1 / 14

An unusual case of hyponatraemia Natasha Porcu Southampton General Hospital

An unusual case of hyponatraemia Natasha Porcu Southampton General Hospital. Mrs M 30 yr old Portuguese female pc : presented in A&E (13/12/04)- abdominal pain and frequent vomiting . On examination : abdomen soft and tender, BP 162/94. Pregnancy test (+) ectopic pregnancy?

taline
Télécharger la présentation

An unusual case of hyponatraemia Natasha Porcu Southampton General Hospital

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. An unusual case of hyponatraemia Natasha Porcu Southampton General Hospital

  2. Mrs M • 30 yr old Portuguese female • pc: presented in A&E (13/12/04)- abdominal pain and frequent vomiting On examination: abdomen soft and tender, BP 162/94 Pregnancy test (+) ectopic pregnancy? - plasma β-HCG: 682 IU/L (500-10,000 3-4 weeks pregnant) - normal ultrasound

  3. pmh: admitted 8 months earlier with abdominal pain Gastritis? pain resolved after 2 days. dh: not on any prescribed medication sh: 10 cigarettes/day, ½bottle of wine/night regular cannabis user

  4. High blood pressure/tachycardia throughout her hospital stay TFT’s (21/12/04) Free T4= 48.9 pmol/L (11.5-24.0) TSH= <0.01 mIU/L (0.35-5.50)

  5. Abdominal pain • Gastritis, constipation, appendicitis ruled out • Porphyria? Random urine porphyrin screen (24/12/04) Porphobilinogen - detected Urine porphyrin 1800 nmol/L (0-320) Porphyrin/creatinine ratio 147.7 (0-35) Acute Intermittent Porphyria

  6. Trend in measured plasma sodium during her hospital stay

  7. Day 14: plasma Na 103 mmol/L (135-145) plasma osmolality=225 mOsmol/kg (280-295) urine osmolality= 735 mOsmol/kg urine sodium= 57 mmol/L Syndrome of inappropriate ADH secretion (SIADH)? Summary: acute porphyria, pregnant, thyrotoxic with SIADH

  8. SIADH: A diagnosis of exclusion • Criteria: • low plasma sodium and osmolality • urine sodium >20 mmol/L • urine osmolality inappropriately high (>200 mOsm/kg) • patient should be clinically euvolaemic • exclude renal, adrenal, hypopituitary and cardiac disease • exclude drugs that may affect water balance • clinical and biochemical improvement to water restriction

  9. Haem Biosynthetic Pathway Acute Intermittent Porphyria Marshall WJ, Bangert SK. Clinical Chemistry. 5th ed. 2004

  10. AIP • rare autosomal dominant disorder (1-2 cases:100,000 in UK) • build-up of neurotoxic porphyrin precursors during an acute attack • Precipitating factors: alcohol • physical/emotional stress • weight loss • hormonal changes • many drugs • -

  11. Symptoms of acute intermittent porphyria (AIP) Abdominal pain Nausea and vomiting Tachycardia Hypertension Hyponatraemia (SIADH) Psychological disturbances Muscle weakness Thyrotoxicosis? neurological

  12. Brodie et al (1978), 17 patients with AIP: 13 in remission (normal thyroid function) 4 in acute attack- had significantly elevated thyroid hormones (increase related to severity of attack) ‘‘AIP may represent a reversible cause of hyperthyroidism in man…… increased thyroidal sympathetic neural stimulation may be responsible’’ Brodie et al. Thyroid function in acute intermittent porphyria: A neurogenic cause of hyperthyroidism? Horm Metab Res 1978; 10: 327-31

  13. Recovery of Mrs M • IV haem-arginate to suppress the pathway (26/12/04) • Propanolol and propylthiouracil for thyrotoxicosis (24/12/04) Random urine sample: porphobilinogen (not detected) urine porphyrin 78 nmol/L (0-320) Free T4= 19.3 pmol/L (11.5-24.0) TSH= 0.02 mIU/L (0.35-5.50) Na = 137 mmol/L on discharge

More Related