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Diagnosis and Treatment > Medication

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Raku Son Department of Nephrology, St. Luke’s International Hospital, Tokyo, Japan

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Masahiko Nagahama Department of Nephrology, St. Luke’s International Hospital, Tokyo, Japan

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Fumiaki Tanemoto Department of Nephrology, St. Luke’s International Hospital, Tokyo, Japan

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Yugo Ito Department of Nephrology, St. Luke’s International Hospital, Tokyo, Japan

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Fumika Taki Department of Nephrology, St. Luke’s International Hospital, Tokyo, Japan

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Ryosuke Tsugitomi Department of Pulmonary Medicine, Thoracic Center, St. Luke’s International Hospital, Tokyo, Japan

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Masaaki Nakayama Department of Nephrology, St. Luke’s International Hospital, Tokyo, Japan

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Summary

The etiology of hyponatremia is assessed based on urine osmolality and sodium. We herein describe a 35-year-old Asian man with pulmonary tuberculosis and perforated duodenal ulcer who presented with hyponatremia with hourly fluctuating urine osmolality ranging from 100 to 600 mosmol/kg, which resembled urine osmolality observed in typical polydipsia and SIADH simultaneously. Further review revealed correlation of body temperature and urine osmolality. Since fever is a known non-osmotic stimulus of ADH secretion, we theorized that hyponatremia in this patient was due to transient ADH secretion due to fever. In our case, empiric exogenous glucocorticoid suppressed transient non-osmotic ADH secretion and urine osmolality showed highly variable concentrations. Transient ADH secretion-related hyponatremia may be underrecognized due to occasional empiric glucocorticoid administration in patients with critical illnesses. Repeatedly monitoring of urine chemistries and interpretation of urine chemistries with careful review of non-osmotic stimuli of ADH including fever is crucial in recognition of this etiology.

Learning points:

  • Hourly fluctuations in urine osmolality can be observed in patients with fever, which is a non-osmotic stimulant of ADH secretion.

  • Repeated monitoring of urine chemistries aids in the diagnosis of the etiology underlying hyponatremia, including fever, in patients with transient ADH secretion.

  • Glucocorticoid administration suppresses ADH secretion and improves hyponatremia even in the absence of adrenal insufficiency; the etiology of hyponatremia should be determined carefully in these patients.

Taxonomy:
Clinical Overview, Gland/Organ, Adrenal, Kidney, Pituitary, Topic, Adrenal, Hormone, Antidiuretic Hormone, Cortisol, Condition/ Syndrome, Adrenal insufficiency, Hyponatraemia, SIADH, Tuberculosis, Patient Demographics, Age, Adolescent/young adult, Gender, Male, Ethnicity, Asian - Japanese, Country of Treatment, Japan, Diagnosis and Treatment, Signs and Symptoms, Abdominal pain, Coughing, Haemoptysis, Hypoglycaemia, Hyponatraemia, Hypotension, Oedema, Pyrexia, Investigation, ACTH stimulation, Cortisol, CT scan, Potassium, Sodium, Urine osmolality, Intervention, Fluid repletion, Small bowel resection, Tracheostomy, Medication, Antibiotics, AVP receptor antagonists, Corticosteroids, Desmopressin, Furosemide, Glucocorticoids, Hydrocortisone, Isoniazid, Phosphate supplements, Tolvaptan, Vaptans, Publication Details, Case Report Type, Error in diagnosis/pitfalls and caveats
DOI:
https://doi.org/10.1530/EDM-19-0155
Volume/Issue:
Volume 2020: Issue 1
Open access