Cerebral salt wasting in tuberculous meningitis: treatment with fludrocortisone

Abstract

Three cases of cerebral salt wasting complicating tuberculous meningitis are described. Diagnosis was based on hyponatraemia associated with high urinary sodium excretion and inappropriately high urine output in the presence of dehydration. Treatment with fludrocortisone resulted in sodium and fluid homeostasis.

British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children

“…There is anecdotal evidence that fludrocortisone replacement therapy and demeclocycline may be useful treatments. 182,183 Clinical deterioration secondary to the expansion of intra-cerebral tuberculoma following the start of antituberculosis drugs e sometimes called paradoxical reactions e are a well-described complication of all forms of cerebral tuberculosis. 126,184 They may also be seen in HIV infected patients in the context of IRD.…”

Hyponatraemia in Community Acquired Bacterial and Tubercular Meningitis in Hospital Admitted Adult Patients

“…It may result from the syndrome of inappropriate antidiuretic hormone secretion, the cerebral salt wasting (CSW) syndrome, or aggressive fluid resuscitation. 3,4,15 Hyponatraemia associating with tubercular meningitis has three main differential diagnosis: adrenal insufficiency, inappropriate secretion of antidiuretic hormone and cerebral salt wasting. Patients with hyponatraemia due to tuberculosis have shown variable responses to water loading in few small studies, ranging from persistent antidiuresis to a normal diuresis.…”

“…Although tuberculosis is considered a cause of the syndrome of inappropriate antidiuretic hormone secretion (SIADH), circulating vasopressin has been documented in only a few cases. 15,16,17,18 SIADH is a volume-expanded state because of antidiuretic hormone-mediated renal water retention. CSW is characterized by a contracted effective arterial blood volume resulting from renal salt wasting.…”

Hyponatremia during a Severe Pneumococcal Meningitis with Renal Salt Wasting: A Cerebral Salt Wasting Syndrome?

“…In the study of Sherlock, hyponatremia after subarachnoid haemorrhage was induced by a CSWS in 6.5% of cases and by SIADH in 69% of cases [10]. A few observations of CSWS after infectious meningitis have been published and they were mainly tuberculous or viral origin [11][12][13]. Yet, at the best of our knowledge, only two cases of bacterial meningitis with a CSWS has been reported [14,15].…”