Dyskinesia-hyperpyrexia syndrome（DHS）is an acute hyperpyrexia syndrome that is different from Parkinsonism-hyperpyrexia syndrome and serotonin syndrome in patients with advanced Parkinson's disease（PD），with the main symptoms of high fever，disturbance of consciousness，elevated creatine kinase，and dyskinesia. Syndrome of inappropriate secretion of antidiuretic hormone（SIADH）is a clinical syndrome caused by excessive secretion of antidiuretic hormone，which leads to the symptoms of dilutional hyponatremia，water retention，and increases in urine sodium and urine osmotic pressure. DHS has not received widespread attention in clinical practice，and there are rare reports of DHS comorbid with SIADH. This article reports the diagnosis and treatment processes of a case of DHS comorbid with SIADH and reviews the relevant literature，in order to guide the diagnosis and treatment of PD-related critical diseases.
Hyponatremia

An 18-day-old male infant was admitted to the hospital due to recurrent hyperkalemia for more than 10 days. The neonate had milk refusal and dyspnea. The blood gas analysis revealed recurrent hyperkalemia, hyponatremia and metabolic acidosis. Adrenocortical hormone replacement therapy was ineffective. Additional tests showed a significant increase in aldosterone levels. Family whole exome sequencing revealed that the infant had compound heterozygous in the SCNNIA gene, inherited from both parents. The infant was diagnosed with neonatal systemic pseudohypoaldosteronism type I. The infant's electrolyte levels were stabilized through treatment with sodium polystyrene sulfonate and sodium supplement. The infant was discharged upon clinical recovery. This study provides a focused description of differential diagnosis of salt-losing syndrome in infants and introduces the multidisciplinary management of neonatal systemic pseudohypoaldosteronism type I.
Infant ; Infant, Newborn ; Humans ; Male ; Pseudohypoaldosteronism/genetics* ; Hyperkalemia/etiology* ; Hyponatremia/diagnosis* ; Diagnosis, Differential

Pituitary immune-related adverse events induced by programmed cell death protein 1 inhibitors in advanced lung cancer patients: A report of 3 cases SUMMARY Programmed cell death protein 1 (PD-1) and its ligand 1 (PD-L1) have been widely used in lung cancer treatment, but their immune-related adverse events (irAEs) require intensive attention. Pituitary irAEs, including hypophysitis and hypopituitarism, are commonly induced by cytotoxic T lymphocyte antigen 4 inhibitors, but rarely by PD-1/PD-L1 inhibitors. Isolated adrenocorticotropic hormone(ACTH) deficiency (IAD) is a special subtype of pituitary irAEs, without any other pituitary hormone dysfunction, and with no enlargement of pituitary gland, either. Here, we described three patients with advanced lung cancer who developed IAD and other irAEs, after PD-1 inhibitor treatment. Case 1 was a 68-year-old male diagnosed with metastatic lung adenocarcinoma with high expression of PD-L1. He was treated with pembrolizumab monotherapy, and developed immune-related hepatitis, which was cured by high-dose methylprednisolone [0.5-1.0 mg/(kg·d)]. Eleven months later, the patient was diagnosed with primary gastric adenocarcinoma, and was treated with apatinib, in addition to pembrolizumab. After 17 doses of pembrolizumab, he developed severe nausea and asthenia, when methylprednisolone had been stopped for 10 months. His blood tests showed severe hyponatremia (121 mmol/L, reference 137-147 mmol/L, the same below), low levels of 8:00 a.m. cortisol (< 1 μg/dL, reference 5-25 μg/dL, the same below) and ACTH (2.2 ng/L, reference 7.2-63.3 ng/L, the same below), and normal thyroid function, sex hormone and prolactin. Meanwhile, both his lung cancer and gastric cancer remained under good control. Case 2 was a 66-year-old male with metastatic lung adenocarcinoma, who was treated with a new PD-1 inhibitor, HX008, combined with chemotherapy (clinical trial number: CTR20202387). After 5 months of treatment (7 doses in total), his cancer exhibited partial response, but his nausea and vomiting suddenly exacerbated, with mild dyspnea and weakness in his lower limbs. His blood tests showed mild hyponatremia (135 mmol/L), low levels of 8:00 a.m. cortisol (4.3 μg/dL) and ACTH (1.5 ng/L), and normal thyroid function. His thoracic computed tomography revealed moderate immune-related pneumonitis simultaneously. Case 3 was a 63-year-old male with locally advanced squamous cell carcinoma. He was treated with first-line sintilimab combined with chemotherapy, which resulted in partial response, with mild immune-related rash. His cancer progressed after 5 cycles of treatment, and sintilimab was discontinued. Six months later, he developed asymptomatic hypoadrenocorticism, with low level of cortisol (1.5 μg/dL) at 8:00 a.m. and unresponsive ACTH (8.0 ng/L). After being rechallenged with another PD-1 inhibitor, teslelizumab, combined with chemotherapy, he had pulmonary infection, persistent low-grade fever, moderate asthenia, and severe hyponatremia (116 mmol/L). Meanwhile, his blood levels of 8:00 a.m. cortisol and ACTH were 3.1 μg/dL and 7.2 ng/L, respectively, with normal thyroid function, sex hormone and prolactin. All of the three patients had no headache or visual disturbance. Their pituitary magnetic resonance image showed no pituitary enlargement or stalk thickening, and no dynamic changes. They were all on hormone replacement therapy (HRT) with prednisone (2.5-5.0 mg/d), and resumed the PD-1 inhibitor treatment when symptoms relieved. In particular, Case 2 started with high-dose prednisone [1 mg/(kg·d)] because of simultaneous immune-related pneumonitis, and then tapered it to the HRT dose. His cortisol and ACTH levels returned to and stayed normal. However, the other two patients' hypopituitarism did not recover. In summary, these cases demonstrated that the pituitary irAEs induced by PD-1 inhibitors could present as IAD, with a large time span of onset, non-specific clinical presentation, and different recovery patterns. Clinicians should monitor patients' pituitary hormone regularly, during and at least 6 months after PD-1 inhibitor treatment, especially in patients with good oncological response to the treatment.
Adenocarcinoma of Lung/drug therapy* ; Adrenocorticotropic Hormone/therapeutic use* ; Aged ; B7-H1 Antigen/therapeutic use* ; Humans ; Hydrocortisone/therapeutic use* ; Hyponatremia/drug therapy* ; Hypopituitarism/drug therapy* ; Immune Checkpoint Inhibitors ; Lung Neoplasms/pathology* ; Male ; Methylprednisolone/therapeutic use* ; Middle Aged ; Nausea/drug therapy* ; Pituitary Gland/pathology* ; Pneumonia ; Prednisone/therapeutic use* ; Programmed Cell Death 1 Receptor/therapeutic use* ; Prolactin/therapeutic use*

INTRODUCTION: A physiological profiling study was conducted to evaluate thermal strain as well as fluid and electrolyte balances on heat-acclimatised men performing a 72-km route march in a field setting. METHODS: 38 male soldiers (age range 18-23 years) participated in the study, as part of a cohort that marched for 72 km, with loads for about 26 hours. Core temperature and heart rate sensors were used for the duration of the march. Fluid and food intake and output were monitored for the duration of the march. Blood samples were taken one day before the march (pre-march), immediately after the march (Post 1) and on the 15^th day after the march to ascertain recovery (Post 2) to assess fluid and electrolyte profiles. RESULTS: Mean core temperature was within safe limits, ranging from 37.1 to 38.1°C throughout the march. There was an overall decrease in serum sodium levels, a decline in serum sodium concentration in 28 participants and three instances of hyponatraemia (serum sodium concentration <135 mmol/L). CONCLUSION Our study found low thermal strain heat-acclimatised individuals during a 72-km route march. However, there was an overall decrease in serum sodium levels, even when the participants were allowed to drink ad libitum. Challenges of exercise-associated hyponatraemia during prolonged activities remain to be addressed.
Humans ; Male ; Adolescent ; Young Adult ; Adult ; Military Personnel ; Hyponatremia ; Water-Electrolyte Balance/physiology* ; Exercise/physiology* ; Sodium

Objectives: To determine if online team-based learning (TBL) is effective in improving knowledge outcomes and confidence about hyponatremia in its clinical recognition, classification, diagnostic work up, and management among fourth year medical students Study design: A quantitative evaluative design. Population and Setting: Fourth year medical students (medical clerks) rotating in the Department of Medicine, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines from July to December 2020. Methodology: A modified TBL workshop is adopted in teaching fourth year medical clerks about hyponatremia. The TBL session was held with a group of medical clerks weekly from July to December 2020. As a pre-workshop preparation, the medical clerks were assigned to read ahead of time the clinical practice guidelines on the diagnosis and treatment of hyponatremia developed by the European Renal Best Practice. After reading it, they were asked to answer an Individual Readiness Assessment Test (IRAT) composed of 20 case-based multiple-choice questions (MCQ). The group was thereafter divided into 4 subgroups and asked to discuss the same MCQ-based exam and present it as a Team Readiness Assessment Test (TRAT). As each subgroup presented their IRAT, the facilitator discussed the underlying concepts for each question and its application in actual cases of hyponatremia. The facilitator then summarized the learning outcomes at the end of the TBL workshop. For team application (TAPP), the students created a concept map and formulated admitting orders. The medical clerks were then surveyed on their confidence in hyponatremia diagnosis and management during pre-TBL workshop, after IRAT, after TRAT, and after discussion with the facilitator. Statistical Design: Descriptive statistics were used to summarize the study variables and included the mean, standard deviation, frequency, and percentage. Within-group comparisons of different outcomes across the different timeframes were conducted using one-way multivariate analysis of variance (one-way MANOVA). Cognizant that the study has multiple outcomes or dependent variables which were compared at four different timeframes, multivariate analysis was utilized to minimize the inflation of family-wise errors (FWE). Results: Comparative analysis indicated that the mean readiness scores of the respondents after TRAT was significantly higher (t=–91.61, p=0.001) compared to the mean readiness scores after IRAT. Comparative analysis using paired t-test indicated that the mean confidence scores of the respondents in the recognition, diagnosis, and treatment of hyponatremia were significantly higher among the respondents after the IRAT (t=–24.26, p=0.001), TRAT (t=–34.58, p=0.001), and facilitator discussion (t=–42.72, p=0.001) approaches compared to the mean pre-TBL confidence score. The mean knowledge score of the respondents on the creation of a concept map and the formulation of admission orders of patients with hyponatremia was 25.54±1.98 (95% CI 25.26-25.82). Conclusion: Findings of this study are not to be interpreted as demonstrating a causal relationship. Furthermore, the results are only hypothesis-generating at best. The study showed that online TBL has the potential to be an effective method in improving knowledge outcomes and confidence about hyponatremia in its clinical recognition, classification, diagnostic work-up, and management among fourth year medical students. As a preliminary evaluation of TBL, further studies can be conducted to determine its effectiveness as a teaching modality in the medical curricula in comparison to the traditional method before being adopted as a teaching-learning activity. Key words: team-based learning, online learning, COVID-19, hyponatremia, medical education
Education, Distance ; COVID-19 ; Hyponatremia

Adult ; Aged ; Aged, 80 and over ; Betacoronavirus ; Coronavirus Infections ; complications ; Female ; Glomerular Filtration Rate ; Glycosuria ; epidemiology ; Hospitalization ; Humans ; Hyponatremia ; epidemiology ; Kidney Tubules, Proximal ; physiopathology ; Male ; Middle Aged ; Pandemics ; Pneumonia, Viral ; complications ; Retrospective Studies

PURPOSE: This study aimed to identify risk factors for brain damage in infants with late-onset circulatory collapse (LCC), a circulatory failure that responds to glucocorticoid therapy. METHODS: We retrospectively reviewed 167 infants (gestational age < 35 weeks) who had hypotension between April 2009 and March 2017 at Boramae Medical Center. Forty infants were diagnosed with LCC and divided into two groups based on ultrasonography and magnetic resonance imaging findings: infants with periventricular leukomalacia (n=9) and those with normal images (n=31) after LCC. The clinical factors of these two groups, including perinatal characteristics, clinical features during the LCC period, and neonatal morbidities, were compared. RESULTS: There were no significant differences in perinatal characteristics and postnatal morbidities between the two groups. Postnatal age was greater in the group with brain damage (16 days vs. 24 days, P=0.047). The lowest mean blood pressure (MBP) and lowest serum sodium concentration were significantly lower in the brain damage group (19 mm Hg vs. 22 mm Hg, P=0.034; 125 mmol/L vs. 129 mmol/L, P=0.043). There were no significant differences in other clinical factors, including cortisol levels, and inotrope and hydrocortisone use. In multivariate logistic regression, older postnatal age (odds ratio [OR], 1.147; P=0.049), lower MBP (OR, 0.616; P=0.031), and lower sodium concentration (OR, 0.728; P=0.037) during the LCC period highly predicted brain damage in infants with LCC (area under the curve 0.882, P=0.001). CONCLUSION: Close monitoring of LCC signs even in long-term stable preterm infants and management for preventing severe hyponatremia and hypotension are important to minimize the occurrence of brain damage in infants with LCC.
Adrenal Insufficiency ; Blood Pressure ; Brain ; Humans ; Hydrocortisone ; Hyponatremia ; Hypotension ; Infant ; Infant, Newborn ; Infant, Premature ; Leukomalacia, Periventricular ; Logistic Models ; Magnetic Resonance Imaging ; Retrospective Studies ; Risk Factors ; Shock ; Sodium ; Ultrasonography

Pseudohypoaldosteronism (PHA) in infants is manifested by presence of hyperkalemia, hyponatremia, and metabolic acidosis. At initial stages, PAH is generally suspected as congenital adrenal hyperplasia. Transient PHA has been reported in infants with urinary tract infection and urinary tract malformation. We report a case of 5-month-old infant with failure to thrive and finally diagnosed with transient PHA due to urinary tract infection with vesicoureteral reflux.
Acidosis ; Adrenal Hyperplasia, Congenital ; Failure to Thrive* ; Humans ; Hyperkalemia ; Hyponatremia ; Infant* ; Pseudohypoaldosteronism* ; Urinary Tract ; Urinary Tract Infections ; Vesico-Ureteral Reflux

No abstract available.
Demyelinating Diseases ; Hyponatremia

Extrapontine myelinolysis is a demyelinating disorder usually caused by rapid correction of chronic hyponatremia. We present an 82-year-old female patient with general weakness, and severe hyponatremia (103 mEq/L) which was corrected 14 mEq/L during 21 hours. She was stuporous and presented status epilepticus. Brain T2-weighted image showed high signal intensities of bilateral thalami and electroencephalogram monitoring indicated right hemisphere lateralized periodic discharges, maximal in the right frontal region. This case shows that status epilepticus can occur in a patient of extrapontine myelinolysis involved bilateral thalami without pontine lesions.
Aged, 80 and over ; Brain ; Demyelinating Diseases ; Electroencephalography ; Female ; Humans ; Hyponatremia ; Myelinolysis, Central Pontine ; Status Epilepticus ; Stupor