Hyponatremia With Siadh with Acute Respiratory Failure Type 2 With Dyselectrolytemia and Acute Demyelination

Abstract

This case report describes a 29-year-old female patient diagnosed with multiple severe health conditions including hyponatremia due to SIADH, acute respiratory failure type II, dyselectrolytemia, sepsis and acute demyelination. The patient presented with generalized weakness, dizziness, vomiting, fever, altered sensorium, paucity of all movements in all limbs and confined to bed. The case was described with a well-structured case presentation and used moderate medical terminology. The complexity of the medical condition and its treatment personalised for the patient including medications, diet and physiotherapy is well described. The case underscores the significance of personalised treatment plans, nutritional support and physiotherapy in achieving patient stabilization and recovery.

Keywords

Introduction

Table-1: C-reactive protein laboratory report:

Table-2: Electrolytes laboratory report:

electrolyte levels (sodium, potassium, chlorides, of the patient compared to normal ranges (note: these results were taken when the patient was receiving electrolyte supplementations).

Table-3: Serum electrolytes laboratory report:

Abnormal levels of Phosphorous and Calcium noted

MRI: features of pontine and extrapontine demyelination

Cardiovascular Imaging and Haemodynamic laboratory Report:

Spontaneous Echo Contrast (SEC) noted in then Inferior Vena cava,

Minimal Pericardial Effusion present.

Ultrasound Scan of Abdomen:

Mild Ascites

Mild right pleural effusion

Urine – aerobic culture, Identification and Antimicrobial Susceptibility Test:

Isolated organism: Enterococcus faecalis

Colony counts: >1,00,000 CFU/ml

First line Drugs: Second line Drugs

Amoxicillin: SUSCEPTIBLE Vancomycin, Linezolid, Ciprofloxacin, Levofloxacin, Nitrofurantoin: RESISTANT             Teicoplanin: Susceptible

Culture Sensitivity-Urine: Isolated organism: Klebsiella pneumoniae

RESISTANT drugs: Amoxicillin, Amikacin, Cotrimoxazole, Ceftriaxone, Cefixime, Cefoperazone, Ceftazidime, Piperacillin, Aztreonam, Ciprofloxacin, Levofloxacin, Doxycycline, Imipenem, Meropenem.

SUSCEPTIBLE drugs: Colistin

D-dimer: 2325 ng/ml was noted where normal range is less than 500 ng/ml.

Creatine kinase: 539 U/L (<145)

Final Diagnosis

Hyponatremia with SIADH with Acute Respiratory Failure with Type 2 Respiratory Failure with Dyselectrolytemia, Sepsis and Acute Demyelination.

Plan Of Treatment

Medical Management with Ventilator Support

Treatment

Cefoperazone 750mg IV BD for

Gentamycin 80mg IV BD for 5 days

Conventional Amphotericin B (Amp B) in 100ml 5% dextrose solution @ 6 hours

Before giving Amp B, patient was administered with 1g paracetamol, 2cc Pheniramine maleate (22.75mg/ml) and 100mg of Hydrocortisone at a time through intravenous route.

IVIg (immunoglobulin G) injection with flow rate 25 ml/hr

Ondansetron 2cc IV BD regularly (4mg/ml)

Nebulisation of Budesonide 12^th hourly

Magnesium Sulphate 2cc IV BD

Potassium Chloride 2 amp in 50ml NS (5ml/hr)

3% Sodium Chloride IV with a flow rate of 3ml/hr on flow

Levetiracetam 500mg PO BD regularly along with Sodium Valproate 500mg

Albumin injection 5ml/hr given for 7 days

Noradrenaline injection 3 ml/hr on flow according to blood pressure

Midodrine 5mg PO BD daily

Ivabradine 5mg PO stat and SOS

Patient was put under further antibiotic regimen to prevent hospital acquired infections with Metronidazole 400mg, Linezolid 600mg given thrice and twice respectively.

occasional vitamin d supplements were given as the patient has no exposure to sunlight (once weekly)

Nutrition:

Dietician prescribed high protein and liquid diet and counselled the patient and attender on the same. After consent, Femoral Central line Catheterization done under strict aseptic precautions which is used to administer nutrition and medication.

Total Nutrient Admixture (TNA) composed of amino acids (10% w/v), electrolytes, dextrose (15% w/v), intravenous fat emulsion with medium and long chain triglycerides (20% w/v) was given @ 30 ml/hr was given via central line.

Ready-to-feed (RTF) 100ml milk second hourly with Renal HP Powder given regularly as part of high protein and liquid diet along with TNA.

Physiotherapy:

As the patient’s GCS score is poor and bedridden physiotherapy was needed to maintain the optimal condition of joints and pressure points. Physiotherapy was performed twice a day with short term goal- to prevent joint contractures and long-term goals- to restore muscle strength and functional independence.

Discharge:

Patient was discharged on forty fifth day of hospitalisation with only a slight improvement in GCS score and could respond to the words and actions. Though unable to walk on her own patient was discharged on request of guardian. Discharge medications were explained clearly and was informed to have a qualified nurse to administer injections. Advised for a follow up after five days of discharge.

Follow up:

Patient still immobile and unable to talk more than few words but the response to touch and speech has improved, patient could follow the words and actions of the physician during examination. Patient was then advised for more rigorous physiotherapy to prevent joint contractures and gain functional independence as earliest as possible.

DISCUSSION

SIADH is a rare condition which cause hyponatremia, induced by increased release of antidiuretic hormone (ADH) by posterior pituitary gland. In SIADH the feed back system of suppression of ADH release is impaired, resulting in retention of water and finally hyponatremia. SIADH characteristics include hyponatremia with plasma hypoosmolality, increased urinary sodium secretion, euvolemia, high urinary osmolality relative to plasma osmolality and normal renal and adrenal function.^[7] One of the cause for SIADH in this case is due to the patients pulmonary status where she was put under positive pressure ventilation for a prolonged period of time and also type 2 respiratory failure potentiated the condition. The patient was completely immobile and bedridden throughout the entire stay in hospital and barely responsive to external stimuli be it audio or touch. To correct SIADH 3% sodium chloride was given as a continuous IV drip to maintain the sodium levels in blood. Route cause of ventilation cannot be withdrawn as patient is unable to breath voluntarily and in an unconscious state throughout hospital stay. Dyselectrolytemia is a condition of anormal electrolyte levels, here the patient had abnormal levels of sodium, potassium, calcium, phosphorous and magnesium. Each of the abnormal electrolyte level is corrected by appropriate supplementation.  Intravenous immunoglobulin (IVIg) is a treatment that boost antibody levels and administration of IVIg has become one of the new successful treatment regimens for demyelinating diseases. There is a concept that IVIgs may have potential to remyelinate axons.^[8] IVIg was shown to be polyreactive, recognising antigens present on oligodendrocytes and other cells, from experimental observations, IVIgs may have a beneficial effect in treating demyelination diseases.^[9] IVIg involves infusing a concentrate of antibodies, in this condition a high dose is used to relive inflammatory and autoimmune condition. Other alternatives for IVIg include neonatal crystallizable fragment receptor inhibition, complement inhibition and Sialylated IgG.^[10] Type II (hypercapnic) respiratory failure is characterised by low oxygen levels, with high carbon dioxide levels. This happens when alveolar ventilation is not sufficient to remove carbon dioxide being produced, which builds up CO2. In our case this is due to respiratory muscle weakness and the patient inability of voluntary breathing. The condition was regulated by installing mechanical ventilation with tracheostomy.  High d-dimer levels is due to autoimmune inflammation not necessarily blood clots, patient had alternating tachycardia and bradycardia which was mitigated by Midodrine and adrenaline respectively. There is a study which concludes that there is an inverse correlation between values of potassium and D-dimer in patients with acute atrial fibrillation.^[11] Creatine kinase levels are elevated at early stages of hospitalisation due to muscle deterioration, demyelination and sepsis conditions. The elevated levels can be controlled by treating the underlying pathologic conditions. As per study, mild hypocalcaemia was observed in 6 out of 12 patients with SIADH associated hyponatremia, which was in fact related to low albumin levels due to body fluid dilution.^[12] our patient condition was also in line with the study as the laboratory reports suggested a slight decrease in serum calcium levels along with albumin. The condition was regulated by administering Albumin infusion regularly and calcium gluconate injections for three days to attain normal levels which can then be maintained by correcting the albumin content. Antibiotic therapy here was a four-drug combination, this was a decision made based on the culture report and sensitivity tests. The antibiotic therapy had to be continued as there is always a risk of infection due to ventilator, hospital acquired infection. According to a study MDR bacteria are more common in patients with acute respiratory complications requiring intubation and mechanical ventilation.^[13] hence it was required to maintain the multidrug antibiotic therapy to prevent bacterial drug resistance. The patients heart rate was consistently higher (>120 bpm) and along with respiratory failure, to mitigate both of these issues Ivabradine 5mg was administered. According to a randomised, double-blind, placebo-controlled, crossover study demonstrated that selective heartrate reduction with ivabradine was effective in patients with respiratory complications, without any alterations in respiratory function. Concluded that ivabradine offers as an effective alternative to beta blockers in lowering heart rate in patients with respiratory disease.^[14] Although there are situations where heart rate fell, controlled infusion of Noradrenaline based on live heart rate monitoring thus mitigating the risk of bradycardia.  As the patient’s unable to perform basic activities there came a requirement for supply of nutrition. For this dietician prescribed central line to deliver supplementation and a feeding tube to deliver liquid protein food into gastrointestinal tract for easy digestion. High protein diet was needed to maintain regular body needs, muscle integrity (reduce the risk of muscle catabolism) and repair of demyelinated parts of central nervous system. Through out the length of hospital stay the patient relied on these sources of nutrition (discussed earlier) and it was successful in preventing muscle deterioration and meet the basic energy requirements of the patient.^[15,16]

CONCLUSION:

The patients severe and multifactorial conditions, including SIADH induced hyponatremia, acute respiratory failure, dyselectrolytemia, sepsis and acute demyelination has shown the complex factors involved in diagnosing and managing critical illness with overlapping symptoms, effective use of diagnostic tools and various approaches to treatment highlights the multidisciplinary approach required for critical patent stabilization and recovery. Despite the severity of the patient’s conditions and prolonged hospital stay, the diligent efforts of medical, nutritional, and physiotherapy interventions resulted in gradual improvement, also the pharmacist for planning the regimen to minimise adverse drug interactions as much as possible, illustrates the importance of comprehensive, integrated patient care. Although patient remained immobile and partially responsive during discharge, continuation of physiotherapy and regular follow-up care offer a possibility of functional independence and further recovery.

This case shows how important is the role of personalized treatment plans, constant monitoring, and adaptive therapeutic strategies in managing complex, life-threatening medical conditions.  

Abbrevations:

SIADH: Syndrome of inappropriate antidiuretic harmone, ADH-Antidiuretic harmone, ARF-Acute respiratory failure, COPD-Chronic obstructive pulmonary disease, ER-Emergency room, ICU-Intensive care unit, MRI-Magnetic resonance imaging, SEC-Spontaneous echo contrast, CRP-C-Reactive protein, NS-Normal saline, TNA-Total nutrient admixture, RTF-Ready to feed, HP-High protein, GCS score- Glasgow coma score, IVIg-Intravenous immunoglobulin, IgG-Immunoglobulin-G, MDR-Multidrug-resistant, Amp B-Amphotericin B, SOS-Si Opus Sit, BD-Twice a day, IV-Intravenous, PO-By mouth, PaCO2-Partial pressure of arterial carbon dioxide.

Consent:

The authors ensured that they have obtained appropriate patient consent forms. The patient is ensured that their names and initials will not be published and efforts will be made to conceal their identity and any information revealing their identity shall not be disclosed.

Conflict Of Interest: Authors and institutions declare no conflict of interest.

ACKNOWLEDGEMENT: Nil

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