Talks
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Medical Student
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Medical Student
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Internal Medicine
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Internal Medicine
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Patient Care
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Case Report
Abstract
Background: Hyponatremia is defined as a serum sodium level less than 135 mEq/L and is considered severe with levels below 125 mEq/L. It is the most common electrolyte abnormality amongst hospitalized patients with a prevalence of 20-35%. Symptoms can range anywhere from nausea, vomiting, fatigue, headache, and muscle cramps to more severe manifestations such as altered mental status and seizures. Adrenal insufficiency describes a failure of the adrenal cortex to make sufficient hormones necessary for normal physiologic functions in the body. It stems from the destruction of the adrenal cortex or a lack of ACTH stimulation. Symptoms of adrenal insufficiency are highly nonspecific and include nausea, vomiting, fatigue, anorexia, and weight loss. Symptoms for both conditions are nonspecific, and etiologies are vast. Here we describe a case of acute on chronic hyponatremia secondary to adrenal insufficiency.
Case: A 69-year-old male with a medical history of gastric cancer on chemotherapy and chronic hyponatremia came to the emergency department with complaints of 2 days of diffuse weakness, headache, nausea, vomiting, and dizziness. Of note, the patient completed a regimen of chemotherapy two weeks prior for his gastric cancer. Labs on admission revealed a sodium of 116 mmol/L {136-145 mmol/L}. Workup for hyponatremia revealed a serum osmolality of 238 mOsm/kg {278-305mOsm/kg}, urine sodium of 42 mmol/L {28-272mmol/L}, and urine osmolality of 257 mOsm/kg {50-1200 mOsm/L}, indicating a hypotonic hyponatremia. The patient was admitted for workup of hypotonic hyponatremia and started on normal saline at 125 mL/hr and sodium levels were monitored every 4 hours. Follow-up sodium levels were 117 mmol/L, 120 mmol/L, and 118 mmol/L overnight. The next morning, a cortisol level was 1.05 ug/dl {7-25 ug/dL} with an ACTH level of 8.0 pg/mL {7.2 – 63.3 pg/mL}, indicating overt adrenal insufficiency. At this point, the patient was started on stress-dose hydrocortisone 50 mg IV every 6 hours for 4 doses. Following the first dose of steroids, the patient’s symptoms improved rapidly. Once the IV hydrocortisone regimen was completed, the patient transitioned to 20 mg oral prednisone and was discharged with close follow up with his primary care provider.
Conclusions: Diagnosing the etiology of hyponatremia can be challenging in the setting of multiple comorbidities. In patients with complex medical conditions such as cancer, the symptoms and etiology of hyponatremia can often be misclassified due to complexity of underlying conditions. The presented case describes a patient previously diagnosed with SIADH, attributed to his gastric cancer in the setting of a COVID-19 infection. This highlights the importance of undergoing an appropriate workup for hyponatremia along with the morbidity and healthcare costs associated with misdiagnosing the etiology of hyponatremia. Both hyponatremia and adrenal insufficiency present with non-specific symptoms, many of which overlap each other. This case is a reminder that clinicians must maintain a high level of suspicion for the diagnosis of adrenal insufficiency in the setting of hyponatremia and other comorbidities.
Recommended Citation
Caldwell, Cameron B.; Patel, Shreel; and Suarez Parraga, Andres, "Severe Hyponatremia as a Consequence of Adrenal Insufficiency in a Patient with Gastric Cancer" (2025). Research Symposium. 6.
https://scholarworks.utrgv.edu/somrs/2025/talks/6
Included in
Severe Hyponatremia as a Consequence of Adrenal Insufficiency in a Patient with Gastric Cancer
Background: Hyponatremia is defined as a serum sodium level less than 135 mEq/L and is considered severe with levels below 125 mEq/L. It is the most common electrolyte abnormality amongst hospitalized patients with a prevalence of 20-35%. Symptoms can range anywhere from nausea, vomiting, fatigue, headache, and muscle cramps to more severe manifestations such as altered mental status and seizures. Adrenal insufficiency describes a failure of the adrenal cortex to make sufficient hormones necessary for normal physiologic functions in the body. It stems from the destruction of the adrenal cortex or a lack of ACTH stimulation. Symptoms of adrenal insufficiency are highly nonspecific and include nausea, vomiting, fatigue, anorexia, and weight loss. Symptoms for both conditions are nonspecific, and etiologies are vast. Here we describe a case of acute on chronic hyponatremia secondary to adrenal insufficiency.
Case: A 69-year-old male with a medical history of gastric cancer on chemotherapy and chronic hyponatremia came to the emergency department with complaints of 2 days of diffuse weakness, headache, nausea, vomiting, and dizziness. Of note, the patient completed a regimen of chemotherapy two weeks prior for his gastric cancer. Labs on admission revealed a sodium of 116 mmol/L {136-145 mmol/L}. Workup for hyponatremia revealed a serum osmolality of 238 mOsm/kg {278-305mOsm/kg}, urine sodium of 42 mmol/L {28-272mmol/L}, and urine osmolality of 257 mOsm/kg {50-1200 mOsm/L}, indicating a hypotonic hyponatremia. The patient was admitted for workup of hypotonic hyponatremia and started on normal saline at 125 mL/hr and sodium levels were monitored every 4 hours. Follow-up sodium levels were 117 mmol/L, 120 mmol/L, and 118 mmol/L overnight. The next morning, a cortisol level was 1.05 ug/dl {7-25 ug/dL} with an ACTH level of 8.0 pg/mL {7.2 – 63.3 pg/mL}, indicating overt adrenal insufficiency. At this point, the patient was started on stress-dose hydrocortisone 50 mg IV every 6 hours for 4 doses. Following the first dose of steroids, the patient’s symptoms improved rapidly. Once the IV hydrocortisone regimen was completed, the patient transitioned to 20 mg oral prednisone and was discharged with close follow up with his primary care provider.
Conclusions: Diagnosing the etiology of hyponatremia can be challenging in the setting of multiple comorbidities. In patients with complex medical conditions such as cancer, the symptoms and etiology of hyponatremia can often be misclassified due to complexity of underlying conditions. The presented case describes a patient previously diagnosed with SIADH, attributed to his gastric cancer in the setting of a COVID-19 infection. This highlights the importance of undergoing an appropriate workup for hyponatremia along with the morbidity and healthcare costs associated with misdiagnosing the etiology of hyponatremia. Both hyponatremia and adrenal insufficiency present with non-specific symptoms, many of which overlap each other. This case is a reminder that clinicians must maintain a high level of suspicion for the diagnosis of adrenal insufficiency in the setting of hyponatremia and other comorbidities.
