Management of a patient with Sheehan’s syndrome and diabetes insipidus complicated by recurrent hyponatremia

Summary A 38-year-old female was initially seen in the intensive care unit after severe postpartum hemorrhage. She was initially diagnosed to have Sheehan’s syndrome and after discharge, she was diagnosed to have a vesicovaginal fistula which initially caused a delay in diagnosing diabetes insipidus in the patient because she was having urinary incontinence. The patient had the vesicovaginal fistula repaired and was on replacement with levothyroxine, prednisone, and desmopressin. Years after her diagnosis, the patient experienced recurrent episodes of hyponatremia in the setting of desmopressin therapy. This case highlights the challenges of diagnosing diabetes insipidus in a patient with Sheehan’s syndrome and a vesicovaginal fistula, as well as the long-term management of central diabetes insipidus in a resource-limited setting. Learning points Sheehan’s syndrome is rarely associated with diabetes insipidus, and in our patient, it was initially missed due to a vesicovaginal fistula which caused urinary incontinence. Water intoxication is more common in young children and older adults but can occur years after initiating treatment with desmopressin in adults and should be kept in mind when treating patients with hyponatremia who have hypopituitarism associated with diabetes insipidus. Water intoxication is much more common in patients with diabetes insipidus being treated with intranasal desmopressin than in those using the oral preparations.

Overconsumption of fluids during labour leading to water intoxication and a tonic–clonic seizure in a healthy labourer

A 33-year-old woman in her first pregnancy with no significant medical history had a tonic–clonic seizure one hour after delivery due to acute hyponatraemia caused by excess intake of fluids. She was admitted to a birthing centre as a low-risk labourer where she spent 19 hours including 4 hours in the second stage of labour. Throughout the labour, she was encouraged to drink as per her own initiative and thirst. However, there was no monitoring of fluid intake. In spite of initial confusion about the cause of the seizure, a multidisciplinary approach helped with diagnosis of an underlying pathology and allowed timely treatment to avoid adverse outcomes in this patient. We would like to increase awareness of a possibility, however rare, of water intoxication due to fluid overconsumption by patients in labour and encourage production of information guidance for monitoring of fluid intake of women in labour.

WATER INTAKE APPLET BASED ON HUMAN EXCREMENT

In order to function properly the human body requires adequate hydration due to 70% of the human body being built up by water with lots of chemical reactions involved in order to work optimally throughout the day. This paper presents an idea to make a water intake app based on human excrement surveillance. It might be a solution to intensify people's ability to become self-conscious when drinking less water by surveying the excreted substance. Currently, available software that measures one indicator which is between urine and feces detector on how much water should the user drink. But actually, both excrement indicators are needed to detect users' drinking amount. If one of these indicators shows a bad result, it could lead to water intoxication or hydration. The application was created using Python to give feedback regarding the user's water intake based on the condition of their excreted substance.

Hyponatremia caused by water intoxication: successful treatment of psychiatric disturbances with olanzapine and fluoxetine

ABSTRACT Hyponatremia is a frequent, yet often unrecognized result of water intoxication caused by psychogenic polydipsia in patients with psychiatric disorders such as schizophrenia and anorexia nervosa. The consequences of hyponatremia may include cerebral edema with tonic–clonic seizures and, in extreme cases, death. In cases of hyponatremia seen in psychiatric practices, the use of psychotropic drugs is often necessary to address both the underlying psychiatric problem and reduce the hyponatremia. Therefore, a patient’s clinical condition, the risk of side effects, the possible effect of the medication on hyponatremia and a history of prior medication use should be considered when selecting appropriate psychotropics. The present clinical case details the beneficial effects of olanzapine and fluoxetine in treating a patient with anorexia nervosa and body dysmorphic disorder experiencing acute hyponatremia, and the stable effect the medications achieved over a period of 2.5 years of maintenance therapy.

Life threatening water intoxication

Water intoxication is a fatal disorder associated with disturbance in brain function, known as hypo-osmolar syndrome which resulting from an excessive water intake, with dilutional hypernatremia leads to a potentially fatal outcome. A change in the electrolyte equilibrium such as this sudden drop in serum sodium level and then subsequent mortality. With hyponatremia, the plasma osmolality decreased leading to water movement into the brain according to the osmotic gradient, resulting in hyponatremic encephalopathy and cerebral oedema. Increased water intake such as in Psychogenic polydipsia is followed by urination of high amount of diluted urine (polyuria) which are the main initial symptoms of water intoxication with headache, blurred vision, nausea, tremor, and deterioration in psychosis. Other serious symptoms involve muscle spasms, Early detection of seizures and coma are more serious outcomes, Untreated cases may lead to death, Risk factor for water intoxication are Marathon runners, military population and athletes and due to this endurance events, these behaviors encouraging heavy sweating that result in heat exhaustion and consume large volumes of fluid, then hyponatremia developed as a result of excessive fluid substitution. Child abuse is other pediatric clinical cases reported with water intoxication. Psychogenic polydipsia which is psychiatric disorder with obsessive water drinking leading to a serious self-induced water intoxication (SIWI), water is normally metabolized and excreted by different means and it is mainly by kidneys in urine, evaporation through the skin, by respiratory system through the respired water vapor and little quantity of water was lost from the gastrointestinal tract (GI).The LD50 of water is > 90 ml/kg orally in rats. The current review illustrates the Life threatening effects of water when it is aggressively consumed.

Effect of Methylprednisolone on Experimental Brain Edema in Magnetic Resonance Imaging

Magnetic resonance imaging has been used for evaluating of a brain edema in experimental animals to assess cytotoxic and vasogenic edema by the apparent diffusion coefficient (ADC) and T2 imaging. This paper brings information about the effectiveness of methylprednisolone (MP) on experimental brain edema. A total of 24 rats were divided into three groups of 8 animals each. Rats with cytotoxic/intracellular brain edema induced by water intoxication were assigned to the group WI. These rats also served as the additional control group CG when measured before the induction of edema. A third group (WIMP) was intraperitoneally administered with methylprednisolone 100 mg/kg during water intoxication treatment. The group WI+MP was injected with methylprednisolone 50 mg/kg into the carotid artery within two hours after the water intoxication treatment. We evaluated the results in four groups. Two control groups (CG, WI) and two experimental groups (WIMP, WI+MP). Rats were subjected to MR scanning 24 h after edema induction. We observed significantly increased ADC values in group WI in both evaluated areas – cortex and hippocampus, which proved the occurrence of experimental vasogenic edema, while ADC values in groups WIMP and WI+MP were not increased, indicating that the experimental edema was not developed and thus confirming the protective effect of MP.