Article

Beer potomania: Atypical cause of severe hyponatremia in older alcoholics

Correspondence / American Journal of Emergency Medicine 36 (2018) 13001320 1303

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Beer potomania: Atypical cause of severe hyponatremia in older alcoholics

Hyponatremia, defined as a serum sodium level of b 135 mEq/L, is an electrolyte abnormality commonly reported in chronic alcoholic patients [1]. The incidence of severe hyponatremia (serum sodium b 125 mEq/L) and its underlying Pathophysiologic mechanisms in elderly alcoholics are not well defined [2]. When caring for these elderly patients, it is important to recognize the syndrome of “beer potomania.” This syndrome, first re- ported in 1971, describes a patient who presents with severe hyponatremia in conjunction with low daily solute intake and excessive beer drinking [3, 4]. Signs and symptoms often associated with beer potomania include: se- vere hyponatremia, low serum osmolality, history of long-standing malnu- trition, and consumption of a large amount of beer (usually N 5L or fourteen 12-oz cans of beer) within one day [4]. With the growing population of el- derly people, and increasing numbers dealing with substance abuse, it is imperative that syndromes such as beer potomania are recognized, allowing for older alcoholics to receive properly managed care.

The aim of this retrospective study was to describe the epidemiology

and clinical features of beer potomania in older alcoholics presenting to the emergency department (ED) of two university-affiliated hospitals. We performed a cohort analysis of consecutive older adults (N 64 years of age) with severe hyponatremia (b 125 mEq/L) presenting over a six- year study period. All eligible patients had a history of chronic alcohol abuse. Demographics, co-morbidities, clinical features, diagnostic testing, complications, and final disposition were obtained from ED and hospital records using standardized abstraction forms. Key outcome measures were the prevalence and reasons for hyponatremia, associated signs and symptoms, treatment provided (particularly correction of sodium deficit), and the development of osmotic demyelination syndrome . ODS re- fers to acute demyelination seen in the setting of osmotic changes, typical- ly with the rapid correction of hyponatremia in chronic alcoholics [3-5].

During the study period, 2983 elderly patients were admitted for causes related to chronic alcohol misuse. A total of 135 of the patients (4.5%) had hyponatremia with a range of serum sodium between 104 and 134 mEq/L. Thirty-eight (1.3%) had severe hyponatremia (serum sodium b 125 mEq/L); 15 were diagnosed with beer potomania. Causes for hyponatremia, other than beer potomania, in these patients included hypo- volemia, malnutrition, syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH), congestive heart failure and hypothyroidism.

Clinical features associated with potomania included weakness (11 pa- tients), altered mental status (8), gait disturbance (7), headache (6), pe- ripheral edema (6), and seizures (3). A consistent finding was a recent personal history of binge drinking and/or history of illness (vomiting, diar- rhea) that predisposed the patient to a rapid drop in serum sodium levels. The average serum sodium concentration was 112 +- 5 mEq/L. Abnormal lab results consistent with diagnosis include hypokalemia (mean potassi- um, 3.1 mEq/L), low blood urea nitrogen (13 mg/dL), plasma osmolality (235 mOsm/kg) and decreased urine Sodium levels (33 mmol/L). Patients were treated with varying concentrations of saline, diuretics, fluid restric- tion, and desmopressin for overdiuresis. The serum sodium increase aver- aged 8.1 mEq/L (mmol/L) within the first 24 h and 13.3 mEq/L (mmol/L) by 48 h. Serum sodium levels typically normalized over approximately five days (range 3-9 hospital days). There were no cases of osmotic de- myelination syndrome (ODS).

Beer potomania is a rare cause of severe hyponatremia that has been previously associated with a high Morbidity and mortality rate. In a litera- ture review of patients diagnosed with beer potomania, 36% experienced

complications with treatment and another 18% expired [4]. Treating physi- cians should closely monitor patients for alcohol withdrawal syndrome (AWS) and osmotic demyelination syndrome. ODS results from a rapid in- crease in osmolality, which may not become evident for 2-8 days following treatment of patients diagnosed with hyponatremia [4]. With close moni- toring and judicious sodium replacement, ideally ODS can be avoided. It has been suggested that there is a therapeutic target correction rate of 6 to 8 mmol/L in 24 h, 12 to 14 mmol/L in 48 h, and 14 to 16 mmol/L in 72 h [5]. This study showed a slightly higher increase than suggested (8.1 mEq/L) over the first 24 h, however no cases of ODS were noted. This study demonstrates the need for understanding the signs and symp- toms of beer potomania in older alcoholics, as well as the importance of cor- rect Case management and treatment for correcting severe hyponatremia.

Lindsey Ouellette1 Keegan Michel2

Michigan State University, College of Human Medicine, Department of

Emergency Medicine, United States

Brad Riley2 Spectrum Health – Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI, United States

Jeffrey Jones

Michigan State University, College of Human Medicine, Department of

Emergency Medicine, United States Spectrum Health – Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI, United States Corresponding author at: 15 Michigan St NE Suite 701, Grand Rapids, MI

49503, United States.

E-mail address: [email protected].

25 October 2017

https://doi.org/10.1016/j.ajem.2017.10.065

References

  1. Liamis GL, Milionis HJ, Rizos EC, et al. Mechanisms of hyponatraemia in alcohol pa- tients. Alcohol Alcohol 2000;35(6):612-6.
  2. Tanner J, Bommersbach BA, Lapid MI, et al. Geriatric Alcohol use disorder: a review for primary care physicians. Mayo Clin Proc 2017;90(5):659-66.
  3. Sanghvi SR, Kellerman PS, Nanovic L. Beer potomania: an unusual cause of hyponatremia at high risk of complications from rapid correction. Am J Kidney Dis 2007;50(4):673-80.
  4. McGraw M. Beer potomania: drink in this atypical cause of hyponatremia. Nursing 2012;42(7):24-30.
  5. Sterns RH, Nigwekar SU, Hix JK. The treatment of hyponatremia. Semin Nephrol 2009;

29(3):282-99.

1 15 Michigan St NE 736, Grand Rapids, MI 49503, United States.

2 15 Michigan St NE, Suite 701, MC 038, Grand Rapids, MI 49503, United States.

A patient with midventricular takotsubo: any attenuation in the amplitude of the QRS complexes in subsequent electrocardiograms?

Dear Editor:

Pruthi et al. [1], in a report of a 59-year old woman with midventricular Takotsubo syndrome (TTS), published on line ahead of print on July 27, 2017 in the Journal, did a marvelous job in discussing the electrocardiogram (ECG), convincingly showing that based on the existing literature, there

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