Causes and Effects of Hyponatraemia

Case Study: Jason

Introduction

This case study is of a 28-year-old male who has been transferred from the psychiatric unit to the acute hospital after three episodes of tonic-clonic seizure with subsequent altered conscious state. The purpose of the study is to provide details of the presenting problem, the health assessment, a critical evaluation of diagnostic investigations, clinical manifestations, aetiology and pathophysiology, interventions, and relevant evaluations.

Patient Demographics and History

Jason is a 28-year-old male with diagnosed schizophrenia. He lives with his parents and one older sister and has very good social support from his family. There is no primary family history of mental illness. Jason was a preterm baby (34 weeks) and has since been diagnosed with psychogenic polydipsia – diagnosed after his most recent hospital admission.

Jason presented with seizures, and was transferred from the psychiatric unit to the acute hospital after three episodes of tonic-clonic seizure with subsequent altered conscious state. However, four days prior to the seizures, Jason had been feeling unwell with nausea, vomiting and lethargy. Jason had also appeared agitated, confused, disoriented, and unsteady on his feet, and held his head as if in pain and intermittently staring into space. Doctors focused on his pre-existing condition of schizophrenia, but are now concerned a co-morbidity of delirium may have been the cause of the recent health issue. This fear was based on the fact that 7 days ago Jason had presented with severe acute hyponatraemia [Serum Na+ 104mmol/L] which was corrected using hypertonic saline over a period of around 28 hours when his Serum Na+ reached 135mmol/L. Three days later, Jason developed acute psychotic symptoms, and was transferred to the psychiatric unit for ongoing management of his schizophrenia. Jason had been prescribed risperidone until recent admission for hyponatraemia; now he is on clozapine. 

Health Assessment and Clinical Manifestations

Upon assessment, it is important to consider the presenting problem in its entirety. In the case of Jason, who is presenting with tonic-clonic seizure, severe acute hyponatraemia, and acute psychotic symptoms, a comprehensive physical examination is warranted. Assessment began by taking note of Jason’s initial vital signs. It was found that Jason’s temperature was 37.6 degrees Celsius, his blood pressure was 115/60, his heart rate was 91 beats per minute, and his respiratory rate was 22 breaths per minute. His oxygen saturation levels were good at 99% on room air, and his Glasgow Coma Scale score was 10. It was also noted that Jason had increased muscle tone throughout his limbs. Based on these findings, doctors could formulate a plan of action to further assess and treat there patient.

There are a number of approaches and techniques that could be used when undertaking a physical assessment for someone who is presenting with tonic-clonic seizure, severe acute hyponatraemia, and acute psychotic symptoms. One approach is to use the Glasgow Coma Scale (GCS) (Singh et al., 2019). This scale is a common tool used to assess someone's level of consciousness. For someone who is presenting with tonic-clonic seizure, the GCS may be used to determine the severity of the seizure and to identify any associated neurological deficits (Pruitt et al., 2019). In addition, the GCS can also be used to assess for acute psychotic symptoms, such as delusions or hallucinations (Khalid et al., 2021). Another approach that can be used is to perform a detailed physical examination. This examination can help to identify any physical abnormalities that may be causing or contributing to the person's presentation. This was done in Jason’s case with regard to finding muscle tone heightened in limbs. Finally, laboratory tests can also be helpful in assessing someone with tonic-clonic seizure, severe acute hyponatraemia, and acute psychotic symptoms. These tests can help to rule out other potential causes of the person’s presentation and to provide information about the severity of the person's condition (Bazmi et al., 2020).

There are several objective and subjective clinical manifestations that could be expected in someone presenting with tonic-clonic seizure, severe acute hyponatraemia, and acute psychotic symptoms. For example, seizure activity would likely be noted on EEG, and the patient may exhibit impaired cognition, catch their breath during the seizure or have a brief loss of consciousness. In addition, they may report subjective symptoms such as auras or fear (Braatz et al., 2021). A patient with severe acute hyponatraemia may have symptoms of delirium, seizures or coma, while those with acute psychotic symptoms may exhibit disorganized thinking, hallucinations or delusions (Adrogue et al., 2022). All of these manifestations would need to be taken into account in order to properly diagnose and treat the patient.

The diagnostic investigations were significant for the following findings: tonic-clonic seizure, severe acute hyponatraemia, acute psychotic symptoms, and a Glasgow Coma Scale score of 10. These findings are consistent with a diagnosis of psychogenic polydipsia. The patient's history of psychiatric problems and use of antipsychotic medications likely contributed to the development of this condition. However, it is unclear whether risperidone or clozapine are factors in the onset of Jason’s symptoms, as either medication could be an agent destabilization (Kumar & Kukreti, 2020). Both are atypical antipsychotic medications commonly used to treat schizophrenia, but adverse effects can be seen in some patients (Kumar & Kukreti, 2020).

Further clinical assessments/diagnostic investigations that should be conducted ought to include: a brain MRI to assess level of normal brain activity; an EEG to assess whether there is any evidence of generalized slowing. A lumbar puncture would show whether there is elevated intracranial pressure. A CT scan of the head would show whether there is any evidence of mass lesions or hydrocephalus (Helms et al., 2020). The patient should in the meantime be treated with intravenous fluids, antiepileptic medication, and a course of steroids. The patient’s condition should be monitored for improvement pending further investigation.

Aetiology and Pathophysiology

The terms aetiology and pathophysiology are often used interchangeably, but they actually refer to two different concepts. Aetiology refers to the underlying cause of a disease or condition, while pathophysiology refers to the changes that occur in the body as a result of the disease or condition. In other words, aetiology is concerned with what causes a disease, while pathophysiology is concerned with how the disease manifests.

In other words, pathophysiology can be used to better understand the progression of a disease and to develop treatment strategies. A better understanding of aetiology can help to prevent diseases from developing in the first place. Therefore, both concepts are important in medical research and practice. By understanding them within the context of schizophrenia and the diagnoses given to Jason, a clearer understanding of how to treat the patient can be achieved. Thus, it is necessary to examine the underlying causes of these diagnoses and how they can progress, for it is often the case that illness is the progression of one or more underlying issues.

Schizophrenia is a mental disorder that can cause a wide range of clinical manifestations. In the case of a patient diagnosed with tonic-clonic seizure, severe acute hyponatraemia, and acute psychotic symptoms, the most likely clinical manifestations would include delusions, hallucinations, disorganized thinking, and abnormal motor behavior. Patients with schizophrenia often experience delusions, which are fixed false beliefs. Hallucinations are another common symptom of the disorder, and can involve hearing voices or seeing things that are not actually present. Disorganized thinking can manifest as incoherent speech, and patients may also exhibit abnormal motor behavior such as agitation or catatonia. The severity of these symptoms can vary depending on the individual, but in general, patients with schizophrenia tend to experience significant impairment in their ability to function in daily life.

Jason presented with clinical manifestations of central pontine myelinolysis (CPM), which is a rare and often fatal neurologic disorder caused by injury to the pontine region of the brainstem. Schizophrenia is a chronic mental disorder that affects a person's thoughts, emotions, and behavior and which best characterizes Jason’s prior medical history. Although CPM has been associated with schizophrenia for many years, the exact relationship between the two disorders is not fully understood, according to research (Abram et al., 2022). CPM is a demyelinating disease of the brainstem that is best characterized by the destruction of myelin, the protective coating around nerve cells. This results in problems with movement, speech, and swallowing. CPM can be caused by a variety of factors, including alcohol abuse, liver failure, malnutrition, and certain medications (Abram et al., 2022). Treatment for CPM typically focuses on managing the underlying condition. For example, if CPM is caused by alcohol abuse, treatment may involve detoxification and counseling. If CPM is caused by liver failure, treatment may involve transplantation. If linked to medication, a new pharmacological regime is likely needed. In any and all cases, rehabilitation is an important part of treatment (Abram et al., 2022). Physical and occupational therapy can help patients regain some of their lost function. Speech therapy can also be helpful in patients with communication problems as well.

Symptoms of CPM typically develop after a sudden drop in sodium levels in the blood (hyponatraemia). These symptoms can include paralysis, loss of coordination, difficulty swallowing, and problems with speech and thinking. In some cases, CPM can also cause dementia. Treatment for CPM is typically supportive and may include intravenous fluids and respiratory support. The prognosis for patients with CPM is generally poor, with most patients dying within days or weeks of onset of symptoms. However, some patients may survive for months or even years. If CPM is diagnosed early enough and appropriate intervention applied, the results can be more favorable for the patient (Abram et al., 2022).

Severe acute hyponatraemia is a condition where the level of sodium in the blood becomes abnormally low (Peritogiannis & Rizos, 2021). This can be caused by a number of factors, including dehydration, certain medications, and certain medical conditions. Severe acute hyponatraemia is a potentially life-threatening condition that can also occur in response to certain medications, medical conditions, or water intoxication. Jason’s diagnosis of psychogenic polydipsia would indicate that water intoxication may be the cause of his hyponatraemia (Ahmadi & Goldman, 2020). Symptoms of severe acute hyponatraemia include nausea, vomiting, headache, confusion, and lethargy. If left untreated, severe acute hyponatraemia can lead to seizures, coma, and even death (Siddiqui et al., 2020). Hyponatraemia can be caused by a number of different factors, including medications, surgery, and medical conditions such as heart failure and liver disease. Treatment for severe acute hyponatraemia generally involves replenishing the body's fluids with intravenous saline solution. In some cases, medications may also be necessary to help correct the imbalance of sodium in the blood causing the problem (Siddiqui et al., 2020).

Potential complications include the fact that severe acute hyponatraemia is a potentially life-threatening condition that can occur when the body’s sodium levels drop too low. One of the most serious complications associated with this condition is central pontine myelinolysis, which is a type of brain damage that can lead to paralysis, difficulty speaking, and even death. While the exact cause of central pontine myelinolysis is not known, it is believed to be linked to the rapid correction of sodium levels in patients with severe hyponatraemia (Abram et al., 2022).

Intervention

Risperidone and clozapine are atypical antipsychotics that have been used to treat patients with psychiatric disorders. Both of these drugs have been associated with the development of severe acute hyponatraemia and possible central pontine myelinolysis. The mechanism by which these drugs cause these serious adverse effects is not fully understood.

However, it is thought that they may work by inhibiting the reuptake of sodium ions from the extracellular space into cells (Yang et al., 2018). This action results in a decrease in the available free Na+ ions, which in turn leads to a decrease in the osmotic pressure of the extracellular fluid (Yang et al., 2018). This can ultimately lead to the development of hyponatraemia and cell death. There have been several case reports of patients who have developed severe acute hyponatraemia and central pontine myelinolysis after taking risperidone or clozapine (Yang et al., 2018). These reports suggest that these drugs may be associated with a significant risk of developing these serious adverse effects. Therefore, it is important that clinicians be aware of this potential risk when prescribing these drugs to patients.

While schizophrenia is typically treated with antipsychotic medication, this class of drugs can sometimes cause severe side effects, such as hyponatraemia (low blood sodium levels) (Yang et al., 2018). In severe cases, this can lead to central pontine myelinolysis. Therefore, when treating a patient with schizophrenia, it is important to carefully monitor blood sodium levels and take steps to prevent hyponatraemia. One option is to use a pharmacological therapy called vaptans. Vaptans are drugs that block the action of vasopressin, a hormone that plays a role in regulating blood sodium levels (Piffer et al., 2022). By blocking vasopressin, vaptans can help to prevent hyponatraemia and its potentially fatal complications.

There are nonetheless a number of symptom management strategies that can be used to treat the clinical symptoms of severe acute hyponatraemia and possible central pontine myelinolysis in a schizophrenia patient (Siddiqui et al., 2020). Pharmacological strategies include the use of antipsychotic medications, mood stabilisers and/or antidepressants. non-pharmacological strategies include cognitive behavioural therapy, psychosocial interventions and/or psychoeducation (Yang et al., 2018). The most effective approach will likely vary from individual to individual, and it is important to work with a psychiatrist or other mental health professional to develop an individualized treatment plan. In some cases, hospitalization may be necessary in order to ensure the safety of the patient and to provide more intensive care (Abram et al., 2022). With proper treatment, however, most patients with severe acute hyponatraemia and possible central pontine myelinolysis will improve and be able to resume their lives (Siddiqui et al., 2020).

For Jason, the patient’s medication should be adjusted as it is likely impacting his regulation of sodium levels, which could be the cause of the latest clinical symptoms of severe acute hyponatraemia and possible central pontine myelinolysis (Yang et al., 2018). Clozapine is a relevant pharmacological intervention that can be used to help treat psychogenic polydipsia (Ahmadi & Goldman, 2020). Thus, the pharmacological intervention should be recommended, but monitored..

Because Jason lives at home and has a strong support system with his family, it is not evident that any other intervention is needed at this time. This is not a new diagnosis (schizophrenia) and the complication that has arisen has a likely evident cause linking back to medication and lack of monitoring of sodium. Some health literacy could be provided on this matter to aid in the monitoring of Jason’s health in the future. Health literacy is the ability to read, understand, and use health information in order to make informed decisions about one's health (Riebschleger et al., 2019). For parents of children with schizophrenia, monitoring sodium levels is an important part of maintaining their child's health.

When a young adult is diagnosed with severe acute hyponatraemia and possible central pontine myelinolysis, their parents may require psychosocial referral/support (Young et al., 2019). The diagnosis can be overwhelming and have a significant impact on the family, so it is important that they have access to resources and supports. Some referrals that may be beneficial for parents include counselling, support groups, and therapy (Young et al., 2019). These services can help parents to cope with the diagnosis, manage stress and anxiety, and provide practical guidance. In addition, psychosocial support can help to build a strong support system for the family. By accessing these services, parents can ensure that they are well-equipped to care for their young adult with schizophrenia (Young et al., 2019).

The clinical evaluation of a patient with severe acute hyponatraemia should include assessments of serum electrolyte levels, serum osmolality, urine output, and central nervous system function (Fernandez Martinez et al., 2019). Interventions for severe acute hyponatraemia should be directed at correcting the underlying cause and managing the symptoms. Close monitoring is essential in order to identify any developing complications, such as central pontine myelinolysis (Sindahl et al., 2020). Early diagnosis and treatment of central pontine myelinolysis is critical to preventing permanent neurological damage.