A report describes a case of a 27-year-old man, who presented with nausea, vomiting, diarrhea, a swollen face and swollen extremities, and dark-colored urine, which developed over the previous two days. 

Laboratory tests revealed leukocytosis with a predominance of granulocytes, increased urea and creatinine, and hypokalemia. Biochemical urine tests revealed microscopic hematuria and positive proteins, and arterial blood analysis showed hyponatremia with a sodium level <100 mmol/L. He thus received fluid restriction and penicillin at 1.6 million units every 12 h, along with a proton pump inhibitor and metoclopramide.

The patient developed an acute symptomatic seizure and coma (Glasgow coma score 3) and thus was transported to the Emergency Center, where he was comatose (Glasgow coma score 3) and normotensive (140/70 mm Hg), with a respiratory rate of 30 breaths/min and a heart rate of 90 beats/min. A CT scan of the abdomen, abdominal ultrasonography, and a chest X-ray, was normal. Sodium levels still indicated hyponatremia and low plasma osmolality, while urine osmolality was relatively high. He showed no signs of hypervolemia and thus received hypertonic sodium, fluid restriction, correction of potassium, and antibiotics. His Sodium levels in blood were gradually normalized (by not more than 0.5 mmol/L/h) to avoid central pontine myelinosis, and the patient gradually regained consciousness over the next three days. For Hypertension, he received angiotensin-converting enzyme inhibitors many a time. His high urea and creatinine levels normalized, and he entered the recovery phase with diuresis of 4,500 mL/day.

On the fourth day, the patient was shifted to the Department of Endocrinology, Diabetes, and Metabolic Disorders to probe the etiology of hyponatremia. His thorough examination revealed a history of sore throat and fatigue ten days before admission to the hospital. These symptoms lasted for a week, and he attributed them to a cold. Despite being unwell for a week, he drank 5,000 mL of beer, 400-500 mL of liquor, and 2,000 mL of energy drink (containing 25 mL/100 mL of caffeine and taurine, vitamins, sugar, citric acid, and caramel) during a 6-h period. The next morning, he noticed swelling in his entire face, neck, and extremities, which was followed by nausea, repeated vomiting, diarrhea, and dark-colored urine, along with excessive weakness and fatigue, which continued to progress. Two days since then, he was hospitalized at the General Hospital, where a throat swab culture test revealed Streptococcus beta haemolyticus of group A and a negative anti-streptolysin O titer. A repeated throat swab was negative, and seroconversion of a previously negative anti-streptolysin O titer (anti-streptolysin O titer 400 IU) occurred together with a decrease in C3 complement components levels. His Urea and creatinine levels and the daily urine volume started normalizing but proteinuria (with a sodium level of 1,800 mg/day) with microscopic hematuria persisted. The estimated glomerular filtration rate was 102 mL/min/1.73 m2. He also showed mild normocytic and normochromic anemia.

Based on the findings, he received the diagnosis of acute post-streptococcal glomerulonephritis. The severe acute hyponatremia followed by coma occurred due to excessive simultaneous consumption of fluids, alcohol, and caffeine. The normal levels of glycemia, thyroid hormones (free T3, free T4), thyroid-stimulating hormone, cortisol, and adrenocorticotropic hormone ruled out hypocortisolism and hypothyroidism as the cause of hyponatremia. 

The patient received a discharge after 14 days and received advice regarding hygiene & diet and to abstain from alcohol and energy drinks. At one month follow-up, he still showed the presence of proteinuria (sodium level 864 mg/day).

Icin T, Medic-Stojanoska M, Ilic T, Kuzmanovic V, Vukovic B, Percic I, Kovacev-Zavisic B: Multiple Causes of Hyponatremia: A Case Report. Med Princ Pract 2017;26:292-295. doi: 10.1159/000468938