Acute Pulmonary Edema Due to Excessive Water Intake in Pyschiatric Patient

Abstract

Water taking diseases are frequent in psychiatric patient. Approximately 3-6% of psychiatric patient water intoxication is seen. Although water intoxication is defined well, the metabolism of this is not understood. In psychiatric patients, headache, ataxia, confusion, urinary incontinence and electrolyte imbalance is reported. If not treated, confusion, acute delirium, coma and death is seen. Cerebellar edema, pulmonary edema, electrolyte imbalance and urinary incontinence due to water intoxication are reported (1). In this case diagnosis and treatment of psychiatric patient that take excessive water is discussed. The patient a 50-year-old woman schizophrenic had been drinking large amounts of water for several hours before and rapid onset respiratory distress and confusion. In history she started to have fear and stress before 6 years. These symptoms began to increase progressively and last year agitation also seen. Respiratory distress began due to water intake above 10 liters. She was confused, dispneic on admission. TA: 160/90 mmHg, pulse rate 90, respiration 26/min. Cardiovascular and neurologic system was normal and rales were heard in both lungs. In laboratory: Glucose: 100, BUN: 7, Creatinine: 0.8, Na: 129, CI: 87, K: 4.2, albumin:4.1, WBC:8000, Hb:12.2, platelet:367000. Blood gas analysis: Ph 7.32, Pco2 55 mmHg, po2 134 mmHg, Bicarbonate; 36.1 and O2Sat: 99.4. His chest X-ray showed bilateral patch consolidation of the lung fields, cardiomegaly was not seen. Echocardiography; ejection fraction 60 % and no failure. These were suggesting non –cardiogenic pulmonary edema due to excessive water intake and treatment started in our emergency department. 5-ml/min oxygen was given, 3 mg intravenous morphine was done and 5-mcg/kg/min nitroglycerin infusion started, 400 mg intravenous furosemide in 12 hours was given. Patient urinate 3500 cc totally in 12 hours.The clinical outcome was favourable after the treatment. She became alert and ralles decreased. After 24 hours all vital symptoms became stable and patient discharged. Water intoxication is reported in marathon runners, psychiatric patients and soldiers. Psychos, psycotrop drugs, diuretics, nicotine and alcohol can cause excessive water intake. Pyschogenic water intoxication is discussed in the light of 150 observations published in the literature since 1935. 87% of all patients were schizophrenic, and 13% had other psychoses (2). In a long-term psychiatric setting, self-induced water intoxication may be a life-threatening situation. At first glance, the symptoms or behaviors of self-induced water intoxication are similar to schizophrenia, i.e., inappropriate behavior, delusions, hallucinations, confusion, and disorientation.. Affected individuals develop polydipsia, which is accompanied by overhydration and dilutional hyponatremia. If untreated, the symptoms may progress from mild confusion to acute delirium, seizures, coma, or death (3). In our case excessive water intake was due to schizophrenic condition. Pulmonary edema is a rare complication of water intoxication in a psychiatric patient.The physiology of pulmonary edema caused by excessive water intake can’t be explained. Furosemide and water restriction in these patients give good response (2). In our case, echo was normal, bilateral rales were heard and bilateral opacity was seen, these suggested is non –cardiogenic pulmonary edema.