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Abstract: PO1431

Hyponatremia: It’s in the Eye of the Beholder

Session Information

Category: Trainee Case Report

  • 902 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

  • Jan, Muhammad Yahya, Indiana University School of Medicine, Division of Nephrology and Hypertension, Indianapolis, Indiana, United States
  • Hellman, Richard N., Indiana University School of Medicine, Division of Nephrology and Hypertension, Indianapolis, Indiana, United States
Introduction

An 85 year old Asian American female presented with 2 days history of worsening right eye pain, headache, scalp tenderness, and hypertensive urgency. Medical history was notable for keratoconjunctivitis sicca, osteoarthritis, and central retinal occlusion of the left eye. Initial labs showed erythrocyte sedimentation rate of 75 mm/hr. and C reactive protein of 3 mg/dL. A presumptive diagnosis of Giant Cell Arteritis (GCA) was made. She was started on high dose oral prednisone. Hypertension was treated with labetalol, amlodipine, and pain with opioids. Over the course of the next 36 hours she began to have somnolence. Initial sodium (Na) on admission was 131 mmol/L, with prior normonatremia. She was given a normal saline bolus followed by infusion due to concern for hypovolemia and reduced oral intake. This resulted in a consistent drop in her serum sodium acutely to 116 mmol/L and a nephrology consultation was sought.

Case Description

Our evaluation showed euvolemia with confusion and obtundation. Labs showed serum osmolality of 252 mosm/kg, urine osmolality of 626 osm/kg and Urine Na consistently around 90-129 mEq/L. A diagnosis of SIADH with desalination was made. She was treated with free water restriction, 3% saline, salt tablets, and furosemide. Na improved to 120 mmol/L however it dropped again next day to 117mmol/L requiring repeated doses of 3% Saline. Daily urine osmolality continued to decrease to 500s osm/kg and later to 360 mosm/kg as did urinary sodium 48 hours after these interventions. Peri-ocular swelling and a herpes zoster rash appeared on her eye 48 hours later. PCR for herpes was positive.

Discussion

Acyclovir was started and corticosteroids stopped. Over 8 days the hyponatremia resolved with Herpes Zoster Opthalmicus (HZO) treatment.

HZO is a rare cause of SIADH thought to be due to dysregulation of stimulating signals from nucleus tractus solitarious to the supraoptic and paraventricular nuclei in the brainstem. In our case pain and opioids may have also been factors. Desalination needs to be considered in the correction of hyponatremia in SIADH, hyponatremia correction in HZO takes an average of 7 days although up to 4 months has been reported in 1 case series1. HZO should be considered in the differential diagnosis of SIADH.