Severe Hyponatremia: An Unconventional Presentation

Introduction: Hyponatremia management is a time sensitive correction that requires close monitoring. Irreplaceable neurologic damage could be done if not effectively managed. Hyponatremia has many different etiologies, and it is imperative to identify the cause to treat it. We present a case of a patient who presented to the emergency department with severe hyponatremia and able to recover without any neurologic disturbances. Case Description: A 61 y/o male with history of alcohol abuse presented with melena. Patient was admitted for GI bleed with covid infection, beer potomania and severe hyponatremia. The patient was found to have Na of 104 on presentation. Patient was oriented only to person due to alcohol intoxication. Pt did not present with neurologic symptoms which was unusual for these Na levels. Initially, the patient was thought to be hypervolemic given 3+ pitting edema in his lower extremities. The patient was given Lasix which brought his Na levels further down. Urine studies supported Hypovolemic Hyponatremia as the urine osmolality was not low initially (351) and then decreased further (99) after administration of hypertonic saline indicating that volume reduced ADH release. Pt was given 1L of NS bolus which failed to improve his Na levels. Pt was given 70cc 3% hypertonic saline two separate times with a D5W maintenance fluid which improved the Na over the next week. It was found by the treating Nephrologist that patient never experienced severe neurological disturbances such as nausea, vomiting, seizure activity, or blurred vision because although patients Na was severely depleted, his osmolarity was maintained by his heavy alcohol consumption. The patient’s initial serum osmolality was higher than expected (257). The cause of hypovolemia was a lower GI bleed. Discussion: In this complex case, the Na correction must be maintained at a rate of 8mmol in 24 hours to avoid complications like osmotic demyelination syndrome. Urine and serum osmolarity are vital indicators of volume state. On presentation, the patient’s physical exam and history of alcohol abuse suggested a hypervolemic state, but the elevated urine osmolarity along with the acute drop in Na from 126 to 103 in setting of GI bleed indicated volume depletion. Our recommendation is that careful consideration should be taken into account in patients with multiple causes of hyponatremia regardless of neurologic symptoms of the patient on presentation.