Lessons Learnt from a Case of Hyponatraemia

Presentation Number: SUN 294
Date of Presentation: April 2nd, 2017

Jessie Ruijun Wang*1 and Vinod Patel2
1Tameside General Hospital, Manchester, UNITED KINGDOM, 2Tameside General Hospital

Abstract

Background: Hyponatraemia is a common endocrinology presentation. This clinical case discusses how the cause and complication of hyponatraemia could have been prevented.

Clinical case: A 53-year-old woman was presented to emergency room with hypotension, weakness and history of weight loss (11.4 stones in 6 months). Past medical history included gastroeosophageal reflux disease, iron deficient anaemia, tylosis, 3 episodes of pulmonary embolism (PE), two of which were during her twenties. She also had ischaemic small bowel and partial hemicolectomy 6 months prior to presentation, which removed 75cm of ileum, 9.5cm of caecum and 6.5cm of appendix. Furthermore, she had recently been started on duloxetine for depression. 

Initial blood work showed serum sodium to be 116 mmol/L, magnesium 0.55[UNIT], adjusted calcium of 2.09[UNIT] and inorganic phosphate 0.34[UNIT]. After ruling out other causes of hyponatraemia such as Cushing’s syndrome with a normal dexamethasone suppression test, and malignancy associated SIADH with a normal CT thorax abdomen and pelvis, it was apparent her electrolyte disturbance was due to gastrointestinal (GI) loss following hemicolectomy 6 months ago. Deluxetine was temporarily suspended for potential contribution to the hypontraemia. Her management was centred around nutritional replenishment and electrolyte correction with daily monitoring. Her case was being reviewed by the surgeons for reversal of colostomy. 

Given the history of recurrent emboli, coagulopathy screen was performed, also for the first time, during this admission. The patient was tested positive for anti-phospholipid antibodies. Due to poor GI absorption, patient was started on subcutaneous dalteparin as the primary treatment option for anticoagulation. 

Whilst waiting for surgical review of colostomy reversal, she was intubated briefly when she was unable to maintain saturation above 50% secondary to aspiration. Upon extubation, she had dysarthria, dysphagia, loss of balance, ataxia, weakness of limbs, and increased reflexes. MR brain showed ‘high signal affecting pons bilaterally’ consistent with the findings of central pontine myelinolysis. 

The events above caused her to be bed-bound and unfit for discharge for 7 months at the time of this case study. Her predisposition for embolism due to antiphospholipids syndrome was not diagnosed early enough in life to prevent the ischaemic bowel which lead to hemicolectomy, excessive GI electrolytes loss and subsequently, central pontine myelinolysis. 

Conclusion: The case highlighted the importance of testing for coagulopathy - always be mindful of patients with no known risk factors presenting with blood clots as the consequences of missing underlying diagnosis can be devastating. 

 

Nothing to Disclose: JRW, VP