Excessive water ingestion and repeated seizures: the domino effect

Abstract

Despite variations in sodium and water concentrations, our body relies on several mechanisms to maintain the plasmatic osmolality within the normal range of 275-290 mOsm/L 1 . Hyponatremia is defined as a reduction in plasma sodium concentration below 136 mmol/L 2 . It occurs in 12% of the hospitalized patients and in 30% of the patients in the intensive care unit (ICU) 3 . Hyponatremia installed progressively usually causes no symptoms. If installed acutely, severe symptoms such as vomiting, progressive somnolence and confusion, coma and seizures often occur 2,4 . Hyponatremia related to the ingestion of free water is uncommon in healthy subjects that are neither athlete nor have psychiatric disorders [2][3][4][5] . Thus, after approval of the Hospital Ethics Committee and signed informed consent obtained from a patient representative.We report a case of hyponatremia associated with fast ingestion of large amounts of potable water causing severe neurological impairment. CaSeA 34-year-old male, previously healthy, was admitted in ICU of the Hospital da Cidade (Salvador BA, Brazil). The patient was transferred from the emergency department with a history of ingestion of 40 glasses of potable water, equivalent to approximately 8 liters, during a period of a few hours. The patient was playing domino and the players bet that one who loses a game should drink a full glass of water. The unlucky patient lost one game after the other and started to become sleepy, culminating with a generalized tonic-clonic seizure. Taken to the hospital, he developed new episode of seizure, lingered, requiring intubation and mechanical ventilation. The admission tests revealed plasma sodium of 123 mmol/L and mild cerebral edema at CT scan. The diagnosis of hypovolemic hyposmolar hyponatremia with low urinary osmolality ("the marathon runner's hyponatremia") was made based on plasmatic osmolality (262 mmol/L), urinary osmolality, urinary sodium (undetectable) and the volemic status was estimated by pre-load pressures. Since the installation of hyponatremia was rapid with severe symptoms, 3% saline solution was started with infusion rate of 0.5 mL/kg/h. Plasma sodium was measured hourly, aiming for an elevation of sodium level by 0.5 mEq/L/hour. After discontinuing sedation he gradually recovered, being disconnected from mechanical ventilation in the third day of hospitalization. He was discharged from ICU after five days without any neurological deficit. diSCuSSionThe initial approach to hyponatremia requires determination of plasmatic osmolality , in order to classify the hyponatremia in hypertonic, isotonic or hypotonic. The determination of osmolar gap -difference between measured and calculated osmolality, normal <10 mOsm/kg -helps with the interpretation and suggests which solutions should be utilized in the treatment 6 . Hypertonic hyponatremia is typically observed during hyperglycemia or after mannitol use and is also known as translocational hyponatremia. Isotonic hyponatremia is diagnosed in settings of severe hypertriglyceri...

Water intoxication resulting in ventricular arrythmias

“…Excessive water intake in a short period of time may result in severe deteriorations in electrolyte balance leading to cardiac and neurologic symptoms. [1,2] This rare entity known as 'water intoxication' was first described by Barahal in 1938 [5] This disorder presents a variety of clinical signs and symptoms which may be challenging for clinician who is not aware of this rare situation. In the literature, the majority of water intoxication cases are described in the psychiatric disorders, particularly in schizophrenia.…”

“…This condition, known as 'water intoxication' , is generally encountered in psychiatric illnesses such as schizophrenia. [1,2] Water in-toxication is also reported in child abuse cases, in urology patients after uroflowmetry evaluation, and occasionally in otherwise healthy individuals. [3,4] However, excessive water ingestion with suicidal purpose is an extremely rare clinical presentation.…”

Diagnostic challenge in neuropsychiatry: two case reports

“…Often the patients are aware of their lapses, and almost all of them experience some form of memory disturbance, even if nothing more than a vague inability to grasp things with sufficient precision. Other rare presentations include anorexia nervosa [25], multiple personality [26] or compulsive water drinking [27]. Spitting and embarrassment have been described as the aura of a complex partial seizure [28,29].…”

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“…Santos-Soares et al relataram o caso de um homem de 34 anos, previamente hígido, que se apresentou à emergência com crises convulsivas e [Na+] = 123 meq/L, após ingerir cerca de 8 L de água. 24 Ele estava jogando dominó numa roda de amigos e a aposta era que, quem perdesse uma rodada, teria que beber um copo de água (aproximadamente 200 mL). Porém, ele acabou perdendo uma rodada após a outra e acabou ingerindo cerca de 40 copos de água num curto espaço de tempo.…”