Journal Information
Vol. 28. Issue. 5.October 2008
Pages 475-573
Vol. 28. Issue. 5.October 2008
Pages 475-573
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Hyponatremia secondary to cerebral salt-wasting syndrome associated to bacterial meningitis
Hiponatremia secundaria a síndrome pierde sal cerebral asociado a meningitis bacteriana.
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MANUEL HERAS BENITOa, ROSA SANCHEZ HERNANDEZa, MARIA JOSE FERNANDEZ-REYESb, PEDRO IGLESIASc, PALOMA GUEVARAd
a Servicios de Nefrología, Hospital General, Segovia, Segovia, España,
b Servicios de Nefrología, Hospital General Segovia, Segovia, España,
c Servicios de Endocrinología, Hospital General, Segovia, Segovia, España,
d Servicios de Bioquímica, Hospital General, Segovia, Segovia, España,
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Abstract
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La hiponatremia es el trastorno hidroelectrolítico más prevalente en la práctica clínica habitual (1). El síndrome pierde sal cerebral (SPC) es una causa infrecuente de hiponatremia. Presentamos el caso de un varón con meningitis bacteriana que desarrolló una hiponatremia secundaria a un SPC.
To the editor: Hyponatremia is the most prevalent water and electrolyte disorder in standard clinical practice.1 The cerebral salt-wasting syndrome (CSWS) is an uncommon cause of hyponatremia. The case of a male patient with bacterial meningitis who developed hyponatremia secondary to CSWS is reported below.
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To the editor: Hyponatremia is the most prevalent water and electrolyte disorder in standard clinical practice.1 The cerebral salt-wasting syndrome (CSWS) is an uncommon cause of hyponatremia. The case of a male patient with bacterial meningitis who developed hyponatremia secondary to CSWS is reported below.



CASE REPORT

A 21-year-old male patient with an unremarkable history was admitted to the intensive care unit (ICU) with a diagnosis of meningococcal meningitis associated to sepsis with multiorgan failure that required mechanical  ventilation, hemodynamic support with dopamine, treatment with human recombinant activated C protein, and anticonvulsant drugs  due  to  a  secondary  irritative focus.  Empiric  treatment  was  started with  ampicillin,  cefotaxime, vancomycin, and dexamethasone, and was switched to cefotaxime alone after the causative  germ was isolated (Neisseria meningitidis) and the results of susceptibility testing were known. Serum creatinine (SCr) levels  at ICU admission were 3.2 mg/dL, and normalized after two days (0.9 mg/dL). Once hemodynamic stabilization, renal function control,  and  spontaneous  breathing  had been  achieved,  the  patient was moved to the ward.



During  the  final  days  of  stay  at  the ICU, a progressive decrease in natremia was documented (see table I), associated to polyuria of 4-5 liters daily, with normal serum levels of antidiuretic hormone (ADH) and high levels of  brain natriuretic peptide (pro-BNP). Adequate  intravenous  volume  replacement with physiological saline based on urinary  sodium  loss  allowed  for normalization of natremia and a normal volume status (table I).



DISCUSSION

In  patients  with  central  nervous  system  diseases,  hyponatremia  does  not have to be necessarily related to  a syndrome  of  inappropriate  ADH  secretion  (SIADH),  but may  be  secondary to a CSWS.2,3 Subarachnoid  hemorrhage  is  the most  common  cause of  CSWS,  but  this  has  also  been  reported  to  be  associated  to meningitis of an infectious origin. A new case of CSWS  occurring  in  a  young  adult after resolution of a bacterial meningitis is reported.



Diagnosis  of  CSWS  requires  the presence  of  an  inappropriate diuresis for circulating sodium levels and volume depletion.4 Diagnostic suspicion of CSWS  is  essential  for  hyponatremia control, because its treatment is totally different  from  that  of  SIADH. While volume and sodium replacement is essential  in CSWS, SIADH  responds  to water restriction.5 In the case reported, CSWS  was  suspected  based  on  the existence of polyuria associated to hyponatremia  and  elevated  natriuresis. Elevated  serum  levels  of  pro-BNP confirmed diagnosis of CSWS. The increase in pro-BNP serum levels secondary to the inflammatory process in the central nervous system could be related  to  the  inappropriately high natriuresis.



To sum up, occurrence of hyponatremia combined with increased natriuresis and volume depletion in patients with  central  nervous  system  disease should raise the suspicion of a CSWS.

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Nefrología (English Edition)

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