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Abstract: SA-PO717

A Case of Iatrogenic Hyponatremia from Adrenal Insufficiency

Session Information

Category: Fluid, Electrolytes, and Acid-Base Disorders

  • 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Author

  • Zou, Guangchen, Johns Hopkins University, Baltimore, Maryland, United States
Introduction

Adrenal insufficiency can cause hypersecretion of ADH and lead to hyponatremia. A patient with panhypopituitarism developed severe hyponatremia when hydrocortisone were inadvertently held.

Case Description

A 47-year-old male was admitted for aspiration pneumonia. He had medulloblastoma in his teens and had resection and radiation therapy complicated by panhypopituitarism, and recurrent ischemic strokes with residual right-sided hemiparesis. He was on levothyroxine, hydrocortisone, aspirin, clopidogrel and pravastatin at home. Pneumonia improved and he had a percutaneous gastrostomy tube placed. He was then NPO for a gastric emptying study and his hydrocortisone was inadvertently held and not restarted afterwards. He was restarted on continuous tube feeding (Osmolite 1.2 at 55 ml/h) along with enteral water flushes (150 ml q4h). His sodium was normal since admission for 14 days but dropped from 142 to 117 over 3 days. Systolic blood pressure were 100s-140s. Creatinine was 0.4 mg/dL and potassium was 4.6 mmol/L. Urine sodium was 193 mmol/L, potassium was 37.7 mmol/L and osmolality of 577 mOsm/Kg. Tube feeding were held and he was restarted on hydrocortisone. He was edematous and was given IV furosemide 20 daily. His sodium improved and repeat urine studies 3 days later showed urine sodium of 24 mmol/L. He was later restarted on tube feeding with TwoCal HN. Sodium level remained within normal range 2 weeks later. He was discharged to a skilled nursing facility.

Discussion

Serum sodium dropped when his hydrocortisone was held while being started on tube feeding. Very high urine sodium level which decreased after restarting hydrocortisone were consistent with SIADH from adrenal insufficiency.

Clinicians should be careful not to withhold hydrocortisone inadvertently for patients with adrenal insufficiency. For patients with SIADH, serum sodium level should be carefully monitored when they are being started on tube-feeding.

Figure 1. Serum sodium trend. Last dose of hydrocortisone was 14 h before time 0. Hydrocrotisone restarted at 106 h.