Hyponatremia and Encephalopathy in a 55-Year-old Woman with Syndrome of Inappropriate Antidiuretic Hormone Secretion as an Isolated Presentation of SARS-CoV-2 Infection

Abstract

Patient: Female, 55-year-old Final Diagnosis: COVID-19 • SIADH Symptoms: AMS • seizure Medication: — Clinical Procedure: — Specialty: Critical Care Medicine • Nephrology Objective: Unknown ethiology Background: During the coronavirus disease 2019 (COVID-19) pandemic of 2020, varied presentations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported. The present report is of a case of hyponatremia and encephalopathy due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) as the main presentation of SARS-CoV-2 infection in a 55-year-old woman. Case Report: A 55-year-old woman with type II diabetes mellitus presented with confusion and slurring of speech, with a temperature of 38.5°C, heart rate of 120 bpm, blood pressure of 159/81 mmHg, and oxygen saturation of 98% on room air. She did not have edema on examination. Laboratory testing showed a low sodium level of 116 mEq/L (reference range, 135–145 mEq/L) with urine osmolarity of 364 mOsm/kg, urinary sodium of 69 mEq/L, urinary potassium of 15.6 mEq/L, and serum osmolarity of 251 mOsm/kg. The patient had normal serum thyroid-stimulating hormone and cortisol levels. A chest X-ray should no pulmonary infiltrates nor did a lumbar puncture reveal signs of infection. A real-time SARS-CoV-2 polymerase chain reaction assay was positive for COVID-19. Brain imaging with computed tomography was negative for acute infarct, intracranial hemorrhage, and mass effect. Based on findings from laboratory testing and physical examination, a diagnosis of SIADH was made. The patient was treated with 3% hypertonic saline, followed by salt tablets and fluid restriction, with improvement in her clinical symptoms and serum sodium level. Conclusions: The present report is of a rare but previously reported association with SARS-CoV-2 infection. Encephalopathy and hyponatremia associated with SIADH without pneumonia or other symptoms of infection should be an indication for testing for SARS-CoV-2 infection.

Hypernatraemia and low eGFR at hospitalization in COVID-19 patients: a deadly combination

“…The pathogenesis of electrolyte unbalance is only partially understood and several factors may contribute, thus explaining the differences observed in various settings. For instance, there have been reports associating hyponatraemia to the development of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with inappropriate secretion of antidiuretic hormones [ 10 , 11 ]. Proximal tubular necrosis or an incomplete Fanconi syndrome could also contribute to electrolyte alterations as a reflex of direct kidney injury by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), as viral particles have been demonstrated in renal tubular cells [ 12 , 13 ].…”

Severe Hyponatremia in the Setting of COVID-19-Associated Syndrome of Inappropriate Antidiuretic Hormone: A Case Report

“…Disorientation, confusion, seizures, stupor, and coma in the absence of respiratory symptoms could lead to misdiagnosis of COVID-19 and delay of treatment resulting in poor outcomes. While several case reports to date discuss this manifestation of COVID-19 pneumonia, none have described it in the setting of patients with underlying alcohol use disorder and cognitive impairment (Table 1) [13][14][15][16][17][18][19][20][21]. These underlying conditions leave the potential for anchoring and can result in a misdiagnosis of the patient's illness.…”

A case of Acute Disseminated Encephalomyelitis with Syndrome of Inappropriate Antidiuretic Hormone Secretion

“…In that instance, the volume status, levels of natriuretic peptide and changes in the fractional excretion of urate with sodium correction helped to differentiate between cerebral salt wasting and SIADH [10]. There were instances of encephalopathy and hyponatremia in patients with COVID-19 [11]. There are case reports reporting the association of neuromyelitis optica and hyponatremia in children [12].…”