Inappropriate Antidiuretic
Hormone Secretion Sir.\p=m-\Weread with interest the report by Mor et al in the January issue of the Journal (129:133, 1975), describing an infant with pneumonia who developed the syndrome of inappropriate secretion of antidiuretic hormone and hyponatremia. In this case, it was not until three days after hospitalization for pneumonia that the child developed hyponatremia and seizures. We would like to report the cases of two children who had status
epilepticus secondary to hyponatremia, probably resulting from clinically occult pneumonias. In addition, we wish to comment on the use of hypertonic saline in such cases. Report of Cases.\p=m-\Case1.\p=m-\An8-month\x=req-\ old girl developed bilateral tonicoclonic seizures after being seen earlier in the day with otitis media. Seizures were terminated with administration of diazepam, phenobarbital, and paraldehyde. The child was comatose with a temperature of 36.5 C (97.7 F) and blood pressure of 80/60 mm Hg; weight was 8 kg (18 lb). Tympanic membranes were erythematous; fundi were normal. Auscultation of the chest disclosed bilateral rales. Serum sodium level was 117 mEq/liter, with a urine sodium concentra¬ tion of 103 mEq/liter. Serum potassium level was 3.3 mEq/liter; glucose level, 174 mg/100 ml; and blood urea nitrogen (BUN) level, 10 mg/100 ml. Cerebrospinal fluid (CSF) showed no red blood cells (RBCs) and two mononuclear white blood cells (WBCs) per cubic millimeter; protein level was 16 mg/100 ml and glucose level was 103 mg/100 ml; cultures were negative. Chest roentgenogram showed bilateral in¬ filtrates. Blood culture yielded a Strepto¬ coccus. The hyponatremia was successfully treated with an initial infusion of 25 millimols of hypertonic saline (3 millimols/kg body weight), administered during a 20minute period, followed by fluid restriction at calculated half-maintenance levels. The pneumonia responded to treatment with antibiotics, and the patient had no subse¬ quent seizures. Case 2.—An 8-month-old black boy was well except for rhinorrhea, for which he was given aspirin and fluids, until he de¬ veloped opisthotonos and bilateral toni¬ coclonic seizures. Seizures transiently responded to treatment with diazepam and paraldehyde, but the patient subsequently had a respiratory arrest requiring intuba¬ tion and artificial ventilation. After initial laboratory data had disclosed hyponatre¬ mia, recurrent seizures were terminated with administration of hypertonic sa¬ line, 36 millimols during 15 minutes (4.2 millimols/kg body weight). Examination showed an obtunded child with a tempera¬ ture of 35.5 C (95.9 F) and blood pressure of 90/50 mm Hg; weight was 8.5 kg (18.7
lb). Auscultation of the chest showed bilat¬ eral rales and rhonchi; optic fundi were
normal. Initial serum sodium level was 119 mEq/liter, with a urinary sodium concen¬ tration of 93 mEq/liter. Serum potassium level was 3.8 mEq/liter, glucose level was 100 mg/100 ml, and BUN level was 7 mg/100 ml. The CSF showed 180 RBCs and seven mononuclear WBCs per cubic mil¬ limeter; protein level was 44 mg/100 ml and glucose level was 79 mg/100 ml; cul¬ tures were negative. Sickle cell prepara¬ tion was negative. Chest roentgenogram showed a right lower lobe infiltrate. Blood cultures yielded coagulase-positive Staphy¬ lococcus. Serum sodium level rose to 126 mEq/liter with the initial saline infusion, and stabilized at 138 mEq/liter with fluid restriction. The pneumonia responded to antibiotic treatment, and the patient had no further seizures.
Comment-In each of these cases, the cause of the seizures was probably hyponatremia. In one, seizures termi¬ nated with administration of hyper¬ tonic saline; in both, the serum so¬ dium level rose and the clinical condition improved with fluid restric¬ tion. The hyponatremia in the face of high urinary sodium level, normal re¬ nal function, normal serum potassium level, absence of dehydration or edema, and good respone to fluid re¬ striction are all supportive of the diagnosis of inappropriate antidiuretic hormone secretion. Both patients had seizures without prior respiratory symptoms other than otitis and rhinorrhea. In neither case was pneumonia clinically appar¬ ent, although initial roentgenograms showed impressive pulmonary infil¬ trates and blood cultures yielded pathogenic organisms. These cases support the concept that pneumonia can be complicated by severe and symptomatic hyponatremia, and that inappropriate antidiuretic hormone secretion is the likely mechanism. In the absence of meningitis or other central nervous system insults, oc¬ cult pneumonias should be carefully searched for. One further word must be said about the efficacy of hypertonic sa¬ line. Mor et al reported that saline in¬ fusion was unsuccessful, although the precise quantity employed and rate of administration were not stated. Cer¬ tainly, the appropriate treatment is water restriction. However, when the patient is comatose or convulsing, ad¬ ministration of hypertonic saline is potentially lifesaving. We have used a solution of 4.4% sodium chloride (750 millimols/liter), given during a 15-
Downloaded From: http://archpedi.jamanetwork.com/ by a UQ Library User on 06/14/2015
minute
period.
This
provides
an
ade¬
quate amount of sodium without a large fluid excess, and avoids too rapid
shift in serum osmolality. The total dose of sodium chloride is determined by multiplying the desired rise in se¬ rum sodium level, generally 5 mEq/ liter, by the patient's estimated total body water (although sodium is large¬ ly extracellular, it is osmotically ac¬ tive throughout the total body water). Thus, in case 1, the patient received 25 millimols of sodium chloride, or ap¬ proximately 5 millimols/liter of total body water; patient 2 received ap¬ proximately 7 millimols of sodium chloride per liter of total body water. Although the elevation in serum so¬ dium level is transient, unless rein¬ forced with fluid restriction, we have found hypertonic saline to be both ef¬ fective and safe. RON G. ROSENFELD, MD MICHAEL J. REID, MD Department of Pediatrics Stanford University Medical Center Stanford, CA 94305 a
Malignant Hypertension Sir.\p=m-\Iam case
in Children
writing concerning
the
report and review by Dr. Siegler,
which appeared in the December issue of the Journal (128:853,1974). He described the unsuccessful treatment of malignant hyperreninemic hypertension in an 11-year-old girl who subsequently underwent bilateral nephrectomy and allograft transplantation. It is an excellent summary of the subject but leaves unsaid several important points concerning this fortunately rarely encountered problem in pediatric practice. Bilateral nephrectomy for hypertension is a procedure of last resort when all other means for control of high-renin hypertension have failed. Nephrectomy is irrevocable and imposes the need for dialysis and transplantation with their many problems and less-than-ideal survival rates. We have at our disposal an alternative. Contrary to Dr. Siegler's statement, there have been positive, though not widely reported, results with minoxidil therapy in children.1-3 This potent, orally administered vasodilator is now available (though it probably was not when Dr. Siegler's patient was treated) for use in an emergency setting and has been strikingly suc¬ cessful in avoiding the need for ne¬ phrectomy in three of our patients. Two of these children were under-
Hormone Secretion Sir.\p=m-\Weread with interest the report by Mor et al in the January issue of the Journal (129:133, 1975), describing an infant with pneumonia who developed the syndrome of inappropriate secretion of antidiuretic hormone and hyponatremia. In this case, it was not until three days after hospitalization for pneumonia that the child developed hyponatremia and seizures. We would like to report the cases of two children who had status
epilepticus secondary to hyponatremia, probably resulting from clinically occult pneumonias. In addition, we wish to comment on the use of hypertonic saline in such cases. Report of Cases.\p=m-\Case1.\p=m-\An8-month\x=req-\ old girl developed bilateral tonicoclonic seizures after being seen earlier in the day with otitis media. Seizures were terminated with administration of diazepam, phenobarbital, and paraldehyde. The child was comatose with a temperature of 36.5 C (97.7 F) and blood pressure of 80/60 mm Hg; weight was 8 kg (18 lb). Tympanic membranes were erythematous; fundi were normal. Auscultation of the chest disclosed bilateral rales. Serum sodium level was 117 mEq/liter, with a urine sodium concentra¬ tion of 103 mEq/liter. Serum potassium level was 3.3 mEq/liter; glucose level, 174 mg/100 ml; and blood urea nitrogen (BUN) level, 10 mg/100 ml. Cerebrospinal fluid (CSF) showed no red blood cells (RBCs) and two mononuclear white blood cells (WBCs) per cubic millimeter; protein level was 16 mg/100 ml and glucose level was 103 mg/100 ml; cultures were negative. Chest roentgenogram showed bilateral in¬ filtrates. Blood culture yielded a Strepto¬ coccus. The hyponatremia was successfully treated with an initial infusion of 25 millimols of hypertonic saline (3 millimols/kg body weight), administered during a 20minute period, followed by fluid restriction at calculated half-maintenance levels. The pneumonia responded to treatment with antibiotics, and the patient had no subse¬ quent seizures. Case 2.—An 8-month-old black boy was well except for rhinorrhea, for which he was given aspirin and fluids, until he de¬ veloped opisthotonos and bilateral toni¬ coclonic seizures. Seizures transiently responded to treatment with diazepam and paraldehyde, but the patient subsequently had a respiratory arrest requiring intuba¬ tion and artificial ventilation. After initial laboratory data had disclosed hyponatre¬ mia, recurrent seizures were terminated with administration of hypertonic sa¬ line, 36 millimols during 15 minutes (4.2 millimols/kg body weight). Examination showed an obtunded child with a tempera¬ ture of 35.5 C (95.9 F) and blood pressure of 90/50 mm Hg; weight was 8.5 kg (18.7
lb). Auscultation of the chest showed bilat¬ eral rales and rhonchi; optic fundi were
normal. Initial serum sodium level was 119 mEq/liter, with a urinary sodium concen¬ tration of 93 mEq/liter. Serum potassium level was 3.8 mEq/liter, glucose level was 100 mg/100 ml, and BUN level was 7 mg/100 ml. The CSF showed 180 RBCs and seven mononuclear WBCs per cubic mil¬ limeter; protein level was 44 mg/100 ml and glucose level was 79 mg/100 ml; cul¬ tures were negative. Sickle cell prepara¬ tion was negative. Chest roentgenogram showed a right lower lobe infiltrate. Blood cultures yielded coagulase-positive Staphy¬ lococcus. Serum sodium level rose to 126 mEq/liter with the initial saline infusion, and stabilized at 138 mEq/liter with fluid restriction. The pneumonia responded to antibiotic treatment, and the patient had no further seizures.
Comment-In each of these cases, the cause of the seizures was probably hyponatremia. In one, seizures termi¬ nated with administration of hyper¬ tonic saline; in both, the serum so¬ dium level rose and the clinical condition improved with fluid restric¬ tion. The hyponatremia in the face of high urinary sodium level, normal re¬ nal function, normal serum potassium level, absence of dehydration or edema, and good respone to fluid re¬ striction are all supportive of the diagnosis of inappropriate antidiuretic hormone secretion. Both patients had seizures without prior respiratory symptoms other than otitis and rhinorrhea. In neither case was pneumonia clinically appar¬ ent, although initial roentgenograms showed impressive pulmonary infil¬ trates and blood cultures yielded pathogenic organisms. These cases support the concept that pneumonia can be complicated by severe and symptomatic hyponatremia, and that inappropriate antidiuretic hormone secretion is the likely mechanism. In the absence of meningitis or other central nervous system insults, oc¬ cult pneumonias should be carefully searched for. One further word must be said about the efficacy of hypertonic sa¬ line. Mor et al reported that saline in¬ fusion was unsuccessful, although the precise quantity employed and rate of administration were not stated. Cer¬ tainly, the appropriate treatment is water restriction. However, when the patient is comatose or convulsing, ad¬ ministration of hypertonic saline is potentially lifesaving. We have used a solution of 4.4% sodium chloride (750 millimols/liter), given during a 15-
Downloaded From: http://archpedi.jamanetwork.com/ by a UQ Library User on 06/14/2015
minute
period.
This
provides
an
ade¬
quate amount of sodium without a large fluid excess, and avoids too rapid
shift in serum osmolality. The total dose of sodium chloride is determined by multiplying the desired rise in se¬ rum sodium level, generally 5 mEq/ liter, by the patient's estimated total body water (although sodium is large¬ ly extracellular, it is osmotically ac¬ tive throughout the total body water). Thus, in case 1, the patient received 25 millimols of sodium chloride, or ap¬ proximately 5 millimols/liter of total body water; patient 2 received ap¬ proximately 7 millimols of sodium chloride per liter of total body water. Although the elevation in serum so¬ dium level is transient, unless rein¬ forced with fluid restriction, we have found hypertonic saline to be both ef¬ fective and safe. RON G. ROSENFELD, MD MICHAEL J. REID, MD Department of Pediatrics Stanford University Medical Center Stanford, CA 94305 a
Malignant Hypertension Sir.\p=m-\Iam case
in Children
writing concerning
the
report and review by Dr. Siegler,
which appeared in the December issue of the Journal (128:853,1974). He described the unsuccessful treatment of malignant hyperreninemic hypertension in an 11-year-old girl who subsequently underwent bilateral nephrectomy and allograft transplantation. It is an excellent summary of the subject but leaves unsaid several important points concerning this fortunately rarely encountered problem in pediatric practice. Bilateral nephrectomy for hypertension is a procedure of last resort when all other means for control of high-renin hypertension have failed. Nephrectomy is irrevocable and imposes the need for dialysis and transplantation with their many problems and less-than-ideal survival rates. We have at our disposal an alternative. Contrary to Dr. Siegler's statement, there have been positive, though not widely reported, results with minoxidil therapy in children.1-3 This potent, orally administered vasodilator is now available (though it probably was not when Dr. Siegler's patient was treated) for use in an emergency setting and has been strikingly suc¬ cessful in avoiding the need for ne¬ phrectomy in three of our patients. Two of these children were under-
