Hypothermia and SIADH: Manifestations Of Terminal Multiple Sclerosis

Author: M. Auron, M.D, Department of Hospital Medicine, Cleveland Clinic
Reviewer: V. Dimov, M.D., University of Chicago

41-year-old female with secondary progressive multiple sclerosis presented to the MICU with a 24 hrs history of mental status changes. Patient was reported to have confusion, incoherent speech and unresponsiveness that worsened progressively over the day. At baseline patient had clear speech, quadriplegia and blindness.

Medications

Baclofen, Glatiramer acetate, Interferon beta, Propranolol, Omeprazole.

Physical examination

VS - 34.6°C, HR 48.
Neurological exam: Somnolent, arousable with no meningeal signs. Pupils reactive to light, bilateral amaurosis. Speech clear. Generalized atrophy, strength 0/5 B/L proximal and distal in four limbs; with increased tone and generalized hyperreflexia.

What is the most likely diagnosis?

Altered mental status secondary to metabolic encephalopathy. Differential diagnosis in this case include: Multiple sclerosis flare-up; Myxedema coma with bradycardia and hypothermia; pituitary apoplexy with hypothyroidism and hypocortisolism; Cerebrovascular accident; CNS infection.

What tests would you order?

- Accucheck – looking for glucose level in patient with bradycardia and hypothermia
- BMP looking for electrolyte abnormalities.
- Hormonal profile – Cortisol, Prolactin, TSH, LH, FSH.
- CSF
- MRI brain with gadolinium

Laboratory results

- Sodium 105 mmol/L, Potassium 4.5 mmol/l, Chloride 73mmol/L,
- Serum Osmolality: 216 mOsm/L, Urine Osmolality: 430mOsm/L.
- Hormonal Profile: Cortisol: 1.9mcIU/ml, Prolactin: 3.7ng/ml, LH: 0.25mIU/ml, TSH: 5.03mcIU/ml.
- Cerebrospinal fluid was not obtained.

What treatment would you start for this patient?

Diagnosis of hyponatremia with SIADH was done. Patient was started on fluid restriction; external rewarming was provided. Cosyntropin stimulation test was normal.

What happened?

During hospital stay patient’s condition was deteriorating. Twelve hours after presentation patient became comatose requiring endotracheal intubation.

An MRI obtained five days prior revealed extensive white matter abnormality throughout cerebral hemispheres consistent with severe demyelinating disease.



Palliative care consultation was obtained, after an extensive discussion with patient’s family a decision was made to extubate the patient and comfort care measures were initiated.

Subsequent chart review revealed that the patient had multiple admissions in the same year for hypothermia and hyponatremia. Most of these presentations were similar to her most recent admission.

Final diagnosis

SIADH and hypothermia as a manifestation of terminal multiple sclerosis.

What did we learn from this case?

- There are very few reports on terminal MS presenting with both SIADH and hypothermia.
- In our patient, these clinical features occurred repetitively and progressively worse until her death. The etiology can be attributed to severe hypothalamic-pituitary axis derangement as a result of extensive demyelination.
- SIADH and temperature instability can be in our case, the clinical manifestation of terminal MS.
- Clinical course of MS is remains unpredictable with exacerbations and remissions. Identification of signs and symptoms that may help the patient and family members with decision making and planning would be a major step in the management of this condition.
- Patient’s desires and autonomy can be protected with timely discussions for treatment optimization and end of life plans.

References

1. Tsui EY, Yip SF, Ng SH, Cheung YK. Reversible MRI changes of hypothalamus in a multiple sclerosis patient with homeostatic disturbances.Eur Radiol. 2002 Dec;12 Suppl 3:S28-31.
2. Krutisch G, Valentin A.Comatose state due to severe hyponatremia in a patient with the syndrome of inappropriate antidiuretic hormone secretion.Intensive Care Med. 2001 May;27(5):944.
3. Liamis G, Elisaf M.Syndrome of inappropriate antidiuresis associated with multiple sclerosis. J Neurol Sci. 2000 Jan 1;172(1):38-40.

Related reading

Lowest sodium I have ever seen http://goo.gl/QgJmf
It's summer, make sure to warn all of your SIADH patients about sun sensitivity with demeclocycline. Nephrology blog, 2011.
Patient Voices: Multiple Sclerosis - Interactive Feature - NYTimes, 2011.

Published: 01/21/2008
Updated: 12/10/2011

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