Fluid Replacement Versus Fluid Restriction in COVID-19 Associated Hyponatremia

Abstract

Hyponatremia is one of the most frequently observed electrolyte abnormalities in coronavirus disease 2019 (COVID-19). Literature describes syndrome of inappropriate anti diuretic hormone (SIADH) as the mechanism of hyponatremia in COVID-19 requiring fluid restriction for management. However, it is important to rule out other etiologies of hyponatremia in such cases keeping in mind the effect of an alternate etiology on patient management and outcome. We present a case of hypovolemic hyponatremia in a patient with COVID-19, which unlike SIADH, required fluid replacement early in the disease course for its correction. A 52-year-old Filipino gentleman presented with a three-week history of diarrhea and symptomatic hyponatremia. There was no history of fever or respiratory symptoms. Physical examination revealed a dehydrated and confused middle-aged gentleman. Labs revealed lymphopenia, thrombocytopenia, and severe hyponatremia (108 mmol/L). Blood cultures and stool workup were negative. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nasopharyngeal swab was positive. Hyponatremia workup excluded SIADH. The patient had hypovolemic hyponatremia due to gastrointestinal (GI) losses and was managed with saline infusion for correction of hyponatremia with improvement in his clinical status. Hyponatremia in COVID-19 is not only secondary to SIADH but can also be due to other etiologies. Hypovolemic hyponatremia should be distinguished from SIADH as these conditions employ different management strategies, and early diagnosis and management of hypovolemic hyponatremia affects morbidity and mortality.

A Case Report of Severe Hyponatremia Secondary to Coronavirus Disease 2019 Viral Pneumonia

“…As stated earlier, she was given IV 3% saline and tolvaptan, both common ways to treat low sodium levels [10,13]. Our case also showed a W-curve [14] recovery in the patient as she was admitted to the hospital the second time in three weeks and was diagnosed as having post-COVID pneumonia and exhibited high CRP levels. The patient was treated with steroids, antacids, and antibiotics.…”

COVID-19 and diabetes mellitus: from pathophysiology to clinical management

“…Frequent blood glucose and ketone body monitoring is mandatory in patients with COVID-19 and hyperglycaemia. Fluid and electrolyte management in patients with COVID-19 and impaired respiratory function should follow general recommendations 121 , 122 ; no specific guidance exists for fluid and electrolyte management in patients with diabetes mellitus and COVID-19.…”

Management of hyponatraemia and hypernatraemia during the Covid-19 pandemic: a consensus statement of the Spanish Society for Endocrinology (Acqua Neuroendocrinology Group)

“…COVID-19 is a disease with widely variable outcomes, among which 19% develop severe disease [2].Adverse clinical outcome correlates with multi-organ injury, maladaptive functions of the renin-angiotensin-aldosterone system and thirst and appetite abnormalities, all of which potentially disrupt water homeostasis [3]. A number of case reports describing hyponatraemia of various etiologies was initially published [4][5][6][7]. Later, a descriptive study of 16 patients with COVID-19-related hospitalization found 50% of them had hyponatraemia [8], whereas the HOPE study, an international registry of 4664 hospitalized COVID-19 patients, found that 20.5% and 3.7% had hyponatraemia and hypernatraemia, respectively [9]: both hyponatraemia and hypernatraemia were generally mild (130-134 mEq/l in 16.7%), severe hyponatraemia (<120 mEq/l) was found only in 0.4%.…”