancy on CXR and CTPA (non smoker)
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