Encephalopathy with cerebellar deficits in a context of hyponatremia.

BACKGROUND: Hyponatremia can present with various neurological manifestations ranging from altered mental status to cerebral herniation and death. However, cerebellar symptomatology has been rarely reported. CASE PRESENTATION: A 53-year-old male with a history of diabetes mellitus type 2, hypothyroidism, and anxiety disorder presented with impaired level of consciousness and ataxia. His laboratory tests were consistent with sepsis (staphylococcus aureus in blood culture), hyponatremia with euvolemia, low serum and high urine osmolarity. Brain computerized tomography revealed diffuse cerebral edema. Antibiotics and sodium replenishment were initiated. A lumbar puncture and subsequent investigations ruled out alternative etiologies (metabolic, autoimmune, paraneoplastic and other infectious causes). Repeated brain magnetic resonance imaging excluded osmotic demyelination syndromes. After serum sodium restoration his symptoms gradually improved. DISCUSSION: We highlight reversible cerebellar ataxia as a rare manifestation of hyponatremia, in the context of sepsis and possible syndrome of inappropriate antidiuretic hormone ADH release. Extensive diagnostic work-up is essential for the exclusion of other diagnoses.

SIADH and mixed delirium following the abrupt cessation of long-acting benzodiazepines: a case report.

Benzodiazepines (BZDs) are among the most commonly used medications due to their efficacy and rapid onset of action. Although they offer significant therapeutic benefits in treating various psychiatric and neurological conditions, their clinical utility is limited by substantial risks, including dependency and withdrawal symptoms. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) has been linked to BZD withdrawal. In this case report, we examine the case of an elderly female presented with a mixed delirium and SIADH following the abrupt cessation of long-term clonazepam therapy. To our knowledge, this is the second case that documents a link between SIADH and BZD withdrawal.

Smartphone Applications for Remote Monitoring of Patients After Transsphenoidal Pituitary Surgery: A Narrative Review of Emerging Technologies.

OBJECTIVE: Almost all postoperative assessments for pituitary patients are performed in clinical settings under the supervision of medical providers. With the emergence of telemedicine, however, there are opportunities to monitor these patients remotely. The potential for use of such technologies is inconsistently described in the brain tumor literature, especially for patients with pituitary adenomas. METHODS: In this comprehensive narrative review, we present the literature for the use of mobile applications (apps) for monitoring of postoperative symptomatology that is specific to patients undergoing pituitary surgery. Our primary research question was: "Which smartphone apps exist in the literature to monitor parameters associated with common complications of pituitary surgery?" Specifically, we search for apps in the literature that facilitate the measurement of parameters associated with adrenal insufficiency, disorders of water imbalance, and visual changes-3 common complications of pituitary surgery. RESULTS: Twenty-six apps were identified. Fourteen apps pertained to monitoring of visual changes, followed by 9 apps for monitoring water and electrolyte imbalances and 3 apps for monitoring adrenal dysfunction. Novel technologies that were integrated into these apps included digital image-based colorimetry, sonouroflowmetry, visual contrast sensitivity, and lateral flow immunoassays, among others. CONCLUSIONS: Due to advancing capabilities of smartphone apps, the potential of telemedicine may extend beyond patient appointments. We show that by integrating novel advances in medical technologies from a variety of specialties, it is possible to develop smartphone-based protocols for remote monitoring of patients after pituitary surgery.

Transverse Myelitis in a 72-Year-Old Male Presenting With Upper Extremity Weakness.

Acute transverse myelitis (TM) is a rare, acquired neuro-immune spinal cord disorder that can be idiopathic or related to a secondary disease. Clinical signs and symptoms include motor weakness, sensory alterations, and bowel or bladder dysfunction. Often TM occurs in the younger population or middle-aged adults. This patient's presentation is unique in the fact that he does not fall into either of these age categories. In this case, a 72-year-old male with a past medical history of hypertension and type 2 diabetes mellitus presented to the emergency department due to a five-day history of worsening weakness of the upper extremities bilaterally. In addition, the patient reported a new onset of abdominal wall numbness. The patient reported being at a theme park a few days prior, denying any injuries and only complaining of neck discomfort during the car ride home. Labs and imaging were quickly ordered for diagnostic purposes. The patient was diagnosed with TM using magnetic resonance imaging (MRI), lumbar puncture, and clinical signs. The etiology was later discovered to be due to a new diagnosis of Sjögren's autoimmune disease. The patient was treated with high-dose intravenous steroids for five days while being monitored for any neurologic changes. The plan was to continue steroids by mouth once discharged from the hospital. Due to poor adherence to discharge instructions, the patient was readmitted after presenting to the emergency department with worsening symptoms. Physicians need to recognize and diagnose TM quickly, as some etiologies are treatable and can prevent further damage to the spinal cord.

Severe Hyponatremia Associated With Terlipressin Use in Esophageal Variceal Bleeding.

Terlipressin is an analogue of vasopressin that is indicated as first-line therapy for variceal hemorrhage and hepatorenal syndrome. Hyponatremia is an uncommon complication of terlipressin because it has less effect on vasopressin V2 receptors located in the kidneys. Profound hyponatremia related to terlipressin use is a rare complication that needs to be aware of. We described a 35-year-old previously healthy man, who was admitted for esophageal variceal bleeding that was attributed to hepatitis B-related liver cirrhosis. He had a normal baseline sodium level (Na 139 mmol/L) and developed severe hyponatremia 119 mmol/L (euvolemic, hypo-osmolar) at 72 hours of terlipressin therapy. After holding the medication, the hyponatremia corrected rapidly to 135 mmol/L within 24 hrs. Terlipressin was given again as therapy for overcorrection of hyponatremia and the sodium level decreased before being stabilized without neurological consequences. Severe hyponatremia is an uncommon complication of terlipressin therapy; however, our case emphasizes the importance of sodium monitoring during terlipressin therapy in all patients to prevent this complication, and more importantly, to avoid rapid correction that could happen after holding it.

Immature ovarian teratoma with gliomatosis peritonei, paraneoplastic hyponatremia and growing teratoma syndrome: a case report and literature review.

Introduction and relevance: Paraneoplastic hyponatremia is often secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH) by tumour cells. Immature ovarian teratomas (IOT) are uncommon and may present with SIADH. Case report: A 26-year-old female presented with a 3-month history of abdominal pain and constipation. Imaging identified a mixed solid-cystic right ovarian mass containing fat and peritoneal deposits. Biochemistry showed severe, refractory hyponatremia (117 mmol/l). She underwent diagnostic fertility-preserving right salpingo-oophorectomy and resection of peritoneal nodules with the aim to achieve symptom control and hyponatraemia resolution. Pathology revealed a FIGO Stage 2 Grade 2 IOT with extensive benign peritoneal gliomatosis. Initial management was conservative. After 6 months of active follow-up, a rise in AFP, and recurrent hyponatremia supported the decision to administer three cycles of Bleomycin-Etoposide-Cisplatin chemotherapy. One month later, given radiological disease progression despite satisfactory biomarker response, cytoreductive surgery with complete macroscopic resection was performed. Pathology consisted solely of peritoneal mature glial elements: a growing teratoma syndrome (GTS). The patient remains disease-free after 2 years of surveillance. Clinical discussion: Specimen histological assessment from the patient's initial surgery showed immature neuroectodermal tubules, which are thought to be the source of vasopressin secretion. The authors hypothesise that recurrent hyponatremia and rising AFP levels represented postoperative disease relapse. Biochemical response despite radiological disease progression was pathognomonic of a GTS. Conclusion: Paraneoplastic SIADH secondary to an IOT must be considered in female patients presenting with abdominal symptoms and hyponatremia. Management requires a multidisciplinary approach. Serum electrolytes are useful surveillance biomarkers supplementary to tumour markers.

Hyponatremia After Colonoscopy Bowel Preparation: Challenges in Managing Syndrome of Inappropriate Antidiuretic Hormone Without Established Guidelines.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a condition that leads to free water retention and solute excretion, predisposing patients to hyponatremia. We present the case of a 79-year-old female with a history of SIADH well-controlled with fluid restriction and sodium chloride tablets who presented with hyponatremia after bowel preparation. Her medication regimen was not adjusted before she took the bowel preparation. Her SIADH diagnosis was unknown when she presented but was exemplified by her sodium levels dropping while on a normal saline drip on her third day in the hospital. She was able to successfully take the bowel preparation without hyponatremia after oral urea was added to her regimen. There are currently no clinical guidelines for SIADH patients receiving bowel preparation for colonoscopies and no case reports describing this situation. We discuss the pathophysiology behind the patient's fluctuating sodium levels when on various maintenance fluids and when on fluid restriction. This case concludes that it is imperative to either increase solute intake or increase free water excretion for SIADH patients receiving bowel preparation to prevent potentially deadly hyponatremia.

Syndrome of inappropriate anti-diuretic hormone secretion secondary to disseminated strongyloidiasis in a kidney transplant recipient: A case report.

Background: Syndrome of inappropriate anti-diuretic hormone secretion (SIADH) is associated with strongyloidiasis. Herein, a rare case of severe SIADH secondary to disseminated strongyloidiasis in a kidney transplant recipient is reported. Case presentation: A case involving a 43-year-old male kidney transplant recipient with severe disseminated Strongyloides stercoralis infection is reported. The patient was a construction worker with a history of consuming undercooked yellow eel and sashimi. On admission, the patient presented with poor appetite, nausea, vomiting and diarrhea. Laboratory investigations revealed persistent significant hyponatremia and low serum osmolality, confirming the diagnosis of SIADH. S. stercoralis was detected in the stool and bronchoalveolar lavage fluid. He was treated with empirical albendazole because S. stercoralis was detected in the stool; however, his symptoms and hyponatremia did not improve until ivermectin was administered, after which SIADH resolved quickly. Conclusion: This case suggests that S. stercoralis infection should be included in the differential diagnosis when a kidney transplant recipient presents with gastrointestinal symptoms and SIADH. In such situations, pre- or post-transplant screening for S. stercoralis is needed, and early ivermectin treatment is very important.

Urea transporter UT-A1 as a novel drug target for hyponatremia.

Hyponatremia is the most common disorder of electrolyte imbalances. It is necessary to develop new type of diuretics to treat hyponatremia without losing electrolytes. Urea transporters (UT) play an important role in the urine concentrating process and have been proved as a novel diuretic target. In this study, rat and mouse syndromes of inappropriate antidiuretic hormone secretion (SIADH) models were constructed and analyzed to determine if UTs are a promising drug target for treating hyponatremia. Experimental results showed that 100 mg/kg UT inhibitor 25a significantly increased serum osmolality (from 249.83 ± 5.95 to 294.33 ± 3.90 mOsm/kg) and serum sodium (from 114 ± 2.07 to 136.67 ± 3.82 mmol/L) respectively in hyponatremia rats by diuresis. Serum chemical examination showed that 25a neither caused another electrolyte imbalance nor influenced the lipid metabolism. Using UT-A1 and UT-B knockout mouse SIADH model, it was found that serum osmolality and serum sodium were lowered much less in UT-A1 knockout mice than in UT-B knockout mice, which suggest UT-A1 is a better therapeutic target than UT-B to treat hyponatremia. This study provides a proof of concept that UT-A1 is a diuretic target for SIADH-induced hyponatremia and UT-A1 inhibitors might be developed into new diuretics to treat hyponatremia.

Syncope and Brugada-Like ECG Pattern in a Patient with Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH).

Syncope is a brief loss of consciousness caused by reduced blood flow to the brain, characterised by sudden onset, short duration and full recovery without intervention. Anamnesis, physical examination and other diagnostic tests such as laboratory analysis and electrocardiogram (ECG) can be conducted to identify the underlying cause of syncope. A Brugada pattern on an ECG in individuals with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who have syncope symptoms may indicate cardiac issues. A 69-year-old man with hypertension and a history of smoking presented with syncope. His vital signs were within normal limits, with no signs of a neurological deficit. The patient met the diagnostic criteria for SIADH, as evidenced by the presence of hyponatraemia (Na 118 mmol/l), a hyperosmolar condition and euvolemia. Upon arrival, a twelve-lead ECG showed ST-segment anomalies that reflected a Brugada ECG pattern. No ventricular arrhythmias were detected during the 24-hour Holter monitoring. Coronary angiography revealed no abnormalities in the coronary arteries. The ECG demonstrated the normalisation of ST elevations and the disappearance of the Brugada ECG pattern after the correction of hyponatraemia. After three months of follow-up the patient, with a normal sodium level, had no episodes of syncope. LEARNING POINTS: Syncope in elderly patients with Brugada-like ECG patterns can arise from cardiac causes, thus necessitating more examinations.Severe hyponatraemia in patients with SIADH can cause syncope and a Brugada-like ECG pattern.Correction of hyponatraemia, after ruling out cardiac causes, can improve syncope and normalise the Brugada-like ECG pattern.

A case of SIADH following uncomplicated mild traumatic brain injury: Did cognitive bias delay treatment?

To optimize clinical care, it is imperative for providers to recognize their own inherent cognitive biases and the impact that has on their clinical decision making, thereby minimizing complications such as prolonged hospitalization, unnecessary healthcare spending, and impaired patient satisfaction and functional outcomes.

Severe Hyponatremia Triggered by Immune Checkpoint Inhibitor Therapy in a Patient With Mulvihill-Smith Syndrome.

Background/Objective: Immune checkpoint inhibitors (ICI), including Programmed Cell Death 1, Programmed Cell Death Ligand 1, and Cytotoxic T-lymphocyte Associated Antigen 4 inhibitors, upregulate T-cell responses against tumor cells and are becoming a cornerstone in the treatment of various advanced solid and hematological cancers. Mulvihill-Smith Syndrome (MSS) is a rare genetic syndrome that has been associated with metabolic abnormalities and early-onset tumors, including malignancies. We report the first known case of ICI-induced hyponatremia attributable to syndrome of inappropriate antidiuretic hormone ADH release (SIADH) in a patient with MSS. Case Report: A 23-year-old female patient with MSS and hepatocellular carcinoma presented with recurrent hyponatremia. Assessment of fluid status and electrolytes revealed a euvolemic, hypotonic process consistent with SIADH shortly after initiating adjuvant therapy with atezolizumab, a Programmed Cell Death Ligand 1 inhibitor. Discussion: Endocrine etiologies for euvolemic hypotonic hyponatremia, including adrenal insufficiency and hypothyroidism, were excluded. The diagnosis of SIADH was confirmed based on electrolyte and osmolality studies. Sodium levels normalized with fluid restriction. Given the onset of hyponatremia 30 days after atezolizumab initiation, we posit that atezolizumab triggered severe hyponatremia due to SIADH. Conclusion: With the expanding utilization of ICIs, including in patients predisposed to malignancies such as MSS, vigilant monitoring for ICI-mediated electrolyte imbalances is crucial. Monitoring for hyponatremia and SIADH in the setting of ICI therapy is recommended.

Case report: Secondary failure to tolvaptan in a patient with SCLC and paraneoplastic SIADH.

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is frequent in lung cancer patients. Here, we report a case with persistent hyponatremia, which suggested malignant SIADH and facilitated an early diagnosis of small cell lung cancer (SCLC). A combined radio-chemotherapy led to a partial remission and resolution of SIADH. An early relapse was indicated by reoccurring severe hyponatremia and increased copeptin levels, which were used as surrogate markers for the antidiuretic hormone (ADH). As palliative immunochemotherapy, together with fluid restriction and solute substitution, were unable to control hyponatremia, treatment with the ADH V2-receptor antagonist tolvaptan was initiated. Over time, the dose of tolvaptan needed to be increased, paralleled by a well-documented exponential increase of copeptin levels. In summary and conclusion, this is a rare case of a secondary failure to tolvaptan with unique documentary evidence of increasing copeptin levels. This observation supports the hypothesis that exceedingly high ADH levels may lead to competitive displacement of tolvaptan from the V2 receptor.

Severe Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) Following the Initiation of Valbenazine for Tardive Dyskinesia: A Case Report.

Hyponatremia, a common electrolyte disorder, usually has a benign clinical course. However, patients with the syndrome of inappropriate antidiuretic hormone secretion (SIADH) can suffer unfavorable outcomes, including mortality. Atypical antipsychotics, which are among the drugs associated with SIADH, also cause tardive dyskinesia, a condition that physicians can now effectively manage with the recently approved agent - valbenazine. We herein report a case of severe hyponatremia due to SIADH in a 58-year-old man who developed hyponatremia-induced generalized seizures six weeks after valbenazine was added to his regimen to mitigate olanzapine-associated tardive dyskinesia. His electrolyte derangement and clinical course improved following prompt recognition and treatment of SIADH. The temporal association between the commencement of valbenazine and the onset of SIADH suggests a possible but previously unreported link between valbenazine and the development of SIADH. Awareness of this uncommon association is relevant to patient safety.

Targeted Six-Week Intensive Physiotherapy for a Case of Tuberculous Meningitis With a Syndrome of Inappropriate Antidiuretic Hormone Secretion.

Tuberculous meningitis (TBM) is a severe form of extrapulmonary tuberculosis (TB) characterized by the invasion of Mycobacterium tuberculosis into the meninges surrounding the brain and spinal cord. It triggers an intense inflammatory response, leading to neurological complications if not promptly and adequately managed. TBM often precipitates muscle weakness, neurological deficits, respiratory challenges, swallowing difficulties, joint contractures, and pain. Physiotherapy intervention is essential in treating these problems by personalized treatment strategies and treatment plans to enhance muscle strength, motor control, coordination, and overall mobility. This case report aims to highlight the significant role of physiotherapy in improving the quality of life (QOL) and functional abilities of patients with TBM. The current case report reviews the case of a 73-year-old male who presented with complaints of generalized weakness and difficulty in swallowing. The patient had a history of fever for the last six months. Magnetic resonance imaging (MRI) and high-resolution computed tomography (HRCT) diagnosed the case as TBM with miliary TB. Six weeks of targeted intensive rehabilitation program was designed according to the patient's impairments initiated from the intensive care unit (ICU) phase. The main goals of physiotherapy were to start early bed mobility, maintain joint integrity, improve postural strength and swallowing, and make the patient independent in transfer and activities of daily living (ADLs). After a six-week intensive physiotherapy (TIP-6) program, the patient exhibited significant improvements in muscle strength and independence in ADLs. This case highlights the critical role of physiotherapy in enhancing the QOL and functional abilities of patients with severe TB-related conditions.

Non-metastatic Nephrogenic Hepatic Dysfunction (Stauffer Syndrome) and Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) in a Patient With Renal Cell Carcinoma Coinciding With Liposarcoma.

Stauffer syndrome is a non-metastatic, nephrogenic, hepatic dysfunction syndrome that is linked to extrahepatic paraneoplastic tumors. It manifests with varying clinical signs that include jaundice, anicteric transaminitis, elevated alkaline phosphatase, thrombocytosis, elevated erythrocyte sedimentation rate, prolonged prothrombin time, and, in some cases, hepatosplenomegaly in the absence of hepatobiliary obstruction. Stauffer syndrome is mostly associated with renal cell carcinoma, but research shows other solid malignancies are implicated with this syndrome. Stauffer syndrome is characterized by elevated liver function tests, specifically those that indicate the presence of cholestasis with or without hepatosplenomegaly. The abnormality is not due to tumor infiltration but rather indirect paraneoplastic effects that are poorly understood. Additionally, emerging literature also supports the association of syndrome of inappropriate antidiuretic hormone secretion (SIADH) secondary to malignancy in the setting of elevated interleukin-6. In this article, we present the case of a 76-year-old patient with SIADH and abnormalities in liver function tests in the context of Stauffer syndrome tied to renal cell carcinoma coinciding with liposarcoma.

Rhinovirus infection presenting with symptomatic hyponatremia-Atypical presentation of a common infection.

Key Clinical Message: Rhinovirus infection has the potential to exhibit unconventional symptoms like symptomatic hyponatremia. Health care professionals should remain vigilant about this potential complication, especially in cases with uncommon presentations. Timely identification and effective management of hyponatremia can mitigate potential complications and enhance patient prognosis. Abstract: The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a prominent contributor to low sodium levels. Various factors can contribute to hyponatremia, affecting the diagnosis and treatment of the condition. Of note, some infections have been identified as potential causes of SIADH. Although rhinovirus infection has been linked to SIADH, it is usually associated with severe respiratory infections. Herein, we present a distinctive case where rhinovirus caused significant hyponatremia symptoms, even in the absence of typical respiratory symptoms or fever.

Vortioxetine-induced syndrome of inappropriate secretion of antidiuretic hormone: A case report.

BACKGROUND: Vortioxetine, known for its efficacy in treating depression through its effects on various neurotransmitters, has not been previously reported to induce syndrome of inappropriate secretion of antidiuretic hormone (SIADH). CASE PRESENTATION: This case report describes a 74-year-old man with major depressive disorder who developed SIADH 1 week after starting treatment with vortioxetine. SIADH is characterized by symptoms such as headache, nausea, disorientation, and seizures, stemming from hyponatremia (123 mEq/L), without dehydration or edema. Vortioxetine was discontinued, and an alternative drug, mianserin, was initiated. The patient was restricted from drinking water due to hyponatremia. The serum Na concentration improved over time to within the normal range by the second week after admission. CONCLUSION: This is the first case report of vortioxetine-induced SIADH.

Atypical Clostridium difficile Infection in a Pregnant Patient: A Case Study on Non-Diarrheal Presentation and Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Complication.

Clostridium difficile (C. difficile) is a Gram-positive, spore-producing bacterium that often leads to pseudomembranous colitis, typically manifesting as watery diarrhea. The risk factors for C. difficile infection (CDI) include exposure to broad-spectrum antibiotics, immunocompromised states, advanced age, usage of proton pump inhibitors (PPI), and comorbid conditions such as chronic kidney disease (CKD). This report details a case involving a 23-year-old pregnant woman who presented with symptoms of abdominal pain and constipation. She was diagnosed with a urinary tract infection (UTI) and treated with ceftriaxone. During her hospitalization, she was administered opioid pain relievers and underwent an intensive bowel regimen. Despite these measures, her constipation and abdominal discomfort persisted, and magnetic resonance imaging (MRI) of the abdomen revealed significant dilatation of the large bowel. The patient, discovered to have hyponatremia, underwent further evaluation. This revealed elevated urine osmolality and decreased blood plasma osmolality, indicative of a syndrome of inappropriate antidiuretic hormone secretion (SIADH). The patient received treatment with hypertonic saline. Later in her hospital stay, she tested positive for CDI through stool analysis and was treated with oral vancomycin. This case underscores the importance of considering CDI as a differential diagnosis in cases of ileus, abdominal pain, and constipation, especially in patients with notable risk factors for CDI. It highlights that the presence of diarrhea or watery bowel movements is not a necessary symptom for CDI testing.

Symptomatic syndrome of inappropriate anti-diuretic hormone as a rare early presentation of primary thymic carcinoma: a case report.

Syndrome of inappropriate anti-diuretic hormone (SIADH) can be presented as a paraneoplastic syndrome in primary malignancies involving the lung and brain. However, the development of SIADH in primary thymic carcinoma is poorly documented. We report a case of an elderly, with an initial presentation of symptomatic persistent hyponatremia as a paraneoplastic syndrome of SIADH with an incidental finding of anterior mediastinal mass confirmed on imaging. Further investigations are consistent with the diagnosis of poorly differentiated locally advanced thymic carcinoma with lung infiltration (T3N1Mx). The patient underwent an En-bloc total thymectomy and subsequently completed adjuvant chemotherapy and further follow-up showed a complete resolution of hyponatraemic SIADH. In conclusion, SIADH may be presented as a paraneoplastic syndrome in primary thymic carcinoma and early detection of thymic malignancy is paramount to ensure early diagnosis and prognostication.