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Postmortem Diagnosis of Hyponatremia: Case Report and Literature Review

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Postmortem Diagnosis of Hyponatremia: Case Report and Literature Review Int J Legal Med DOI 10.1007/s00414-017-1601-y REVIEW Postmortem diagnosis of hyponatremia: case report and literature review Jessica Vanhaebost1 & Cristian Palmiere2 & Maria Pia Scarpelli2 & Fabiola Bou Abdallah3 & Arnaud Capron4,5 & Gregory Schmit1 Received: 13 February 2017 /Accepted: 3 May 2017 # Springer-Verlag Berlin Heidelberg 2017 Abstract Hyponatremia is defined as a plasma sodium con- Keywords Hyponatremia . Vitreous humor . Postmortem centration less than 135 or 130 mEq/L (or mmol/L) and may be biochemistry . Electrolyte imbalance . Sodium responsible for life threatening symptoms that can be observed in a variety of medical conditions. Cases of fatal hyponatremia have been reported in both clinical and forensic literature in Introduction situations of water intoxication due to psychogenic polydipsia, amphetamine derivative drug intake, high-endurance exercise, Hyponatremia, one of the most common electrolyte abnormal- iatrogenic causes, and exceptional cases of child abuse by ities encountered by physicians in the hospital setting, is gen- forced water intoxication. Vitreous sodium levels have been erally defined as a decrease in plasma sodium concentration to determined to be relatively stable during the early postmortem <135 or 130 mEq/L (or mM or mmol/L) [1–4]. period and similar to levels found in normal serum of living In the living, plasma sodium concentration reflects ex- subjects. Nevertheless, there are relatively few cases of fatal changeable total body sodium relative to water content. In hyponatremia described in literature that underwent exhaustive the clinical setting, most cases of hyponatremia imply a rela- postmortem biochemical investigations. A case of fatal water tive excess of total body water relative to extracellular sodium intoxication in a psychiatric patient who underwent medicole- and can be considered the result of water balance disorders gal investigations, including postmortem biochemistry, was rather than sodium imbalance [4–7]. chosen as a starting point to a literature review of deaths by Hyponatremia may be the cause of mild (and difficult to hyponatremia that may be encountered in the forensic setting. detect) to life-threatening symptoms that can be observed in a variety of medical conditions. These include congestive heart failure, liver disease, inappropriate antidiuretic hormone syn- drome, and medication use (e.g., thiazide diuretics, psychotro- * Cristian Palmiere pic agents, and chemotherapeutic agents) [2, 6]. [email protected] Both clinical and forensic literature have reported cases of fatal hyponatremia in situations of water intoxication due to 1 Service d’Anatomie Pathologique et Médecine Légale, Cliniques psychogenic polydipsia, amphetamine derivative drug intake, Universitaires Saint-Luc, Université Catholique de Louvain, high-endurance exercise, iatrogenic causes, and exceptional Brussels, Belgium cases of child abuse by forced water intoxication [8, 9]. 2 CURML, University Center of Legal Medicine, Chemin de la Though postmortem assessment of electrolyte imbalances Vulliette 4, 1000, 25 Lausanne, Switzerland (such as sodium and chloride) is considered difficult to per- 3 University Paris-Descartes, Laboratory of Medical Ethics and form for a myriad of reasons, there is a broad consensus re- Forensic Medicine, Paris, France garding the reliability of vitreous sodium levels to estimate 4 Clinical Chemistry Department, Cliniques Universitaires St Luc, antemortem serum sodium concentrations [8–12]. Brussels, Belgium A case of fatal water intoxication in a psychiatric patient who 5 Louvain Center for Toxicology and Applied Pharmacology, underwent medicolegal investigations was chosen as a starting Université Catholique de Louvain, UCL, Brussels, Belgium point to a literature review of deaths by hyponatremia that may Int J Legal Med be encountered in the forensic setting. The results of postmortem Microscopically, the heart revealed no evidence of contraction biochemical analyses that can support this diagnostic hypothesis band necrosis, subendocardial hemorrhage, or acute myocardial were also examined. ischemia. Toxicology (systematic toxicological analysis based on the use of chromatographic techniques and mass spectrometry) Case history revealed the presence of paliperidone, aripiprazole, and venlafaxine within therapeutic blood ranges. The security staff of the psychiatric unit of a metropolitan prison Due to the unavailability of postmortem femoral blood se- was warned by two inmates that a third one was convulsing and rum samples, biochemical investigations were performed ex- Bvomiting a transparent fluid.^ Despite rapid medical interven- clusively in the vitreous humor, which was collected 33 h after tion and resuscitation attempts, the patient did not survive. death. These revealed a sodium concentration of 117 mmol/L The deceased inmate, a 54-year-old Caucasian, tobacco and a chloride concentration of 95 mmol/L. Vitreous potassi- addicted, diabetic, schizophrenic man treated with insulin, um, urea, ketones, and glucose were all within serum refer- paliperidone, aripiprazole, and venlafaxine, was seen compul- ence ranges. Though lower values of vitreous sodium might sively drinking water by two other inmates during the 3 hours be partially explained by the elapsed postmortem interval, the preceding his death. The amount of water intake was retro- cause of death was given as hyponatremia resulting from acute spectively estimated at 5 L. water intoxication on the basis of the results obtained from all Macroscopic external examination of the corpse at the death investigations and the absence of pathological findings at au- scene revealed the presence of clear, watery vomit on and around topsy and toxicology. the corpse. No blood or wounds were observed at any site. A medicolegal autopsy was ordered by the public prosecutor due to the circumstances of death (death in custody). External examina- Discussion tion performed at the medicolegal center (postmortem interval 33 h) did not reveal anything remarkable. Rigor mortis was pres- Sodium is the principal osmole, essential for maintaining extra- ent in the major and minor joints. Reddish purple postmortem cellular fluid volume as well as regulating blood pressure and lividity was present on the back and dependent body parts in the osmotic equilibrium. Average plasma sodium concentrations are supine position and matched corpse position. normally 140 mEq/L or 140 mmol/L. Extracellular fluid sodium At autopsy, the pericardial sac was unremarkable and is maintained by the action of Na+/K+-ATPase. Unlike water that contained 50 ml of clear fluid. Examination of the pleural freely crosses cell membranes to maintain isotonicity between cavities showed bilateral effusion (approximately 180 ml on intracellular and extracellular fluid, sodium cannot freely cross each side). Upper and lower respiratory airways contained a the cell membrane and requires energy-dependent pumps to be whitish, foamy liquid. The lungs (left lung 800 g, right lung transported. Tonicity, or effective osmolality, of a solution refers 1150 g) were edematous. On cut section, both edematous to its cell shrinking or swelling properties obtained through water lungs exuded frothy pink-white fluid. There was no evidence loss or gain respectively, by cells therein suspended. The water of a bronchial tumor. The heart weighed 420 g and did not transfers are driven by differences in osmotic pressure between reveal any hypertrophy. The coronary arteries had a normal intracellular and textracellular compartments. Hypertonic solu- anatomic course and revealed mild atheromatous disease tions cause water exit from cells, hypotonic solutions cause water without significant stenosis. The stomach contained an esti- entry into cells, and isotonic solutions do not cause any net water mated 200 ml of watery fluid. No identifiable pill components movement whatsoever [2, 5]. or fragments were found in the stomach contents or upper Plasma sodium level is determined by the relationship of ex- gastrointestinal tract. The intra-abdominal organs appeared changeable total body sodium and potassium to total body water. generally wet. The urinary bladder contained 250 ml of pale Changes in plasma sodium are typically inversely proportional to yellow urine. The spleen, kidneys, and adrenal glands did not total body water. Hyponatremia is defined as a plasma sodium show any significant, macroscopic changes. The omentum concentration less than 135 or 130 mEq/L (or mmol/L) and may and small bowel did not show any abnormalities. No other develop following primary sodium deficit, primary potassium macroscopic changes were noticed elsewhere in the body. deficit, primary water excess, or a combination of these condi- The brain weighed 1430 g and displayed edema with flat- tions. In most cases, hyponatremia is the result of higher water tening of the gyri and narrowing of the sulci throughout the retention in relation to sodium and potassium with a possible convexity as well as uncal and mild cerebellar tonsillar groov- concurrent abnormality in sodium balance [4, 5]. ing. The pituitary gland was normal. The cerebral arteries had On the basis of plasma osmolality, hyponatremia can be cat- anormalanatomiccourse. egorized as hypertonic (occurring with an excess of extracellular Histological examinations revealed acute generalized visceral solutes, other than sodium, that encounter difficulties entering congestion as well as cerebral and pulmonary edema. into cells and therefore cause
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