1. Case
A 52-year-old unemployed Japanese woman with depression was brought to our emergency department (ED) after an attempted suicide. She had reportedly ingested 1500 mL of soy sauce (corresponding to 277.5 g sodium chloride) 60 min before presentation. She was taking prescribed mirtazapine, 15 mg daily.
In the ED, she was agitated, and a physical examination revealed a Glasgow Coma Scale (GCS) score of 14 (E4V4M6), a respiratory rate of 20 breaths/min, an oxygen saturation of 100% on room air, a blood pressure of 115/94 mmHg, a pulse rate of 110/min, and a temperature of 35.6 °C. As her initial blood [Na] was 171 mEq/L (serum [Na] was 173mEq/L), 5% dextrose solution (D5W) was intravenously administered. At 30 min post-arrival, a second blood analysis revealed an increase in her blood [Na] to 179 mEq/L and her consciousness level dropped to a GCS score of 7 (E1V2M4) with a convulsive seizure. A plain computed tomography (CT) of the head revealed bilateral cerebellar hemorrhage (Fig. 1A). An intravenous bolus administration of D5W lowered her blood [Na] from 179 to 162 mEq/L over a period of 40 min, which improved her consciousness. After this rapid correction, her blood [Na] was lowered at a rate of 0.55 mEq/L per hour. Although magnetic resonance imaging (MRI) of the head, performed on day 7, revealed hydrocephalus and cerebellar edema (Fig. 1B), she was asymptomatic. She was discharged on day 57 without neurological sequelae.
Fig. 1.
Brain Imaging Findings. Noncontrast-enhanced computed tomography on admission showed bilateral cerebellar hemorrhage (A). Fluidattenuated inversion recovery magnetic resonance imaging obtained on day 7 showed persistent cerebral edema around the hematoma in the cerebellum (B).
2. Discussion
Intracerebral hemorrhage induced by hypernatremia is a rare, critical condition, which stems from the brain cell shrinkage and vascular damage caused by an abrupt increase in blood sodium concentration.1 The first series of such cases was reported in dehydrated neonates2; few were reported in adults with sodium overload.3–6 In a systematic review of 18 case reports of adult hyper-acute hypernatremia, all 3 cases complicated by intracerebral hemorrhage were fatal.7 Rapid correction of acute-onset hypernatremia in adults is not known to be harmful and recommended.1
3. Conclusion
We reported the survival case of a 52-year-old woman with acute severe hypernatremia in whom intracerebral hemorrhage developed. Rapid sodium correction was safely achieved, and she was discharged without neurological sequelae.
Acknowledgment
This research received no specific grant from any funding agency in the public, commercial, or not for-profit sectors.
Abbreviations
- D5W
5% dextrose in water
- ED
emergency department
- GCS
Glasgow Coma Scale
- CT
computed tomography
- MRI
magnetic resonance imaging
Footnotes
Peer review under responsibility of Japanese Pharmacological Society.
Contributors
No additional contributors who do not meet the criteria for authorship.
Prior presentations
This work was presented in part at the 46th Annual Meeting of the Japanese Association for Acute Medicine, held on November 19–21, 2018, in Yokohama, Japan.
Conflict of Interest
The authors declare that there is no conflict of interest.
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