The differential diagnosis of hypernatraemia in children, with ...

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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 4.6 Additional causes of hypernatraemia in adults Clinical question What additional agents and mechanisms causing hypernatraemia are described in adults? There are a number of reported cases of deliberate self-harm in adults involving the taking of sodium. These include 2 reports of Soy sauce ingestion 254, 255 two of sodium hypochlorite (bleach), 256, 257 and one of salt. 258 One patient took an overdose of colchicine and induced a temporary diabetes insipidus. 259 Three adults mistakenly took excessive amounts of salt. Two died as a result. Two had learning difficulties (one aged 41 with Down syndrome 226, 260 and a second aged 45 with Prader-Willi syndrome 261 ); the third, aged 85, had dementia. 223 A 26 year old with learning difficulties died after ingesting flavour intensifier containing sodium chloride and sodium glutamate, apparently in error. His peak sodium was 176 mmol/L. 262 A 35-year-old fisherman was rescued after spending 11 hours in sea water in a hurricane. He had inadvertently swallowed sea water (with a sodium concentration of between 300 and 500 mmol/L). His initial sodium was 175 mmol/L. 228 He made a full recovery. There are three case reports of hypernatraemia following exorcism rituals. 227, 263, 264 In each, as part of the ritual, the subject was required to drink large volumes of salt water. Sodium concentrations of 246, 255 and 153 mmol/L were recorded in women aged 36, 20 and 19 years respectively. All three women died (the third woman was said to have died of asphyxia, having been beaten as well). A 53-year-old man developed hypernatraemia with a sodium of 168 mmol/L 12 days after his ischio-rectal abscess started being irrigated twice daily with Milton as a substitute for Eusol. The Milton contained 780 mmol/L of sodium, and his 24-hour urinary sodium excretion rose to a maximum of over 300 mmol/24 hrs. 265 There are reports of adults developing hypernatraemia whilst on hyperosmolar feeds. The first 266 , in a 59-year-old woman with psychosis who had refused to eat for 8 days, had a sodium of 164 mmol/L after one week of hyperosmolar feeds administered via a nasogastric tube. There was evidence of dehydration. The other reports from the 1950s and 69
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 1960s 267-269 described adults with hypernatraemia (sodiums between 160 and 192 mEq/L) following the introduction of high protein tube feeding. The patients had all been unable to swallow for various reasons, and all had evidence of some degree of dehydration. There are 3 case reports in adults of hypernatraemia developing whilst taking lactulose as a treatment for hepatic encephalopathy. 270-272 Maximum serum sodium concentrations of 175, 169 and 173 mEq/L occurred. All patients had developed severe diarrhoea, and the authors concluded that the mechanism was excess gastrointestinal water loss. A similar mechanism was thought responsible in 3 cases treated for overdose with activated charcoal, in two cases in a 70% sorbitol solution, and in one with magnesium citrate. 273 They all developed diarrhoea and hypernatraemia (sodiums in the range of 160 to over 170 mEq/L). Intravenous 20% mannitol given to promote a diuresis in a patient with severe liver disease was associated with a diuresis and a maximum serum sodium of 194 mEq/L. 274 The urinary sodium concentration was found to be very low, and the proposed mechanism was therefore excessive renal water loss. A 70 year old developed hypernatraemia (sodium 167 mEq/L) after 8 days of intravenous 30% urea treatment given postoperatively following craniotomy for a pituitary chromophobe adenoma (partially resected). 275 The patient’s recovery after rehydration suggested that the mechanism was an induced renal water diuresis rather than either diabetes insipidus or hypodipsia. A case report in 2001 suggested that severe hypernatraemia was a side effect of olanzapine given to a 30 year old with schizophrenia. 276 He had been started on olanzapine 10 days before admission with neuroleptic malignant syndrome (NMS: fever, rigidity, confusion, autonomic dysfunction and rhabdomyolysis). His admission serum sodium was 190 mEq/L. He was clinically dehydrated, and the authors ascribed his hypernatraemia to a combination of reduced fluid intake, fever and excessive sweating, as well as a direct consequence of the neuroleptic malignant syndrome. Although there was good evidence of NMS, the inadequate water intake coupled with increased insensible losses could by itself have resulted in the hypernatraemia. 70
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