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Challenges in the Diagnostics and Management of Hydrochlorothiazide-Induced Severe Hyponatremia in a Habitual Beer Drinker

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Challenges in the Diagnostics and Management of Hydrochlorothiazide-Induced Severe Hyponatremia in a Habitual Beer Drinker ACTA MEDICA LITUANICA. 2020. Vol. 27. No. 1. P. 39–44 © Lietuvos mokslų akademija, 2020 Challenges in the diagnostics and management of hydrochlorothiazide-induced severe hyponatremia in a habitual beer drinker Gabija Laubner1, Introduction. Beer potomania is a syndrome of severe hypona- tremia caused by excessive beer consumption. The risk of hypon- Gabija Gintautaitė2*, atremia increases in the case of a combination of beer potomania and the use of thiazide diuretics. Robertas Badaras1 Case report. A 55-year-old male patient with the anamnesis of a long-lasting alcohol use disorder was presented to the emergen- 1 Centre of Toxicology, cy department after seizures accompanied by an impaired men- Republican Vilnius University Hospital, tal status. He had been drinking beer regularly for ten years. On Faculty of Medicine, physical examination, the patient was tachypneic, tachycardic, dis- Vilnius University, Clinic of Anaesthesiology orientated, restless, the Glasgow Coma Scale score of 9, observed and Intensive Care, tremor, and the smell of alcohol from the mouth. Laboratory re- Vilnius, Lithuania sults showed plasma sodium 105 mmol/L, blood urea nitrogen 1.8 mmol/L, the alcohol concentration in the blood 0.06 g/l, and 2 Faculty of Medicine, calculated serum osmolality 219 mOsm/kg H2O. After a detailed Vilnius University, initial evaluation of the patient and labs for hyponatremia, a di- Vilnius, Lithuania agnosis of beer potomania was established. On the third day of hospitalization, the patient’s anamnesis was filled with informa- tion about the use of Valsartan/hydrochlorothiazide, together with reduced salt intake in the diet for three months for arterial hyper- tension treatment. It was decided that the combination of heavy beer drinking with the use of diuretic and reduced consumption of salt provoked hyponatremia. The patient was treated with infusion therapy of sodium chloride; plasma sodium level reached 136 on the third day of treatment. Conclusions. This case represents an unusual syndrome of beer potomania in conjunction with hydrochlorothiazide usage and reduced salt consumption, which can result in severe hypona- tremia that may provoke severe neurologic damage. Keywords: beer potomania, hyponatremia, thiazide diuretics * Correspondence to: Gabija Gintautaitė, Faculty of Medicine, Vil- nius University, M. K. Čiurlionio St. 21, Vilnius 03101, Lithuania. Email: [email protected] 40 Gabija Laubner, Gabija Gintautaitė, Robertas Badaras INTRODUCTION dysfunction due to hyponatremia caused by beer potomania together with the use of diuretics. ‘Beer potomania’, an uncommon cause of hypona- tremia provoked by excessive beer drinking (usual- CASE REPORT ly five or more drinks per day), was first mentioned by Demanet et al in 1971 (1–3). This syndrome is A 55-year-old male patient was admitted to associated with patients who develop hypona- the emergency department due to seizures that were tremia due to inadequate daily solute intake and provoked by four-day-long drinking. The patient excessive beer consumption (2, 4). Although hy- had a history of heavy drinking of ten years, a head ponatremia is quite common among chronic alco- trauma, and diabetes mellitus. According to the pa- hol abusers, it is vital to diagnose beer potomania tient’s relatives, he had a single episode of epileptic quickly. Time is essential since hyponatremia usu- seizures as a consequence of a long alcohol drinking ally presents with other serious conditions such as period 15 years earlier. The patient was treated in malnutrition, cirrhosis, or congestive heart failure the department of psychiatry several times for his (3, 5). Heavy drinkers, especially in older age, usu- problems with alcohol. However, the treatment did ally use diuretics or antipsychotic drugs (3). For not result in improvement. From the physical ex- this reason, it is necessary to ascertain an anamne- amination: the patient was asthenic (probably be- sis of the use of these medications due to the pos- cause of his habit to skip meals), tachypneic with sibility that hyponatremia is caused by them (6). a respiratory rate of 28, tachycardic with the heart Chronic hyponatremia frequently results in rate of 100, disorientated, restless, with Glasgow cognitive or coordination dysfunction, as well as Coma Scale score of 9, observed tremor, the smell mood disorders (7). On the other hand, severe of the alcohol from the mouth, and a dry tongue. acute hyponatremia can be life-threatening by The patient’s relatives denied any periods of vomit- causing brain oedema, seizures, and, in rare cases, ing or diarrhea or any other health problems. death (8). Considering that there could be nu- The patient’s laboratory results are presented in merous underlying reasons, it is crucial to iden- the Table. Liver enzymes and the AST/ALT ratio tify pathophysiology of hyponatremia because it were typical for alcoholic liver injury. Brain oede- determines its appropriate management. In heavy ma was observed in the computed tomography drinkers’ case, beer, which contains little or no salt scan of the head. Considering the patient’s anam- at all, along with carbohydrate and alcohol causes nesis, laboratory, and diagnostic test results, he suppression of protein breakdown and reduces was admitted to the toxicology department. the solute load to the kidney (9). This mechanism On the next day, the patient developed acute provokes defective water clearance and induces respiratory failure, was intubated and transferred dilutional hyponatremia (2). to the intensive care unit. In the chest X-ray, noth- Recognition of beer potomania is a difficult ing relevant was found. On the following day, an challenge for a physician, particularly in those cases abdomen ultrasound was performed and liver ste- when a patient has other risk factors for develop- atosis and uncomplicated gallstones were detect- ing hyponatremia. Arterial hypertension is a wide- ed. On the third day of hospitalization, anamne- spread disease usually treated with antihypertensive sis was supplemented with the information that drugs such as diuretics, which are used in 70.2% the patient used 160 mg Valsartan and 12.5 mg cases (10). Moreover, recent studies show that al- hydrochlorothiazide for three months for arterial cohol consumption is also common: in a survey hypertension treatment. In addition, his general conducted in 2018, 26.5% of people reported they practitioner recommended reduction of salt in- had engaged in binge drinking in the past month. take. Based on this information, it was suspected In combination, these two conditions may increase that long-term use of diuretics along with the re- the risk that adjusting the treatment of one disease duced salt in the diet and beer binge drinking trig- will not take into account the appearance of anoth- gered such severe hyponatremia. On the same day, er dangerous condition such as hyponatremia. the patient was extubated, his state of conscious- This article presents a 55-year-old alcoholic ness was good, the respiratory function stabilized, male patient, who presented with neurological and he was returned to the ward. Challenges in the diagnostics and management of hydrochlorothiazide-induced severe hyponatremia... 41 Table. Patient’s laboratory test results Result Result Result Normal Blood test (on admission) (after 48 hours) (on discharge day) value WBC (×109/L) 7.2 13.1 – 4.0–9.0 Hb (g/L) 129 124 – 130–180 Plt (×109/L) 185 115 – 150–350 Na (mmol/L) 105 129 137 136–150 K (mmol/L) 4.19 4.05 4.9 3.5–5.1 Cl (mmol/L) 66.9 94.8 103 98–107 Blood urea nitrogen (mmol/L) 1.8 3.6 3,0 2.1–7.1 Creatinine (µmol/L) 57 – 62 62–115 Glucose (mmol/L) 7.3 6.6 5.0 3.9–5.8 AST (UI/L) 305 – 153 10–37 ALT (UI/L) 154 – 148 13–40 Total bilirubin (µmol/L) 20.1 – 9.0 5.1–20.5 Alcohol concentration (g/L) 0.06 – – 0 Serum osmolality (mOsm/kg) 219 268 282 285–295 During the hospitalization, the patient was to 136 mmol/L (Figure). Ten days later, he was re- treated symptomatically with infusion therapy of leased from the hospital with instructions to visit NaCl 0.9%, along with a small amount of NaCl his general practitioner after a week and to apply 10% infusions to treat electrolyte imbalance. In- for addiction rehabilitation. fusion of osmotic diuretics with glucocorticoids was prescribed to treat brain oedema. Treatment DISCUSSION included benzodiazepines to prevent the emer- gence of alcohol-related seizures and other alcohol The patient’s hyponatremia was classified as hypo- withdrawal symptoms, and neuroleptics to reduce tonic hyponatremia since serum osmolality was agitation and disorientation. Thiamine therapy 219 mOsm/kg H2O. It was considered severe due was given to improve the mental status. After three to sodium levels <120 mmol/L (10). Due to sei- days of treatment, the patient’s sodium level rose zures and impaired consciousness that occurred 140 136 137 135 129 130 125 124 120 118 115 110 105 105 100 On admission After 12 hours After 24 hours After 48 hours After 72 hours On discharge day mmol/L Figure. Changes in the sodium serum level during hospitalization 42 Gabija Laubner, Gabija Gintautaitė, Robertas Badaras as the first symptoms, it was probably acute hy- or even seizures (8, 15). Symptoms also depend ponatremia (<48 h) (12). It is unlikely that such se- on the speed of developing hyponatremia: acute vere hyponatremia was caused only by the use of hyponatremia can cause brain oedema or intrac- hydrochlorothiazide because it usually occurs dur- ranial hypertension, which can result in a coma, ing the first two weeks of treatment in such cases brain-stem herniation, respiratory arrest, or even (13). Meanwhile, the patient had been using these death (7). Patients are usually misdiagnosed due medications for three months without any symp- to non-specific symptoms because the same symp- toms.
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