A 42-year-old woman presented to our emergency department with headache, nausea, and
confusion after completing an Ironman triathlon. She performed the race at a slow
pace, in hot and dry weather. The first medical examination reported confusion with
a Glasgow Coma Scale score of 13. A few minutes later, she presented with seizures.
A cerebral computed tomographic (CT) scan showed major cerebral edema. Blood analysis
showed severe acute hyponatremia (123 mEq/L) with hypotonicity (255 mEq/L). Her clinical
condition quickly worsened, leading to a Glasgow Coma Scale score of 3 with fixed
dilated pupils. After intubation and mechanical ventilation, she was transferred to
the intensive care unit. A transcranial Doppler ultrasonography (TCD) showed intracranial
hypertension signs motivating emergency osmotherapy by infusion of 20% mannitol over
15 minutes. To guide the therapeutics, an intracranial pressure monitoring was inserted,
showing a value of 30 mm Hg. A few minutes later, intracranial pressure (ICP) increased
to 68 mm Hg with a low cerebral perfusion pressure. Concomitantly, another TCD reported
critical flows with poor cerebral perfusion. A second infusion of mannitol led to
an ICP lowering and a decrease in pupil size after 10 minutes. During the next hours,
the patient stayed stable without further intervention. Sixteen hours later, natremia
was normal, mainly due to hyperdiuresis. On day 2, the tracheal tube was removed.
A cerebral CT scan showed disappearance of cerebral edema. One month later, the patient
had good recovery apart from some residual memory problems. Six months later, she
was able to come back to work.
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References
- Statement of the second international exercise-associated hyponatremia consensus development conference, New Zealand, 2007.Clin J Sport Med. 2008; 18: 111-121
- Hyponatremia among runners in the Boston Marathon.N Engl J Med. 2005; 352: 1550-1556
- Exertional dysnatremia in collapsed marathon runners: a critical role for point-of-care testing to guide-appropriate therapy.Am J Clin Pathol. 2009; : 336-340
- Three independent biological mechanisms cause exercise-associated hyponatremia: evidence from 2,135 weighed competitive athletic performances.Proc Natl Acad Sci U S A. 2005; 102: 18550-18555
- Exercise-associated hyponatremia.Clin J Am Soc Nephrol. 2007; 2: 151-161
Article Info
Publication History
Published online: December 30, 2013
Accepted:
December 18,
2013
Received:
December 14,
2013
Identification
Copyright
© 2014 Elsevier Inc. Published by Elsevier Inc. All rights reserved.