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While knowledge exists concerning the symptoms and possible causes of water intoxication, the exact etiology remains unclear. If proper nursing strategies are to be developed, it is crucial to carefully assess each patient with polydipsia and plan interventions related to what is known about that patient.
A young man developed pathological thirst and hyperdipsia, hyperphagia, disordered temperature regulation, a lowered threshold for aggressive behavior, apathy, impaired memory, and seizures following encephalitis. He had marked hyponatremia. Bouts of water drinking produced water intoxication and precipitated status epilepticus. Studies of water handling with measurements of plasma osmolality and arginine vasopressin (AVP) revealed a very low thirst threshold (below 242 mOsm/kg) with resetting of the osmostat to a new level (255 mOsm/kg) but normal control of plasma osmolality at that level with adequate AVP release.
In the psychiatric population, psychogenic polydipsia leading to water intoxication and nephrogenic diabetes insipidus secondary to lithium therapy are both well-recognized entities. A case is reported of the apparently unusual combination of these two conditions, where lithium probably not only has caused the nephrogenic diabetes insipidus, but might also have contributed to the state of psychogenic polydipsia.
Sequential magnetic resonance imaging (MRI) was performed to correlate signs of herniation and increase in local brain tissue water content with continuous changes in vital physiologic parameters during progressive water intoxication in anaesthetized dogs. The intracranial pressure increase ultimately resulted in respiratory and cardiac arrest. MRI concomitantly showed an increase in local brain water content starting and dominating in the cerebral cortex but progressing to all parts of the central nervous system. The late appearance of transtentorial pressure gradients and of brain herniation suggests that development of cerebral edema occurs in at least two stages, an intracellular osmotic edema appearing first, being followed by an ischemic edema related to a progressive decrease in local perfusion pressure.
The hypothesis that phenytoin may antagonise the antidiuretic effect of carbamazepine has been examined by comparing the free water clearance response to a standard water load in 36 patients stabilised on different drug regimes. The diuretic response to the water load was significantly greater in patients receiving chronic treatment with carbamazepine and phenytoin in combination than in matched control subjects receiving carbamazepine as a single drug. Acute administration of phenytoin (1,100 mg), however, had no significant influence on carbamazepine-induced antidiuresis. Evidence is presented that reversal of the antidiuretic effect of carbamazepine by chronic phenytoin administration is secondary to a marked reduction of the serum carbamazepine concentration during combined therapy. These results suggest that the risk of developing water intoxication is greater in patients receiving carbamazepine alone than in those receiving phenytoin in combination. Since the antidiuretic effect is correlated with the serum carbamazepine concentration rather than with the prescribed daily dose, monitoring the serum level of the drug is likely to provide the best rational approach to the prevention of excessive water retention.
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This paper reports a rare autopsy case, a 21-years old healthy female worker, who died of acute iatrogenic water intoxication after she had swallowed powder scraped off 17 matches in an apparent suicide attempt. Gastric lavage was performed as she was wrongly considered to have taken poison containing phosphorus. She was given 7.8 1 water within 2 h. The pathological findings and 16 cases from the literature between 1978-1994 are reviewed.
Demeclocycline, a competitive inhibitor of antidiuretic hormone at renal tubules, was studied in a patient with the syndrome of psychosis, psychogenic polydipsia, and episodic water intoxication. Under double-blind, placebo-controlled conditions, demeclocycline substantially reduced the severity and frequency of hyponatremic episodes.
A study was conducted on 16 schizophrenic patients with compulsive water drinking (CWD) and 10 normal controls, and the relation between serum antidiuretic hormone (ADH) and serum osmolality measured under ordinary conditions of free water intake. A water deprivation test and a water load test were also carried out on 10 schizophrenics with CWD and 10 normal controls. A comparison between the patients and controls showed the following results: the patients showed a significantly high level of serum ADH for their serum osmolality level, and 3 of them were consistent with the syndrome of inappropriate secretion of ADH (SIADH); the urine osmolality after the water deprivation in the patients was relatively low for their serum ADH; inhibition of ADH secretion after the water load was insufficient in the patients; and the water load test proved favorable to water diuresis (106%) in the patients with CWD of less than a 5-year duration, and insufficient diuresis (62.6%) in the patients with CWD of more than a 5-year duration. Two cases of the latter group had SIADH. The dilution and concentration of the urine after the water load were delayed also in the schizophrenic patients without SIADH. These findings suggest a strong possibility that the regulatory mechanism of ADH secretion might be impaired in the schizophrenic patients with CWD.
Ten patients [9 men and 1 woman; mean age 42.4 +/- 8.5 (+/- SD) years] who were smokers and who suffered the complications of self-induced water intoxication and psychosis (SIWIP) (8 patients with schizophrenic disorders, 1 patient with manic-depressive illness, 1 patient with dementia) are reported. Each patient underwent serial determinations of parameters of water metabolism including plasma and urine osmolality and plasma arginine vasopressin (AVP). The syndrome of inappropriate antidiuresis (SIAD) was found in each patient. Because of the reported effect that cigarette smoking has on antidiuresis, we correlated serum nicotine (NIC) levels with plasma and urine osmolality, AVP, and 24-hour urine volume (24 degrees-UV). We found no relationship between NIC and plasma or urine osmolality, AVP, or 24 degrees-UV. In the presence of SIWIP and SIAD, we infer the limbic-hypothalamic neurotransmitters in these psychotic patients are sufficiently powerful in stimulating both compulsive water drinking and inappropriate release of AVP so as to overshadow any effects that NIC may have on water metabolism.
With recent emphasis on increased water intake during exercise for the prevention of dehydration and exertional heat illness, there has been an increase in cases of hyponatremia related to excessive water intake. This article reviews several recent military cases and three deaths that have occurred as a result of overhydration, with resultant hyponatremia and cerebral edema. All of these cases are associated with more than 5 L (usually 10-20 L) of water intake during a period of a few hours. The importance of maintaining adequate hydration in exertional heat illness prevention cannot be overemphasized, but excessive fluid intake may lead to life-threatening hyponatremia. Current guidelines provide safety by limiting fluid intake during times of heavy sweating to 1 to 1.5 L per hour.
A 28-year-old woman, treated for schizophrenia, developed severe hypotonic hyponatremia (serum Na: 109 mEq/L) after several days of compulsive water drinking. The patient was admitted in a coma and required intensive supportive therapy. Rhabdomyolysis quickly followed with high serum creatine phosphokinase levels and myoglobinuria. A high volume alkaline diuresis was initiated. Renal failure or compartment syndrome did not complicate the clinical picture. The mechanisms causing water intoxication and hyponatremia are discussed as are the possible pathogenetic explanations behind acute hyponatremia and rhabdomyolysis.
Uroflowmetry is considered a simple and noninvasive test in the evaluation of urinary symptoms. It requires patients to consume fluid orally for a full bladder prior to undertaking the test. Guidelines regarding the amount and rate of oral fluid intake have not been accurately defined. We report on a patient who suffered a serious complication of water intoxication with hyponatremia and seizure due to excessive water consumption and absorption during uroflowmetry. We discuss the underlying factors concerning this complication and recommend a more conservative approach to attain a full bladder in a certain subgroup of patients at risk of developing such a complication.
A review of the literature and the three presented cases indicate that multiple factors are often involved in the development of water intoxication in the psychotic. Although the syndrome of inappropriate secretion of antidiuretic hormones (SIADH) is one of these factors, it is usually associated with other causes of the SIADH. Evidence is lacking that the SIADH is an essential feature of a psychotic illness.
Eleven episodes of severe hyponatremia secondary to hiccup-induced potomania were recorded in 3 years in a man who had essential hypertension, a low protein intake and a normal diluting ability. Paradoxical increase in hematocrit and plasma protein with acute extensive natriuresis was associated as well as urine potassium loss and hypokalemia producing paralysis in 1 episode. During a chronic water loading test, the defect in water excretion was related to a low urine solute delivery which was partially reverted by the natriuretic response to plasma volume expansion, promoting water diuresis. In acute water intoxication, this natriuretic response was exaggerated, producing a brisk water diuresis. Plasma volume was rapidly normalized but without any improvement in plasma sodium due to the concomitant negative sodium balance. Thus, water diuresis persisted until plasma volume was significantly contracted. Potassium loss appeared to be related to sodium excretion. Metabolic disturbances have not reoccurred despite persistent hiccup and potomania during 2 years of urea therapy.
The purpose of this study was to test a theoretical framework that proposed a relationship between severe psychiatric symptoms and self-induced water intoxication (SIWI) by using reliable and valid measures. Twenty of 28 community-dwelling individuals with severe mental illness (SMI) in the sample exhibited excess fluid consumption as reflected by a mean urine specific gravity of 1.003 mEq/L. The psychometric measures included the Positive and Negative Syndrome Scale (PANSS), the Self Deficit Syndrome Scale (SDSS), and the Spielberger State-trait Anxiety Scale (STAI From X-1). A significant relationship was found at p .01 between severity of psychotic symptoms and severity of SIWI and between severity of SIWI and psychopathology symptoms within the PANSS. Anxiety was higher in those with SIWI before fluid loading compared with those with less excess fluid intake (i.e., USG < 1.010), and anxiety decreased from morning to evening in those with SIWI compared with those who did not exhibit excess fluid intake. The findings revealed a strong relationship between SIWI and severe psychiatric symptoms, including psychosis and a broad range of psychiatric symptoms. The findings provided initial support for the proposed theory, and consideration needs to be given to the development of interventions to augment existing treatment of fluid control.
A patient was evaluated medically after submitting a urine sample for drug screening that was considered inappropriately dilute. Although it was thought that the dilute urine was the result of purposely adding water, the medical evaluation revealed that the patient had chronic water intoxication from a very strict weight loss regimen. The effect of dietary solute intake on water metabolism by the kidneys and the development of hyponatremia are discussed.
Drinking is an activity determined partly by oropharyngeal stimulation and gastrointestinal sensations as well as biochemical changes, and thirst need not be involved. It is sometimes disturbed in mania or depression. Overdrinking (polydipsia) is common in long-stay in-patients, but only gives rise to water intoxication when there is a variable functional renal abnormality such as SIADH causing water retention. In contrast, in affective disorders, disturbance of sodium retention may be seen, possibly representing failure of nervous vascular control as part of the mental illness.