Challenges of Diagnosing Hyponatremic Syndromes in Pulmonary and Extra Pulmonary Tuberculosis

Abstract

Introduction Pulmonary tuberculosis (PTB) is one of the rare pulmonary infections causing hyponatremia (serum sodium ˂135 mmol/L) and severe hyponatremia (serum sodium ˂125 mmol/L). Although the major cause of hyponatremia in TB patients is syndrome of inappropriate antidiuretic hormone (SIADH) secretion, cerebral salt wasting syndrome (CSWS) can occur and requires evidence of inappropriate urinary salt losses and reduced arterial blood volume. Adrenal insufficiency (AI) is rare in TB with scanty literature describing it. The two reported cases highlight three possible causes of severe symptomatic hyponatremia in TB pleural effusion and disseminated TB, their treatment modalities, and the need to increase the index of suspicion to diagnose TB hyponatremia in children.

Case Report Case 1: a 10-year-old girl with TB pleural effusion who developed recurrent hyponatremia in the first few weeks of anti-TB treatment which was responsive to sodium correction. Case 2: an 8-year-old girl presenting to our facility with presumptive TB. She deteriorated over several months and progressed to disseminated TB with AI.

Discussion Early diagnosis and prompt and correct treatment of TB hyponatremia cannot be overemphasized, as AI, SIADH secretion, and CSWS, each require different therapeutic regimens, most especially AI on its own poses a huge clinical challenge.

Conclusion A high index of suspicion, with intensified case finding at all levels of care, is necessary to identify and manage children with TB hyponatremia because early diagnosis and prompt treatment is lifesaving.

Keywords

tuberculosis - hyponatremia - SIADH - CSWS - adrenal insufficiency

Authors' Contributions

Conception and design, or acquisition, or analysis and interpretation of data: A.U.E., E.A.O, and K.O.I.

Drafting the article or revising it critically for important intellectual content: A.U.E.

Final approval of the version to be published: E.A.O., A.I.C., and K.O.I.

Agreement to be accountable for all aspects of the work to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: A.U.E., A.I.C., E.B.A., K.C.A., E.J.I., and E.S.B.

Publication History

Received: 11 September 2020

Accepted: 10 November 2020

Article published online:
14 January 2021

• References

• 1 Jonaidi Jafari N, Izadi M, Sarrafzadeh F, Heidari A, Ranjbar R, Saburi A. Hyponatremia due to pulmonary tuberculosis: review of 200 cases. Nephrourol Mon 2013; 5 (01) 687-691
• 2 Vinnard C, Blumberg EA. Endocrine and metabolic aspects of tuberculosis. Microbiol Spectr 2017; 5 (01) 1-19
• 3 Park SJ, Shin JI. Inflammation and hyponatremia: an underrecognized condition?. Korean J Pediatr 2013; 56 (12) 519-522
• 4 Oh JY, Shin JI. Syndrome of inappropriate antidiuretic hormone secretion and cerebral/renal salt wasting syndrome: similarities and differences. Front Pediatr 2015; 2: 146
• 5 Jayakumar B, Sambasivam E. Clinical profile, etiology, management and outcome of serum sodium disturbances in children admitted in PICU. Int J Res Med Sci 2017; 5 (06) 2546-2551
• 6 Kinjo T, Higuchi D, Oshiro Y. et al. Addison's disease due to tuberculosis that required differentiation from SIADH. J Infect Chemother 2009; 15 (04) 239-242
• 7 Lee P, Ho KK. Hyponatremia in pulmonary TB: evidence of ectopic antidiuretic hormone production. Chest 2010; 137 (01) 207-208
• 8 Camous L, Valin N, Zaragoza JL. et al. Hyponatraemic syndrome in a patient with tuberculosis--always the adrenals?. Nephrol Dial Transplant 2008; 23 (01) 393-395
• 9 Bosnak M, Özdoğan H, Yel S, Bosnak V, Haspolat K. Hyponatremia in a child with tuberculosis meningitis in PICU: cerebral salt wasting syndrome. Dicle Med J 2009; 36 (03) 200-202
• 10 Verbalis JG. The curious story of cerebral salt wasting: fact or fiction?. Clin J Am Soc Nephrol 2020; 15 (11) 1666-1668
• 11 Friedman E. Tuberculosis of the adrenal glands in a child of twelve, with necropsy. Am J Dis Child 1936; 51 (01) 113-117
• 12 Barnes DJ, Naraqi S, Temu P, Turtle JR. Adrenal function in patients with active tuberculosis. Thorax 1989; 44 (05) 422-424
• 13 Al-Mamari A, Balkhair A, Gujjar A. et al. A case of disseminated tuberculosis with adrenal insufficiency. Sultan Qaboos Univ Med J 2009; 9 (03) 324-327
• 14 Upadhyay J, Sudhindra P, Abraham G, Trivedi N. Tuberculosis of the adrenal gland: a case report and review of the literature of infections of the adrenal gland. Int J Endocrinol 2014; 2014: 876037
• 15 Miller BS, Spencer SP, Geffner ME. et al. Emergency management of adrenal insufficiency in children: advocating for treatment options in outpatient and field settings. J Investig Med 2020; 68 (01) 16-25
• 16 Poddighe D. Common finding of mild hyponatremia in children evaluated at the Emergency Department and its correlation with plasma C-reactive protein values. Minerva Pediatr 2016; 68 (03) 173-176
• 17 Maesaka JK, Imbriano LJ, Miyawaki N. Evolution and evolving resolution of controversy over existence and prevalence of cerebral/renal salt wasting. Curr Opin Nephrol Hypertens 2020; 29 (02) 213-220
• 18 Auron M, Raissouni N. Adrenal insufficiency. Pediatr Rev 2015; 36 (03) 92-102 , quiz 103, 129
• 19 Bowden SA, Henry R. Pediatric adrenal insufficiency: diagnosis, management, and new therapies. Int J Pediatr 2018; 2018: 1739831
• 20 Bobbio F, Di Gennaro F, Marotta C. et al. Focused ultrasound to diagnose HIV-associated tuberculosis (FASH) in the extremely resource-limited setting of South Sudan: a cross-sectional study. BMJ Open 2019; 9 (04) e027179
• 21 Bélard S, Heuvelings CC, Banderker E. et al. Utility of point-of-care ultrasound in children with pulmonary tuberculosis. Pediatr Infect Dis J 2018; 37 (07) 637-642
• 22 Ewa AU, Ochang EA, Inaku KO, Anachuna KC, Imoke EJ. Recurrent hyponatremia in tuberculous pleural effusion-who is the enemy within?. Am J Respir Crit Care Med 2019; 199: A4974