A 52-year-old man was admitted to A&E presenting with a fever nausea and vomiting that has lasted over 2 weeks. However, in the last few days he has become irritable and confused. ON PRESENTATION Chest X-ray, ultrasound abdomen and echocardiography were all normal. Blood serum tests revealed the following: Serum analysis Test Result Reference range Sodium 125 mmol/L (135-145 mmol/L) (3.6-5.0 Potassium 4.2 mmol/L mmol/L) Chloride 100.0 mmol/L (98-107 mmol/L) Uric acid (3.0-7.2 1.4 mg/dL mg/dL) (3.3-6.7 mmol/L) (50-110 Urea Creatinine 4.7 mmol/L Omol/L 100 Omol/L) Glucose mmol/L (4.0-8.0 mmol/L) (275-295 5 Serum osmolality mOsmol/Kg) 245 mOsmol/Kg Serum cortisol 253.8 nmol/L (221-552 nmol/L) LH IU/L 1.6 (0.5-9.0 IU/L) FSH 3.4 IU/L (1.0-8.0 IU/L) GH (0.5-3.0 0.65 ug/L Hg/L) 2.5 (0.2-4.0 TSH mU/L mU/L) Free T pmol/L) pmol/L (12-25 16 Urine analysis Urinary osmolality 900 mOsmol/Kg) mosmol/Kg (300- 524 Sodium 44 mmol/L Fractional excretion 1.2% of sodium
FOLLOW UP-ONE WEEK LATER Subsequently the patient became less responsive with a decreased level of consciousness and a low Glasgow Coma Scale score. A lumbar puncture was performed and revealed that there was no fungal smear and the acid-fast bacilli PCR was negative. Lumbar Puncture Test Reference Result range Protein 314 mg/dL (<45 mg/dL) Lactate dehydrogenase 7 U/mL) Total Leucocyte count 5) U/mL 63 (2- 490 (90% lymphocytes (0 After two weeks his serum sodium continued to fall to 118 mEq/L with a high urine output (4L/24Hr) and a spot urinary sodium of 188 mEq/L (REFERENCE: 20-40 mEq) and a spot urine osmolarlity of 762 mosm/Kg. Fluid restriction did not improve the patient
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