Severe Hyponatremia Research Articles

#2136 Hyponatremia as a presenting symptom of secondary adrenal insufficiency induced by immune checkpoint inhibitors

Abstract Background and Aims Endocrinopathies are common complication of treatment with immune checkpoint inhibitors (ICI). Adrenal axis may be affected through either direct adrenal toxicity leading to primary hypoadrenalism or due to pituitary dysfunction resulting in secondary adrenal insufficiency. Patients with secondary insufficiency may have variable presentation and, in some cases, initially present with hyponatremia only. This abstract reports a cohort of patients who developed hyponatremia as initial symptom of secondary adrenal insufficiency. Method After obtaining approval from the institutional review board, medical records of the nephrology service at a large cancer center were reviewed. Patient is well included in the study if they developed moderate (plasma Na <130 mEq/L) and severe (plasma Na <120 mEq/L) hyponatremia during treatment with ICI and met a biochemical criterion for adrenal insufficiency (morning serum cortisol level <3.0 mcg/dL). Results Nine patients who met the criteria were identified (Table 1). There were 5 males and four females. Mean age was 67.6 year. Median number of ICI therapy cycles was 10 but treatment number ranged from 2-84. For patient's would treat with combination of CTLA-4 and PD 1 inhibitors and 5 patients were treated with PD 1 inhibitor alone. Four patients had severe hyponatremia and five presented with moderate hyponatremia. All patients were normotensive on presentation. All patients had low morning cortisol level but only two patients had low ACTH level. All patients had low normal ACTH levels. One patient underwent ACTH stimulation test which was negative. Additionally for patient has had normal thyroid function. Eight patients underwent an MRI and 4 of them had evidence of possible pituitary inflammation. All patients were started on physiologic corticosteroid replacement with prompt resolution of hyponatremia. All patients required ongoing corticosteroid replacement therapy. Conclusion Secondary adrenal insufficiency in the setting of ICI toxicity can present with initial diagnosis of hyponatremia. Patients in this cohort were normotensive on presentation despite adrenal insufficiency and therefore required high index of suspicion for the diagnosis. Most patients in the study also had low normal ACTH levels however responded clinically to treatment with corticosteroid replacement indicating that adrenal sufficiency was the cause of hyponatremia. ACTH test may be falsely negative in these patients if adrenal insufficiency developed less than six weeks prior and adrenal atrophy did not occur yet.

#2590 Electrolyte abnormalities in HIV patients with CKD

Abstract Background and Aims Individuals with HIV infection and CKD are prone to various water & electrolyte disorders with previous studies showing prevalence of 70%. Many of these disturbances remain clinically silent until they reach an advanced stage, emphasizing the need for a high level of clinical suspicion and awareness, as they contribute to both morbidity and mortality. The prevalence of CKD in HIV patients has been increasing, yet data on electrolyte disturbances is sparse. The study we conducted aims to determine electrolyte imbalances in this population. Method Prospective observational single center study for a period of 2 years including HIV seropositive patients >18 years of age who were screened for CKD as per KDIGO definition (eGFR < 60 ml/min/1.73 m2 or significant proteinuria > 300 mg/day for more than 3 months). Demographic features, laboratory investigations for serum electrolytes including Sodium, Potassium, Phosphorous & Calcium levels were done at baseline with follow up at 3, 6 & 12 months. Results Out of 695 HIV patients screened, 56 who had CKD were included in our study. The average age was 53.8 ± 11.3 years, including 41 males (73.2%). Median creatinine at baseline was 1 (1.3) mg/dL, & median eGFR was 59 (24.82) ml/min/1.73 m2 (Table 1). Commonest abnormality at baseline was hyponatremia (53.6%), and only 8.9% had severe hyponatremia (<125 mmol/L). Other abnormalities prevalent were hypocalcemia (35.7%) and hypophosphatemia (46.4%). Follow up details are presented in Table 2. Conclusion CKD was prevalent in 56 (8%) of our patients. Dyselectrolytemias were seen in 91% of study population. Hyponatremia (89.2%) was the commonest electrolyte imbalance followed by Hypophosphatemia (62.5%) & Hypocalcemia (57.1%). Notably, our study identified a significantly higher incidence of hypocalcemia, and hypophosphatemia compared to other studies.

Episodic Hyponatremia in Acute Intermittent Porphyria: A Case Report

Background: Acute intermittent porphyria (AIP) is an uncommon, ubiquitously distributed autosomal dominant disorder with low penetrance characterized by decreased enzyme activity of hydroxymethylbilane synthase (HMBS) an enzyme of heme synthesis pathway. It is often an elusive diagnosis due to rarity and non-specific signs and symptoms. Case report: A 28 years old female from Nawalparasi (district in central Nepal) presented with history of recurrent episodes of abdominal pain and vomiting. Her current episode began two weeks before presentation to our center. Abdominal pain was diffuse, colicky in nature without exacerbating or relieving factor. There was no postural or diurnal variation. On examination, there was no tenderness and abdominal examination findings were unremarkable. Her biochemical investigations were unremarkable except for severe hyponatremia (S. Na of 100mmol/L) which was SIADH/SIADH like presentation (Table 1 and Table 2). Severe episodic hyponatremia, port-wine color of urine, gastrointestinal symptoms and previous hospital stay two years back with similar episode of hyponatremia and abdominal pain were valuable clues for suspicion of acute porphyria. On further evaluation, patient was found to have presence of porphyrogenic precursors in urine and diagnosis of acute intermittent porphyria was confirmed. After diagnosis, she was managed conservatively with carbohydrate loading with intravenous dextrose, opioids and pregabalin as analgesics. Her symptoms gradually improved, hyponatremia subsided and was discharged in normal condition. Conclusion: Acute intermittent porphyria has signs and symptoms common to several clinical, neurological, psychiatric and gastroenterological pathologies, which complicate diagnosis. In young patients with hyponatremia (with SIADH –like picture), AIP should be considered in differential diagnosis.

Case report on confusion: an unusual presentation of lung cancer

Introduction: Cancer of the lung can be insidious and manifest clinicallyin relatively unexpected forms. The incidence of hyponatremia in lungcancer is 18.9% [1].Case: An 87-year-old woman presented with confusion. She smoked10–15 cigarettes a day for 70 years. Blood tests done; Na: 118. I made animpression of severe symptomatic hyponatremia secondary to suspectedSiADH from possible small cell lung cancer.I requested CXR, urine Na, paired osmolality, fluid restricted and discussedwith the medical registrar who suggested a transfer to Generalhospital. CXR showed a round mass in the right upper lobe.At the GH, Na was replaced slowly and the patient was planned forCT scans. After 2 days, she developed gradual SOB (? PE). CT scans weredelayed because she could not lie flat and got SOB. ENT and anaesthesiareviewed her and suggested supported airway CT under GADay 5 – Distended neck veins? SVCO. Anaesthetists were no longercomfortable with GA. Unfortunately, steroids did not make her morecomfortable. DNAR in place, family informed of poor prognosis andrequested fast track discharge with palliative support. Died at home after18 days.Conclusion: While it is quite unusual for a respiratory condition to presentwith confusion, quick recognition, open mindedness, and inter disciplinarycooperation are essential in day-to-day practice.

Prospective study of post-operative hyponatremia in patients undergoing lower-limb orthopedic surgery

Prospective study of post-operative hyponatremia in patients undergoing lower-limb orthopedic surgery

6287075 United Kingdom Obstetric Surveillance System (UKOSS) study of severe peripartum hyponatraemia: comparing cases with and without documented symptoms

6287075 United Kingdom Obstetric Surveillance System (UKOSS) study of severe peripartum hyponatraemia: comparing cases with and without documented symptoms

A case of hyponatraemia cured by delivery

Hyponatraemia is the most common electrolyte abnormality in pregnancy. In severe cases, it can result in significant maternal and fetal morbidity and mortality. The prevalence of hyponatraemia in pregnancy has been estimated to be 0.27%, with the major causes being hyperemesis gravidarum in the first half and preeclampsia in the latter half of pregnancy. Pregnancy-specific causes of the syndrome of inappropriate antidiuretic hormone release include preeclampsia, prolonged labour, caesarean section, postpartum haemorrhage, cortisol deficiency and oxytocin. Excess water intake can also lead to hyponatraemia during labour, a period of excess antidiuretic hormone secretion. A case of idiopathic severe hyponatraemia with biochemistry consistent with inappropriate antidiuretic hormone secretion progressing during the third trimester with rapid spontaneous resolution post-partum is presented.

Albumin: a comprehensive review and practical guideline for clinical use.

Nowadays, it is largely accepted that albumin should not be used in hypoalbuminemia or for nutritional purpose. The most discussed indication of albumin at present is the resuscitation in shock states, especially distributive shocks such as septic shock. The main evidence-based indication is also liver disease. In this review, we provided updated evidence-based instruction for definite and potential indications of albumin administration in clinical practice, with appropriate dosing and duration. Data collection was carried out until November 2023 by search of electronic databases including PubMed, Google Scholar, Scopus, and Web of Science. GRADE system has been used to determine the quality of evidence and strength of recommendations for each albumin indication. A total of 165 relevant studies were included in this review. Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin. Moreover, albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use. Also, in modest volume paracentesis, severe hyponatremia in cirrhosis has a low to moderate quality of evidence and a weak recommendation. Albumin administration is most indicated in management of cirrhosis complications. Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin. Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin.

Safety and efficacy of proactive versus reactive administration of desmopressin in severe symptomatic hyponatremia: a randomized controlled trial

This randomized controlled trial aimed to evaluate the safety and efficacy of proactive versus reactive desmopressin (DDAVP) strategies in treating severe symptomatic hyponatremia. Conducted from June 20, 2022, to February 20, 2023, it involved 49 patients with serum sodium levels below 125 mmol/L. Patients were assigned to either the proactive group, receiving DDAVP immediately upon diagnosis, or the reactive group, receiving DDAVP only if the serum sodium level tended to be overcorrected. The primary outcome was the incidence of overcorrection. The study revealed no significant difference in the overcorrection incidence between the proactive (16.7%) and reactive (28%) groups (p = 0.54). The change in serum sodium levels at 1, 6, 12, and 24 h were not different, however, at 48 h, the proactive group exhibited a higher but still safe change in serum sodium levels compared to the reactive group (10.3 ± 3.6 mmol/L vs. 7.7 ± 3.6 mmol/L, p = 0.013). Other parameters including time to symptom improvement, total intravenous fluid administered, DDAVP dose, urine volume, hospital stay duration, osmotic demyelination syndrome incidence, and 28-day mortality did not significantly differ between the groups. In conclusion, our findings suggest that there was no significant disparity in overcorrection rates between proactive and reactive DDAVP strategies for treating severe symptomatic hyponatremia. However, further large-scale studies are warranted to validate these results.

A Case of Intra- and Extra-Pontic Myelinolysis Complicating the Rapid Correction of Severe Hyponatremia

A Case of Intra- and Extra-Pontic Myelinolysis Complicating the Rapid Correction of Severe Hyponatremia

Study of Clinicoetiological profile of hyponatremia patients admitted in Medical wards

Hyponatraemia is the most common electrolyte disorder in hospitalized patients. Its epidemiology depends on the serum sodium used to define hyponatraemia, which varies from study to study. It can be an early or even first sign of important underlying disease. It can be complicated by two types of neurological disorders cerebral oedema and osmotic demyelination syndrome. It is associated with increased morbidity and mortality rates in hospitalized patients, although it remains unclear whether these associations are mainly due to the underlying disease, direct effects of hyponatraemia, or a combination of both. Aims and Objectives - to study clinical profile of hyponatremia in hospitalized subjects. To study the aetiology of hyponatremia in hospitalized subjects. To assess morbidity and mortality due to hyponatremia. Materials and Methods - 100 patients with hyponatremia were studied. Most common symptoms were Lethargy and tremors, followed by headache, nausea, altered sensorium, convulsion and coma, in order. Hypervolemic hyponatremia is most common followed by euvolemic hyponatremia and hypovolemic hyponatremia. Euvolemic subjects had propensity to develop more severe and symptomatic hyponatremia. Dilutional hyponatremia is the most prevalent underlying pathophysiology of hyponatremia followed by diuretic use, SIADH, GI loss, Hypothyroidism, extra renal/GI loss and Cerebral salt wasting in order. Congestive cardiac failure was the most common cause of hypervolemic hyponatremia, followed by cirrhosis of liver and renal failure. Acute gastroenteritis was most common cause of hypovolemic hyponatremia. SIADH was the most common cause of euvolemic hyponatremia, followed by thiazide diuretics and hypothyroidism, in order.

Association Between Early Hyponatremia and Clinical Outcomes in Critically Ill Patients: A Retrospective Cohort Study.

Hyponatremia, frequently encountered in intensive care (ICU) settings, plays a critical role in shaping patient outcomes. Despite its prevalence, contemporary research into its newly classified severity categories and their implications on mortality, renal function, and length of stay remains limited. This study aims to fill this gap by examining the impact of hyponatremia severity on these critical outcomes. A retrospective analysis of ICU patients aged >18 years who were admitted between March 2019 and December 2022 was conducted at Hamamatsu University Hospital, Shizuoka, Japan. Patients who were readmitted or had incomplete data were excluded. Hyponatremia was categorized as mild (130-135 mmol/L), moderate (125-129 mmol/L), or severe (<125 mmol/L), following the criteria set by the European Society of Intensive Care Medicine. This classification utilized thelowest sodium concentration within 24 hours of ICU admission. The outcomes were in-hospital mortality, ICU mortality, newly implemented renal replacement therapy (RRT), and length of hospital and ICU stay. Outcomes were analyzed using multivariable logistic and linear regression models, adjusting for relevant covariates including age, sex, Acute Physiology and Chronic Health Evaluation (APACHE) III scores, and the use of mechanical ventilation. Of the 3,538 patients analyzed, 1,072 (30.3%) experienced hyponatremia: 894 (25.3%) mild, 144 (4.1%) moderate, and 34 (1.0%) severe. Multivariable analysis revealed no significant association between hyponatremia severity and in-hospital mortality rates across normonatremia (3.8%), mild (5.2%), moderate (11.8%), and severe (23.5%) groups, nor with ICU mortality. However, compared to normonatremia, moderate and severe hyponatremia were associated with increased RRT initiation (odds ratios = 3.83 and 6.36, respectively) and prolonged hospital stay (mean difference = 7.06 and 9.66 days, respectively), and ICU stays (mean difference, 1.02 and 2.70 days, respectively). Mild hyponatremia was not significantly associated with RRT or length of stay. Moderate-to-severe hyponatremia did not influence mortality but was associated with increased RRT initiation and prolonged hospital and ICU stay. By contrast, mild hyponatremia was not associated with any clinical outcome.Further research is required to determine if correcting hyponatremia directly improves ICU patient outcomes, given the observational nature of the study.

Assessment of 2% vs 3% Peripheral Hypertonic Sodium Chloride Administration and Its Impact on Safe and Timely Treatment

Abstract Objectives Evaluate if peripheral administration of 3% hypertonic saline (HTS) provides timely treatment with a rate of infusion-related adverse events at or below what is reported in the literature. Methods This was a single-center, retrospective study conducted in a large academic medical center in New York City. Eligible patients were inpatients receiving either 2% or 3% HTS for severe hyponatremia, elevated intracranial pressure, or cerebral edema. The primary outcome was incidence of infusion-related adverse events. Secondary endpoints included achievement of appropriate sodium correction, incidence of over-correction, length of time from ordering to medication administration, and incidence of osmotic demyelination syndrome (ODS). Main Results A total of 199 patients were included in analysis (85 in the 3% HTS group and 114 in the 2% HTS group). No difference was found between groups for rate of infusion related adverse events or incidence of sodium overcorrection groups (0 vs 1 [0.9%]; p = 0.39). Significantly more patients in the 3% HTS group received intermittent administration (p &lt; 0.001), whereas more patients in the 2% HTS group received a continuous infusion (p &lt; 0.001). There were no reports of ODS in either group. No difference in length of time to administration was found between groups. Conclusion Our study, one of the largest to evaluate peripheral administration of 3% HTS, found that it is not associated with an increase in infusion related adverse events or sodium overcorrection versus 2% HTS. Peripheral administration should be recommended to provide timely treatment for patients requiring HTS.

CHARACTERIZATION OF HYPONATREMIA IN PATIENTS WITH ISCHEMIC STROKE

Objective: To characterize the hyponatremia based on severity in patients with ischemic stroke in the first twenty-four hours. Materials &amp; Methods: This cross-sectional descriptive study was done in the Medicine Department of Khyber Teaching Hospital, Peshawar, after obtaining approval from IREB. For a proportion of 25% population with mild hyponatremia, a sample of 289 was calculated using Open EPI Software keeping 95% as the confidence interval and 5% as the margin of error. We included all adult patients from age 16 years of either gender, having newly diagnosed ischemic stroke and yet had not started any treatment. Patients having other chronic diseases and endocrine disorders which can cause electrolyte disturbances, and act as confounders, were excluded. A Non-probability consecutive sampling technique was used. All data including name, age, gender, address, and the presence or absence of and the severity of hyponatremia was recorded. Data was analyzed using SPSS-22. Results: The mean age of the patients was 53 years with SD ± 8.53 (range 40-69 years). Male patients were 56.1% while 43.9% were females. Out of 289 patients, 101 (35%) patients had hyponatremia. Amongst these patients having hyponatremia, mild hyponatremia was present in 63 (62%), moderate hyponatremia in 27 (27%) and profound or severe hyponatremia was present in 11 (11%). Conclusion: Hyponatremia was present in about 1/3rd of patients who presented with ischemic stroke in our hospital. Among these, severe hyponatremia was seen in 11% of the patients. Keywords: Hyponatremia, ischemic stroke.

The feasibility of emergency department observation units in the management of mild to moderate hyponatremia

ObjectiveTo describe the feasibility of managing hyponatremia patients under outpatient observation status in an academic medical center, and compare outcomes based on the use of an emergency department observation unit (EDOU). MethodsThis is a retrospective cohort study of emergency department hyponatremic patients managed in four hospitals within a large urban academic medical center over 27 months. All patients had an admit-to-observation order, ICD-10 codes for hyponatremia, and mild (130–135 mmol/L) to moderate (121–129 mmol/L) hyponatremia. Observation settings were divided into two groups: EDOU and Non-Observation Unit (NOU) inpatient beds. Severe hyponatremia (≤120 mmol/L) was excluded. Primary clinical outcomes were inpatient admit rate, length of stay (LOS), total direct cost, the rate of adverse events and 30-day recidivism. Results188 patients were managed as an observation patient, with 64 managed in an EDOU setting (age 74.0 yr, 70.3% female) and 124 managed in a NOU setting (age 71.5 yr, 64.5% female). Patient subgroups were similar in terms of presenting complaints, comorbidities, and medication histories. Initial and final sodium levels were similar between settings: EDOU (125.1 to 132.6 mmol/L) vs NOU (123.5 to 132.0 mmol/L). However, outcomes differed by setting for observation to inpatient admit rate (EDOU 28.1% vs NOU 37.9%, adjusted effect 0.70), overall length of stay (EDOU 19.2 h vs NOU 31.9 h; adjusted effect −10.5 h and total direct cost ($1230 vs $1531; adjusted effect -$167). EDOU sodium correction rates were faster (EDOU 0.44 mmol/L/h vs 0.24 mmol/L/h; adjusted effect 0.15 mmol/L/h) and 30-day recidivism rate was similar (EDOU 13% vs NOU 15%). There were no index visit deaths or intensive care unit admissions. ConclusionManagement of selected hyponatremia patients under observation status is feasible, with the EDOU setting demonstrating lower admit rates, shorter length of stay, and lower total direct costs with similar clinical outcomes.

Serum sodium level fluctuations following the resection of childhood-onset craniopharyngioma.

Craniopharyngiomas are low-grade malignancies (WHO I) in the sellar region. Most cases of childhood-onset craniopharyngioma are adamantinomatous craniopharyngioma, and neurosurgery is the treatment of choice. Affected patients have postoperative complications, including water and electrolyte disturbances, because these malignancies develop near the hypothalamus and pituitary gland. Determining postoperative serum sodium fluctuation patterns in these patients can reduce postoperative mortality and improve prognosis. To measure changes in serum sodium levels in pediatric patients who underwent craniopharyngioma surgery and identify influencing factors. This retrospective study measured the serum sodium levels of 202 patients aged 0-18 years who underwent craniopharyngioma resection in Beijing Tiantan Hospital and Beijing Children's Hospital and identified predictors of severe hyponatremia and hypernatremia. The mean age of the cohort was 8.35±4.35 years. The prevalence of hypernatremia, hyponatremia, and their severe forms (serum Na+ >150mmol/L and serum Na+ <130mmol/L) within 14 days after surgery was 66.3%, 72.8%, 37.1%, and 40.6%, respectively. The mean postoperative serum sodium level showed a triphasic pattern, characterized by two peaks separated by a nadir. Sodium levels peaked on days 2 (143.6±7.6mmol/L) and 14 (143.2±6.7mmol/L) and reached their lowest on day 6 (135.5±7.5mmol/L). A total of 31 (15.3%) patients met the diagnostic threshold for hyponatremia and hypernatremia of the triphase response, whereas 116 (57.4%) patients presented this pattern, regardless of met the diagnostic criteria or not. The prevalence of severe hyponatremia varied depending on preoperative endocrine hormone deficiency, tumor status (primary or recurrent), and surgical approach. Serum sodium levels after craniopharyngioma resection in children showed a triphasic pattern in most cases. The risk of postoperative hyponatremia varied depending on preoperative endocrine hormone deficiency, tumor status (primary or recurrent), and surgical approach.

Etiology, Clinical Approach, and Therapeutic Consequences of Hyponatremia

A perturbation in the water balance rather than any change in salt content is the main cause of hyponatremia, the most frequent electrolyte abnormality, defined as a serum sodium concentration &lt;135 mEq/L. Hyponatremia may be divided between mild (Na &gt; 120 mEq/L) or severe (Na &lt; 120 mEq/L) hyponatremia, and is most frequently observed in elderly ICU hospitalized patients. Based on tonicity, hyponatremia may be hypotonic (a decreased concentration of the solute), isotonic, and hypertonic (falsely low sodium). According to the volume of extracellular fluid (ECF), hyponatremia is further divided among hypovolemic, euvolemic, or hypervolemic hyponatremia. Finally, hyponatremia may develop rapidly as acute (&lt;48 h), usually with severe symptoms, or slowly as chronic hyponatremia, usually being asymptomatic or with mild symptoms. Acute severe hyponatremia presents with severe CNS problems, increased hospitalization rates, and mortality. The treatment with 3% sodium chloride and a 100 mL IV bolus based on severity and persistence of symptoms needs careful monitoring. A non-severe hyponatremia may be treated with oral urea. In asymptomatic mild hyponatremia, an adequate solute intake with an initial fluid restriction of 500 mL/d adjusted according to the serum sodium levels is preferred. Vaptans could be considered in patients with high ADH activity regardless of whether they are euvolemic or hypervolemic. In general, the treatment of hyponatremia should be based on the underlying cause, the duration and degree of hyponatremia, the observed symptoms, and volume status of patient.

70 - Severe hyponatremia in an elderly patient due to syndrome of inappropriate antidiuretic hormone secretion: can chronic opioid pump be the culprit?

70 - Severe hyponatremia in an elderly patient due to syndrome of inappropriate antidiuretic hormone secretion: can chronic opioid pump be the culprit?

Mortality predictors of patients diagnosed with severe hyponatremia in the emergency department.

To determine the factors affecting mortality as a result of the analysis of the demographic and clinical characteristics and laboratory parameters of patients whose serum Na value was determined to be 125mEq/L or below at the time of admission to the emergency department (ED). Patients over 18years of age who admitted to the ED of a tertiary hospital between September 2021 and September 2022 and whose serum sodium level was determined to be 125mEq/L and below were included in the study. Demographic and clinical characteristics, admission complaints, medications used, Charles comorbidity index (CCI), laboratory parameters, and outcomes of the patients included in the study were recorded in the data form. Three hundred ninety-nine patients were included in the study. When the 30-day mortality of the patients is examined, the mortality rate was found to be 21.6%. In the analyses performed for the predictive power of laboratory parameters for mortality, it was determined that the highest predictive power among the predictive values determined by the area under the curve (AUC) was the albumin level (AUC 0.801, 95% CI 0.753-0.849, p < 0.001). In the binary logistic regression analysis, urea and albumin were independent predictors of 30-day mortality. According to study data, albumin and urea levels are independent predictors of 30-day mortality in patients diagnosed with severe hyponatremia in the emergency department.

Case report: Fatal Borna virus encephalitis manifesting with basal brain and brainstem symptoms

BackgroundSince the first report of fatal Borna virus-1 (BoDV-1) encephalitis in 2018, cases gradually increased. There is a lack of diagnostic algorithm, and there is no effective treatment so far.Case presentationWe report an acute BoDV-1 encephalitis in a 77-year-old female with flu-like onset, rapid progression to word-finding difficulties, personality changes, global disorientation, diffuse cognitive slowness, and gait ataxia and further deterioration with fever, meningism, severe hyponatremia, epileptic seizures, cognitive decline, and focal cortical and cerebellar symptoms/signs. The extensive diagnostic workup (cerebrovascular fluid, serum, and MRI) for (meningo-)encephalitis was negative for known causes. Our empirical common antiviral, antimicrobial, and immunosuppressive treatment efforts failed. The patient fell into coma 5 days after admission, lost all brainstem reflexes on day 18, remained fully dependent on invasive mechanical ventilation thereafter and died on day 42. Brain and spinal cord autopsy confirmed an extensive, diffuse, and severe non-purulent, lymphocytic sclerosing panencephalomyelitis due to BoDV-1, affecting neocortical, subcortical, cerebellar, neurohypophysis, and spinal cord areas. Along with our case, we critically reviewed all reported BoDV-1 encephalitis cases.ConclusionThe diagnosis of acute BoDV-1 encephalitis is challenging and delayed, while it progresses to fatal. In this study, we list all tried and failed treatments so far for future reference and propose a diagnostic algorithm for prompt suspicion and diagnosis.