Zoltán Györgyi21/04/2015

Case report for 5th year medical students

2016Zoltán Györgyi

H.C. 11 year old girl•2008: medulloblastoma removal, VP-shunt insertion

•Chemo+radiotherapy (High risk)• June 2009: Autologous BMT

•No sign of relapse since then.

H.C. 11 year old girl• May 2015: Severe, acute headache, loss of consciousness• Ambulance: Intubation, mechanical ventilation beacause of pulmonary edema

• ???

• CT: acut posterior scala brain haemorrhage, brain stem compression, tonsillar herniation

• Surgery, histology: no sign of malignant disease• Postop: MRI: ischaemic lasesions (area of post.inf.cerebellar artery)

• In the postop. 2 weeks she developed hyponatraemia with polyuria-polydipsia. ADH has been tried with no benefit (Neurosurgery Dept).

H.C. 11 year old girl• On admission:• Known scars on the skull. VP-hunt on the left side, good reservoir function. Internal organs: 2/6 systolic murmur. Physical signs of dehydration.

• Somnolency, slow psychomotor function, but oriented. GCS:4-4-6. Nuchal rigidity, positive Brudzinski-sign, Kernig neg.

• Pupils: O,=,+.• Eyes move only to the right side, inconvergently. Stabism. Left central facial paresis. Muscles weaker, mainly on the left side. No pathological reflexes present.

H.C. 11 year old girl• Increased fluid traffic, precisely unknown at the moment.• ADH had no effect.

• Hyponatraemia.• High urine specific gravity.• After 2,5 hours of admission, GCS deteriorates to 9, AVPU: P

• Fluids: 200ml in / 900ml out

• Diabetes insipudus (?)• SIADH (?)• ICP ?

Possible causes of hyponatraemia• Hypergylcaemia• Chronic RF (BUN)• Etanol or metanol• Mannisol• (pseudohypoNa+?)

• Uosm: 319 mOsm/l

• UNa: 178 mmol/l

• ECF fluid loss

• (pseudohypoNa+?)

Pseudohyponatremia?

Dehydrated?

Urine sodium? Oedema?

Uosm?

yes no

no

Loss to 3rd space

Tubular dysfunctionCerebral salt wastingHypadrenia

high low yes

Nephrotic syndrome

no

lowhighWater poisoning

SIADH

Other causes: Iatrogenic, CRF, hypothyroidism, occult diuretics, CHF, CLF

Cerebral salt wasting

• CNS disease in the history: operation or SAB.• Hyponatraemia and extracellular fluid loss.• Pathomechanism: BNP vs. autonomic NS dysfunction?• Less frequent, than SIADH. Rare in childhood.• Mostly presents after 10 days of surgery.• Diagnosis: High urine output, high UOsm, high UNa,

low uric acid in the serum, high serum BNP levels• SIADH therapy make the symptoms worse.

Cerebral salt wasting

• Treatment:• Solve dehydration• Increase per os NaCl intake• Consider mineralocorticoids• Monitor BNP levels

• Prognosis• Quiets down in 2-3(-4) weeks

• Fluid traffic: 8-10 liters/day• Serum uric acid: 60 umol/l • BNP: 128 pg/ml (0-100)