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Water Intoxication

Dilutional Hyponatremia

Water intoxication is a potentially fatal condition, which essentially occurs due to overhydration that causes an imbalance in the level of electrolytes. 


Presentation

In the initial stages, the signs and symptoms of water intoxication may be insignificant and resemble some common illnesses. Affected individuals usually vomit, experience headache and also develop certain changes in mental state, characterized by confusion and disorientation [5].

In the advanced stages of the disease, water intoxication can cause the sodium levels to drop dramatically which can lead to weakening of muscles, spasms and muscle cramps. Affected individuals can also experience seizures, followed by state of unconsciousness and finally coma [6] [7].

Infants or babies affected by water intoxication, exhibit signs of inattentiveness, irritability and drowsiness as part of altered mental state. They may also experience difficulty in breathing, muscle cramps and spasms, twitching along with blurred vision. The face of the affected babies may swell, following a slight drop in their body temperature.

Hemophilia A
  • The importance of ruling out primary polydipsia when this drug is used, not only for central diabetes insipidus but also for other current indications such as classic hemophilia, is stressed.[ncbi.nlm.nih.gov]
Hypothermia
  • This article reports a case of a 3-month-old male presenting with hyponatremic seizure and hypothermia. The presence of marijuana in the infant's urine was remarkable. An etiologic role for the drug is questioned.[ncbi.nlm.nih.gov]
  • Physical signs and symptoms can be manifested as difficulty breathing during exertion, muscle weakness and pain, twitching, cramping, dilated pupils, cyanosis, hypothermia, nausea, vomiting and thirst.[backpackingmastery.com]
  • Advanced hyponatraemia can be associated with hallucinations, inappropriate behaviour, altered temperature regulation (including hypothermia), seizures, coma, diabetes insipidus and respiratory arrest.[erowid.org]
  • DISCUSSION These examples illustrate a well-described spectrum of symptoms that characterize water intoxication, consisting of altered mental status (typically irritability or somnolence), hypothermia, edema, and seizure. 1, 12 Symptoms are preceded by[pediatrics.aappublications.org]
  • […] of breathing (in pulmonary edema) or decreased frequency and volume of breathing (in respiratory arrest) Bluish discoloration of the lips and hands (cyanosis due to pulmonary edema) Decreased (hypotension) or increased blood pressure (hypertension) Hypothermia[ehealthstar.com]
Hypoxemia
  • All had seizures, emesis, and coma, presenting to hospitals with hypoxemia (PO2 44 /- 8 mm Hg) and hyponatremia (plasma Na 112 /- 2 mmol/L).[ncbi.nlm.nih.gov]
Cough
  • […] the blood sodium levels fall below 105 mmol/L: Muscle cramps, tremor, shaking Swelling of the hands and feet, or abdomen (ascites), especially in alcoholics Drowsiness, blurred vision Confusion, unusual behavior, agitation, hallucinations, delirium Coughing[ehealthstar.com]
Snoring
  • The night before his death, his family reported he drank a large amount of water, vomited, collapsed, and snored loudly while sleeping, but they did not view the event seriously as he did it routinely. The following morning, he was found dead.[ncbi.nlm.nih.gov]
Nausea
  • The condition may go unrecognised in the early stages when the patient may have symptoms of confusion, disorientation, nausea, and vomiting, but also changes in mental state and psychotic symptoms.[doi.org]
  • Home British & World English water intoxication water intoxication noun Medicine A condition resulting from excessive water intake or administration, or from impaired water excretion, characterized by headache, nausea, unsteadiness, and confusion, progressing[en.oxforddictionaries.com]
  • At first, when the intoxication is mild, you may feel light-headedness, dizziness, or nausea.[athleticheartsf.com]
  • When the brain is affected, it begins to swell, and symptoms range from confusion to nausea, and in extreme cases, seizures. Without proper treatment, brain stem herniation can occur, which can be fatal.[ahchealthenews.com]
  • With more severe cases of hyponatremia, you may need to take medications to offset the feelings of nausea and headaches.[symptomfind.com]
Hiccup
  • Metabolic disturbances have not reoccurred despite persistent hiccup and potomania during 2 years of urea therapy.[ncbi.nlm.nih.gov]
Psychiatric Symptoms
  • The findings revealed a strong relationship between SIWI and severe psychiatric symptoms, including psychosis and a broad range of psychiatric symptoms.[ncbi.nlm.nih.gov]
Anger
  • Anger and vomiting were found to be the two most predominant symptoms experienced when excess fluid consumption occurred.[ncbi.nlm.nih.gov]
Polyuria
  • Increased water intake (polydipsia) is followed by urination of high amount of diluted urine (polyuria) which are the main initial symptoms of WI. We present four case reports of WI.[ncbi.nlm.nih.gov]
  • We conclude that the incorporation of a vasopressin assay improves accuracy in the differential diagnosis of polyuria. (N Engl J Med. 1981; 305:1539–46.)[doi.org]
Seizure
  • Patient consciousness returned to normal by day 5 after the seizure. In patients treated with desmopressin the risk of a seizure or altered level of consciousness can be minimized by not ingesting large quantities of fluid.[ncbi.nlm.nih.gov]
Confusion
  • As the sodium concentration falls, the symptoms progress from confusion to drowsiness and eventually coma.[doi.org]
  • The acute drop in serum osmolality leads to cerebral edema, causing headaches, confusion, seizures, and death.[ncbi.nlm.nih.gov]
  • The most common symptoms of the condition in small children are confusion, fatigue and headache, but bodily temperature may decrease slightly as well, and the baby can become irritable or sleepy.[ic.steadyhealth.com]
Altered Mental Status
  • If left untreated, the condition can lead to an altered mental status, seizures, and death. Unfortunately, many practitioners have difficulty recognizing the condition and treating it appropriately.[sciencedaily.com]
  • More severe cases lead to vomiting, headache, altered mental status such as confusion, agitation and delirium, as well as seizure and coma.[mirror.co.uk]
  • ‘Early symptoms of EAH include nausea, vomiting and headache, which can rapidly progress to confusion, altered mental status, seizure, and death if untreated,’ the doctors wrote in the case report.[dailymail.co.uk]
  • DISCUSSION These examples illustrate a well-described spectrum of symptoms that characterize water intoxication, consisting of altered mental status (typically irritability or somnolence), hypothermia, edema, and seizure. 1, 12 Symptoms are preceded by[pediatrics.aappublications.org]
Stupor
  • A 44-year-old woman was admitted because of stupor. She had consumed 3 liters of water due to thirst after drinking alcohol. Laboratory findings on admission revealed marked hyponatremia (sodium: 115 mEq/l).[ncbi.nlm.nih.gov]
  • As the electrolyte levels get dangerously out of balance, body systems begin to fail and the sufferer exhibits signs of crisis such as diarrhea, over-salivation, stupor, vomiting, muscle tremors, confusion, frequent urination and other general symptoms[erowid.org]
Neurologic Manifestation
  • However, it is reported that non-neurological manifestations such as rhabdomyolysis are comparatively rare. The mechanism underlying rhabdomyolysis remains controversial. To investigate this further, we evaluated 22 SIWI patients for rhabdomyolysis.[ncbi.nlm.nih.gov]

Workup

A past medical history about disease and drug profile will be gathered, followed by physical examination of signs and symptoms. However, physical examination alone would not be sufficient to diagnose the condition of hyponatremia that has occurred due to water intoxication. Therefore, a complete blood profile along with urine tests to determine the levels of sodium level would be required.

Blood tests to assess drug intoxication and underlying disease conditions such as diabetes would also form an important part of diagnostic procedure. Along with this, mental health screening for determining presence of psychiatric illness is also indicated [8].

Hyponatremia
  • Water intoxication is an unusual but potentially lethal cause of perioperative hyponatremia. We report a patient with severe postoperative hyponatremia resulting from excess perioperative water consumption.[ncbi.nlm.nih.gov]
Hypouricemia
  • This finding, taken together with the patient's decreased free water clearance, inhibition of the renin-aldosterone system and hypouricemia with elevated uric acid clearance led us to make a tentative diagnosis as secondary SIADH, and the diagnosis was[karger.com]

Treatment

In the initial stages, restricting fluid intake forms the basis of treatment regime in order to correct hyponatremia. This is followed by treating underlying disease conditions. The patient would also be put on diuretics in order to improve the sodium levels. In more severe cases, hospitalization would be indicated. Intravenous administration of sodium is indicated to increase the serum sodium levels. Medications would also be required to effectively manage the symptoms associated with water intoxication [9].

Prognosis

Prognosis of patients suffering from water intoxication is fairly good if the condition is promptly treated when the first signs and symptoms appear. However, delay in initiation of treatment can call for irreversible damage to set in and eventually cause death.

Etiology

Excessive consumption of water knowingly or unknowingly can cause overhydration to set in. Certain medications can increase the thirst in individuals which can eventually cause an increased consumption of water. Increase in thirst mechanism can also be an indication of some underlying disease condition such as diabetes. Psychiatric illnesses can also lead to compulsive drinking of water. In addition, other risk factors for water intoxication include low body mass in infants, heat stress or overexertion, iatrogenic and drinking water for some sort of competition. Individuals who adhere to a strict dietary regime for intentional weight loss, where they are required to consume more water are at an increased risk for developing water intoxication [2] [3].

Epidemiology

According to various research studies carried out across the globe, it was reported that water intoxication can be a significant cause of mortality amongst patients suffering from schizophrenia. Of 353 patients under a study, about 38 were found to be polydipsic and one third of them was at an increased risk of water intoxication.

Sex distribution
Age distribution

Pathophysiology

In the condition of water intoxication, the electrolyte content in the fluid outside the cells is extremely low in contrast to what is present inside the cells. Such a kind of phenomenon causes the fluid to shift, in order to balance the concentration. This in turn causes the cells to swell, which eventually increases the intracranial pressure. This is what gives rise to the preliminary signs and symptoms of water intoxication. If the condition is not corrected, then the brain cells further undergo swelling giving rise to cerebral edema which occurs due to interruption in blood flow [4].

Prevention

Individuals are advised against drinking more than 1 litre of water per hour. Appropriate hydration prior to participating in race or any other strenuous activities can also help prevent excessive drinking of water. Athletes are also advised to sip in sports beverages containing sodium and potassium. These would help replenish the lost electrolytes. Individuals are also advised to consult doctor if they experience a strong desire to drink water or are excessively thirsty [10].

Summary

The condition is also termed as dilutional hyponatremia. Just like any other substance, water too can turn poisonous for the body if consumed beyond limits. It has been estimated that majority of death that have occurred due to water intoxication have resulted from excessive consumption of water by individuals who are either participating in contests or by athletes who after heavy exercise have consumed large amounts of water [1].

Patient Information

  • Definition: Water intoxication occurs when there is excessive consumption of water either knowingly or unknowingly. The condition can really turn fatal if treatment is not initiated on time. Various complications of water intoxication include onset of cerebral edema and death in many cases. Individuals suffering from underlying disease condition such as diabetes or psychiatric illnesses are at an increased risk of water intoxication.
  • Cause: Excessive consumption of water in a short period of time can lead to water intoxication. Underlying disease conditions can increase the urge to drink water which can lead to onset of water intoxication. In addition, other factors include medications such as diuretics, disease conditions such as hypothyroidism, dehydration, kidney and heart diseases.
  • Symptoms: Preliminary symptoms of water intoxication include headache, vomiting, slurred speech, feeling of restlessness and bloating. In severe cases, individuals may also develop seizures, muscle cramps and can even enter the comatose stage.
  • Diagnosis: Physical examination of the signs and symptoms is done at the preliminary level. In addition, blood tests and urine analysis are required to determine the levels of sodium. These tests are also required for evaluating underlying disease conditions that is causing hyponatremia.
  • Treatment: Treatment of water intoxication is carried out by restricting the fluid intake in the initial levels. This is followed by administration of diuretics to increase the sodium concentration. In severe cases, hospitalization would be required to administer sodium intravenously.

References

Article

  1. Adrogué HJ, Madias NE.The challenge of hyponatremia. J Am SocNephrol 2012; 23:1140.
  2. vLanggard H, Smith WO. Self-induced water intoxication without predisposing illness. N Engl J Med 1964;266:378–381.
  3. Adrogué HJ, Madias NE. Hyponatremia. N Engl J Med 2000; 342:1581.
  4. Ayus JC, Varon J, Arieff AI. Hyponatremia, cerebral edema, and noncardiogenic pulmonary edema in marathon runners. Ann Intern Med 2000; 132:711.
  5. Sterns RH, Ocdol H, Schrier RW, et al. Hyponatremia: Pathophysiology, diagnosis, and therapy, in Narins RG (ed): Maxwell &Kleeman's Clinical Disorders of Fluid and Electrolyte Metabolism. New York, McGraw- Hill Health Professions Division, 1994, ed 5, pp 590–599.
  6. Halawa I, Andersson T, Tomson T. Hyponatremia and risk of seizures: a retrospective cross-sectional study. Epilepsia 2011; 52:410.
  7. Sterns RH. Severe symptomatic hyponatremia: treatment and outcome. A study of 64 cases. Ann Intern Med 1987; 107:656.
  8. Verbalis JG, Goldsmith SR, Greenberg A, et al. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med 2013; 126:S1.
  9. Soupart A, Decaux G. Therapeutic recommendations for management of severe hyponatremia: current concepts on pathogenesis and prevention of neurologic complications. ClinNephrol 1996; 46:149.
  10. Ayus JC, Arieff A, Moritz ML. Hyponatremia in marathon runners. N Engl J Med 2005; 353:427.

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Last updated: 2019-07-11 21:29