Successful Use of Fludrocortisone in a Child with Refractory Cerebral Salt Wasting Syndrome: A Case Report and Review of Literature

Abstract

Hyponatremia post-neurosurgical intervention can be dangerous and potentially life-threatening. Two of its most common causes are cerebral salt wasting (CSW) and syndrome of inappropriate anti-diuretic hormone release (SIADH). CSW is proposed to be secondary not only to the elevated levels of circulating atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) but inhibition of steroidogenesis in the zona glomerulosa of the adrenal cortex, thus resulting in mineralocorticoid deficiency. We present a two-year-old male who had developed acute hyponatremia secondary to CSW on post-operative day two after a sub-total resection of a low-grade juvenile pilocytic astrocytoma (WHO grade I). Fludrocortisone was successfully used to manage the refractory hyponatremia and alleviated the need to use very large amounts of oral sodium supplementation.

Tratamiento con fludrocortisona en una paciente con cerebro perdedor de sal asociado a meningitis por criptococosis

“…El uso de la fludrocortisona como fármaco de manejo de la hiponatremia en el CPS ha sido valorado en la literatura por diferentes reportes de caso y un ensayo clínico aleatorizado (16,18); asimismo, el Stroke Council of the American Heart Association recomienda el uso de fludrocortisona como fármaco para el manejo de la hiponatremia, siendo en la actualidad este medicamento usado en pacientes neurocríticos con CPS (17).…”

“…Esto debido al mecanismo de acción de la fludrocortisona, un esteroide adrenocortical activado por vía oral que imita la acción de la aldosterona (un mineralocorticoide), la cual actúa en el túbulo distal de la nefrona para facilitar la reabsorción de sodio e hidrógeno y promover la excreción de potasio, llevando a la disminución de la respuesta natriurética y previniendo la hiponatremia, interrumpiendo así la fisiopatología del CPS causante de un estado hipomineralocorticoide en la paciente (16,17). Volumen 8, número 4 de 2021…”

Differential diagnosis between syndrome of inappropriate antidiuretic hormone secretion and cerebral/renal salt wasting syndrome in children over 1 year: proposal for a simple algorithm

“…Similar to what happens in adults, CRSW syndrome in children mostly represents a consequence of intracranial surgery, subarachnoid hemorrhage, meningoencephalitis (most frequently of tuberculous etiology), and brain injuries and is frequently described in sporadic case reports. CRSW syndrome can also occur after ketamine infusion or can be associated with medulloblastoma, status epilepticus, Kawasaki disease, hematopoietic stem cell transplantation, or lissencephaly [28][29][30][31][32][33][34][35].…”

Inappropriate Antidiuretic Hormone Secretion and Cerebral Salt-Wasting Syndromes in Neurological Patients

“…As a result, all three patients responded well to fludrocortisone therapy (Ishikawa et al, 1987). Single reports of its administration in CSWS patients have appeared sporadically (Berendes et al, 1992; Kinik et al, 2001; Lee et al, 2008; Gurnurkar et al, 2018). Following the treatment of fluid and salt replacement, mineralocorticoid supplement also seems to be a safe and effective treatment for CSWS.…”