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Abstract: PO0072

SIADH with COVID-19-Induced Hemophagocytic Lymphohistiocytosis: A Case Report

Session Information

Category: Coronavirus (COVID-19)

  • 000 Coronavirus (COVID-19)


  • El Chediak, Alissar, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Burgner, Anna Marie, Vanderbilt University Medical Center, Nashville, Tennessee, United States

The effects of COVID-19 on the body are still being unraveled as we learn more about this disease. Here we report a case of hyponatremia secondary to Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) from COVID-19 induced hemophagocytic lymphohistiocytosis (HLH).

Case Description

A 47-year-old female with hypertension was admitted with COVID-19 infection. She had persistent fever, elevated inflammatory markers (ferritin: 6094 ng/ml, C-reactive protein: 217.1 mg/l, LDH 614 unit/L), and liver tests (ALP:275 unit/L, AST 106 unit/L, ALT 196 unit/L) and was thus diagnosed with COVID-19-associated HLH. Patient was treated with dexamethasone with resolution of fever but still had elevated CRP, ferritin, and LDH. She was discharged on a dexamethasone taper but returned just over a week later with malaise, brain-fog, and poor oral intake. Patient was then found to have severe hyponatremia with a serum sodium (Na) of 119 mmol/L and the following lab data: urine osmolality: 503 mOsm/kg, urine Na: 46, serum osmolality: 262 mOsm/Kg. Moreover, she had no edema on exam, nor did she display any signs of orthostatic hypotension. This was consistent with SIADH. Her medication list didn’t include any medications that can cause SIADH. No hormonal disturbances were detected. She was given high dose steroids again and Intravenous Immunoglobulin for persistent fever and lack of clinical improvement. Meanwhile, despite treatment with urea and fluid restriction, her Na stayed in the low 120’s. The decision was then made to start Interleukin-1 (IL-1) antagonist therapy. 1 day after the Interleukin-1 antagonist therapy was started, sodium started rising again by around 2 meq/day till it normalized.


HLH has a wide range of causes including viruses but all can lead to a hyperinflammatory state. SARS-CoV-2 is known to cause a cytokine storm. Cases of COVID-19 associated HLH have been reported. The proposed mechanism of SIADH is related to the surge of interleukins associated with inflammation due to HLH induced COVID-19. Particularly, IL-6 is increased with both HLH and COVID-19. IL-6 can cause the release of ADH by stimulating the hypothalamic-pituitary-adrenal axis. Thus, hyponatremia can be found in patients with COVID-19. One way of addressing that is through Interleukin receptor antagonism. More data is needed to prove the efficacy of that therapy.