Meraz MA, Zúńiga VJ, Steta OJM

Language: Spanish
References: 12
Page: 68-72
PDF size: 193.38 Kb.

ABSTRACT

We report the case of a 51-year-old female with a history of stage IV malignant melanoma with central nervous system metastases. Two weeks prior to her hospitalization, she underwent a right frontal metastasectomy without complications. She sought medical attention for altered speech, short-term memory, weakness and imbalance. On the physical examination, the presence of orthostatic hypotension and postural tachycardia were noticed. She was admitted to the hospital for a diagnostic and treatment approach. The presence of moderate symptomatic hypotonic hyponatremia was documented in her laboratory tests. In the extension tests, arginine-vasopressin activity, high urinary sodium, high fractional excretion of sodium, low uric acid, and high fractional excretion of uric acid were found. With these data, the diagnosis of cerebral salt wasting syndrome was established. The initial treatment consisted of intravenous fluid replacement with 0.9% saline solution until she reached normal serum sodium. Neurological symptoms resolved within 24 hours. However, on the fourth day, she experienced a symptomatic decrease in her serum sodium despite being euvolemic. An increase in urinary osmolarity was addressed and an inadequate increase of arginine vasopressin was documented. With these findings, an aggregated inappropriate antidiuretic syndrome was diagnosed. The new therapy consisted in restricting the water intake, increasing the oral solute intake and use of fludrocortisone. Again, a gradual increase in serum sodium levels was achieved. She was discharged without further complications.

REFERENCES

1. Al-Mufti H, Arieff AI. Hyponatremia due to cerebral salt-wasting syndrome. Combined cerebral and distal tubular lesion. Am J Med. 1984; 77 (4): 740-746.

2. Maesaka JK, Imbriano LJ, Ali NM, Ilamathi E. Is it cerebral or renal salt wasting? Kidney Int. 2009; 76 (9): 934-938.

3. Sterns RH, Silver SM. Cerebral salt wasting versus SIADH: what difference? J Am Soc Nephrol. 2008; 19 (2): 194-196.

4. Palmer BF. Hyponatremia in patients with central nervous system disease: SIADH versus CSW. Trends Endocrinol Metab. 2003; 14 (4): 182-187.

5. Bitew S, Imbriano L, Miyawaki N, Fishbane S, Maesaka JK. More on renal salt wasting without cerebral disease: response to saline infusion. Clin J Am Soc Nephrol. 2009; 4 (2): 309-315.

6. McGee S, Abernethy WB 3rd, Simel DL. The rational clinical examination. Is this patient hypovolemic? JAMA. 1999; 281 (11): 1022-1029.

7. Dholke H, Campos A, Reddy CN, Panigrahi MK. Cerebral salt wasting syndrome. J Neuroanaesthesiol Crit Care. 2016; 3 (3): 205-210.

8. Moritz ML. Syndrome of inappropriate antidiuresis and cerebral salt wasting syndrome: are they different and does it matter? Pediatr Nephrol. 2012; 27 (5): 689-693.

9. Moritz ML, Ayus JC. 100 cc 3% sodium chloride bolus: a novel treatment for hyponatremic encephalopathy. Metab Brain Dis. 2010; 25 (1): 91-96.

10. Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014; 170 (3): G1-G47.

11. Mohmand HK, Issa D, Ahmad Z, Cappuccio JD, Kouides RW, Sterns RH. Hypertonic saline for hyponatremia: risk of inadvertent overcorrection. Clin J Am Soc Nephrol. 2007; 2 (6): 1110-1117.

12. Taplin CE, Cowell CT, Silink M, Ambler GR. Fludrocortisone therapy in cerebral salt wasting. Pediatrics. 2006; 118 (6): e1904-e1908.