Severe hyponatremia – a form of presentation of hypophyseal apoplexy

Abstract

The authors describe the case of a 68-year-old man, formerly a
smoker with a history of alcoholism. Admitted to the emergency
department complaining of pollakiuria and hypogastric pain
evolving for a couple of days and fever in the previous week,
with headaches and vomiting. He presented diffuse hair loss
and gynecomastia; neurological examination was normal. Severe hyponatremia was found (Na+ 113 mEq/L), along with low
serum osmolarity, normal urinary osmolarity, urinary ionogram
and urinalysis. He started intravenous fluid therapy to correct the
natremia. The chest and brain computed tomography scans were
normal, the abdominal ultrasound showed signs of chronic liver
disease. The hormonal study showed decreased levels of cortisol,
adrenocorticotropic hormone, luteinizing hormone, follicle-stimulating hormone, testosterone and thyroxine; triiodothyronine,
thyroid-stimulating hormone and prolactine were normal.
The pituitary magnetic resonance imaging revealed intra-adenomatous hemorrhagic lesion, establishing the diagnosis
of hypophyseal apoplexy. Since surgery was not recommended,
he started hydrocortisone and levothyroxine therapy with clinical
and analytic improvement.
This case shows how important it is to ascertain hyponatremia
etiology.