From Hypernatremia to Hyponatremia: Sequential Central AVP Deficiency (AVP-D) and Cerebral Salt Wasting (CSW) in Tuberculous Meningitis (TBM)
https://doi.org/10.15605/jafes.041.S1
- Author:
Chia Yin Por
1
;
Ee Wen Loh
1
;
Pei Lin Chan
1
;
Florence Hui Sieng Tan
1
Author Information
1. Endocrinology Unit, Department of Medicine, Sarawak General Hospital
- Publication Type:Journal Article
- MeSH:
Hypernatremia;
Hyponatremia;
Tuberculosis, Meningeal
- From:
Journal of the ASEAN Federation of Endocrine Societies
2026;41(S1):84-
- CountryPhilippines
- Language:English
-
Abstract:
Introduction:Electrolyte imbalance is common in central nervous system
infections. Arginine vasopressin deficiency (AVP-D),
Cerebral Salt Wasting (CSW), and Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) are important etiologies that can cause opposing extremes of serum
sodium, posing diagnostic and therapeutic challenges.
We report a rare case of transient central AVP-D followed
by CSW secondary to tuberculous meningitis (TBM).
Case:An 18-year-old female presented with a 1-month history of
fever, reduced responsiveness, and visual hallucinations.
Her Glasgow Coma Scale was E4V1M4 with neck stiffness
and upper motor neuron signs. Initial investigations revealed
severe hyponatremia (119 mmol/L) and communicating
hydrocephalus with third ventricle ballooning on brain
imaging. Coupled with a positive tuberculosis contact,
anti-tuberculous therapy was initiated for probable TBM
alongside 3% saline correction prior to insertion of external
ventricular drain (EVD). Her condition deteriorated on day
5, requiring intubation for aspiration pneumonia. Repeated
imaging showed worsening hydrocephalus, necessitating
EVD revision. She subsequently developed polyuria (urine
output [UO] 150–300 mLs/hour), with biochemical findings
consistent with AVP-D (serum sodium 154 mmol/L; urine osmolality 96 mOsm/kg; urine sodium <20 mmol/L).
Intravenous desmopressin 1 mcg was administered, and
UO reduced to 30 mLs/hour. However, polyuria recurred
on Day 9, accompanied by tachycardia, hypotension, and
a rapid decline in serum sodium to 120 mmol/L. Diagnosis
of CSW was established (urine sodium 204 mmol/L; urine
osmolality 470 mOsm/kg). Oral fludrocortisone was
initiated and titrated to 0.4 mg daily to maintain serum
sodium >130 mmol/L. Due to persistent hydrocephalus,
right ventriculoperitoneal shunt was inserted on Day 22,
after which her UO gradually decreased, allowing tapering
of fludrocortisone. She remains on fludrocortisone 0.1 mg
daily with ongoing rehabilitation.
Conclusion:TBM can be complicated by SIADH, AVP-D, or CSW.
Concurrent AVP-D and CSW have not been reported.
This case highlights the dynamic electrolyte disturbances
in TBM which may lead to diagnostic confusion and
therapeutic error. Early recognition and tailored therapy,
alongside definitive management to reduce intracranial
pressure, are essential for optimal outcomes.
- Full text:2026080414154077922EP_A117.pdf
