VCOM Carolinas Research Day 2023

Clinical Case-Based Reports

Beer Potomania: A Case of Severe Hyponatremia and Implications of Management Richard McKinley Gannon III, OMSIII Edward Via College of Osteopathic Medicine, Spartanburg, South Carlina.

Abstract # CBR-16

Abstract

Conclusions

Results and Hospital Course

Beer potomania is an underreported cause of hyponatremia associated with excessive consumption of beer. The low solute content of beer paired with the exclusion of other solute intake can lead to severe dilutional hyponatremia. A 63-year-old male with a history of alcoholism and stage IV non-small cell lung carcinoma presented to the emergency department with complaints of suicidal ideation and fatigue. On physical exam the patient was slurring his words but otherwise oriented; he appeared outwardly anxious and fatigued. Labs revealed an initial serum sodium of 114; the patient’s urine sodium and osmolality were within normal limits. To correct his sodium, the patient was initially given a 100 ml bolus of 3% NaCl IV. Due to rapid correction during the treatment course; dDAVP 2 mcg IV push + 100 cc of D5W bolus were also administered. Four days after admission, the patient’s serum sodium stabilized fluctuating between 127 128. Though first reported in 1971 by Demanet et al: there are few reports that outline both etiology and treatment considerations of hyponatremia caused by beer potomania. The pathophysiology of this disorder is well elucidated by T.H. Imam, 2014 and Hind Rafel, 2016. This case, however, will serve to illuminate not only the pathophysiology of beer potomania but also the delicate management which can be complicated by overcorrection potentially leading to critical neurological impairment. . consciousness, head trauma, and musculoskeletal pain. He stated that he was told to by his oncologist to check into E.D. 3 days prior due to low sodium but opted to come after the weekend. Pt later admitted to drinking closer to 20 beers and 2 bottles of wine before admission. • Past Medical History: Chronic obstructive pulmonary disease, Stage IV non-small cell carcinoma of the lung, Prostate cancer, Anxiety, and HLD. • Social History : Patient smokes 1.5 PPD. He admits to drinking 5-10 beers every night. • Review of Systems Gen- Denies fever, chills, HA. Endorses generalized weakness and fatigue. Pulmonology – Endorses chronic SOB and dry cough. Gastroenterology – Patients states he vomited last night due to intoxication. Psych – Endorses feeling anxious. • Physical Exam Constitutional – WDWN, NAD, Cardio – Regular rate and rhythm. No MRG. No lower extremity edema. Respiratory- Diminished BS bilaterally. Expiratory wheezes throughout. Unlabored breathing on 4 L via N.C .. Neuro- Slurring words but otherwise oriented x3 Psych – Appears anxious . Pt states he does not want to hurt himself or others and does not have a plan to do so. Introduction and Case Description . • .A 63-year-old male presented to the E.D. with suicidal ideation after drinking excessive amounts of alcohol. Patient stated he was drinking outside on a particularly hot day behind his barn and fell. Patient denied loss of

Severe Hyponatremia Treatment Guidelines • For treatment of chronic severe hyponatremia (<120 mEq/L - Initiate intravenous 3 percent saline beginning at a rate of 15 to 30 mL/hour, administered via a peripheral vein. • An alternative option is to give 1 mL/kg (maximum, 100 mL) boluses of 3 percent saline intravenously every six hours, with dose modification as needed. Some patients may also require desmopressin (dDAVP) to prevent overly rapid correction. _________________________________________________________________ While the administration of a 3% saline bolus was certainly appropriate given the treatment guidelines; clinically, the consensus among nephrology and the internists attached to this case was that 3% saline should have been held. This patient did not experience any neurological symptoms as a result of the hyponatremia and given his history, most likely had chronically low serum sodium. Due to the potentially devastating neurological consequences of rapid correction, further research using clinical endpoints should be conducted to improve morbidity and mortality as well as reducing hospital stay and resource usage. • Clinical manifestations of ODS include seizures, ataxia, disorientation, and coma . “Locked in syndrome” has been inextricably linked to overcorrection leaving the patient conscious and aware but paralyzed. Patients retain control of the eye musculature and communicate using blinking and eye movement. ______________________________________________________________ • The goal of sodium correction is to replete Na by no more than 10 mEq/L – 12 mEq/L in 24 hours. • Overly rapid correction puts the patient at risk for Osmotic Demyelination Syndrome (ODS) • The exact mechanism of demyelination is unknown, but theories suggest that the change in osmotic gradient results in compression and degradation of the myelin sheath and loss of oligodendrocytes.

Hyponatremia Timeline and Management

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• Presenting Na – 114 (23:57 8/21) Target sodium 122 by (23:59 8/22) E.D. Physician administered NaCl 3% 100 mL IV ____________________________________________________________

• Na – 123 (14:20 8/22) and Na – 125 (17:30 8/22) D5W ordered 1000 mL/hr over 12.5 hr around (12:00) Delay in starting dextrose (4 hours)

Nephrology consulted – dDAVP 2 mcg IV push + 100 cc of D5W bolus ____________________________________________________________ • Na stabilized between 123-125 overnight (8/22-8/23) Patient was given 2 L of D5 water overnight ____________________________________________________________ • Na between 127-128 (8/24) Importance of fluid restriction to 1 L/day reiterated. Continuance of 1 g salt tablets. Follow up with labs in 1 week.

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References

• Kujubu, Dean A, and Ardeshir Khosraviani . “Beer Potomania -- an Unusual Cause of Hyponatremia.” The Permanente Journal , The Permanente Journal, 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500484/. • Milionis, Haralampos J, et al. “The Hyponatremic Patient: A Systematic Approach to Laboratory Diagnosis.” CMAJ : Canadian Medical Association Journal = Journal De L'Association Medicale Canadienne , U.S. National Library of Medicine, 16 Apr. 2002, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC100882/. • Abbott, Rachel, et al. “Osmotic Demyelination Syndrome.” BMJ (Clinical Research Ed.), U.S. National Library of Medicine, 8 Oct. 2005, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1246086/. • Hyponatremia - StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK470386/.

Acknowledgements

Urine osmolality and sodium were WNL on all readings throughout the hospital stay. Given the patient history and lab values consistent with a euvolemic hyponatremia, the diagnosis of beer potomania was made.

I would like to thank Dr. Gerald Bennett for guidance and education on this topic.

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