Cerebral salt-wasting syndrome in children: a case report

Hyponatremia is an electrolyte disturbance presenting the potential for morbidity and mortality in patients with neurological complications secondary to brain injury, trauma-related or not. In such patients, hyponatremia is frequently accompanied by the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). However, in rare cases, hyponatremia can be accompanied by a controversial pathology known as cerebral salt-wasting syndrome (CSWS), which is generally associated with subarachnoid hemorrhage in adults. In this report, we describe the clinical evolution and treatment of a 47-month-old male patient with ventriculo-peritoneal shunt resulting from congenital hydrocephalus. The patient had developed severe hyponatremia (121 mEq/l) accompanied by signs of dehydration, intracranial hypertension and hypouricemia, as well as elevated urinary sodium and osmolality. In addition to intravenous fluid replacement and infusion of 3% saline, high levels of sodium replacement (up to 25 mEq/kg/day), together with fluorocortisone administration, were required in order to maintain appropriate serum levels of sodium. The diagnosis of CSWS was confirmed on the basis of the high serum level of atrial natriuretic peptide. The patient showed progressive improvement and resolution of the condition after confirmation of intracranial hypertension and clearance of the ventriculo-peritoneal shunt obstruction. We emphasize the importance of recognizing CSWS in patients with hyponatremia accompanied by central nervous system disturbances, as well as the differential diagnosis with SSIADH.