Hata Masako, Okazaki Yuji, Tanabe Shota, Kashiwa Kenichiro, Ichiba Toshihisa
Department of Emergency Medicine, Matsue Red Cross Hospital, 200 Horo-chou, Matsue City, Shimane 690-0886, Japan.
Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima City, Hiroshima 730-8518, Japan.
Am J Emerg Med. 2025 Jul 28. doi: 10.1016/j.ajem.2025.07.062.
Acute hyponatremia in emergency care settings can be life-threatening due to neurological complications such as cerebral edema. While water intoxication is a well-recognized cause of acute severe hyponatremia with prominent neurologic manifestations, non-neurologic complications such as intravascular hemolysis are rarely reported. We report a rare case of acute hyponatremia, initially manifesting as intravascular hemolysis, due to water intoxication over just two hours. A 67-year-old woman presented to the emergency department in an agitated state (Glasgow Coma Scale score of 13). She had a history of untreated depressive symptoms. She had intentionally confined herself to a bathroom for approximately two hours, repeatedly drinking tap water using a 500 mL bottle. Two hours after being found in the bathroom, she was taken to the emergency room. On arrival, serum sodium was 111 mEq/L and plasma osmolality was 233 mOsm/kg. Initial urine appeared reddish-brown, raising suspicion of hemoglobinuria. Laboratory findings revealed markedly elevated levels of creatine kinase, lactate dehydrogenase, and myoglobinuria, and undetectable serum haptoglobin. She was diagnosed with water intoxication causing intravascular hemolysis and rhabdomyolysis. She was managed with fluid restriction in the intensive care unit. As serum sodium normalized, her mental status fully recovered, and there was no recurrence of hemolysis and rhabdomyolysis. Water intoxication over a short period may lead to intravascular hemolysis due to an abrupt decline in plasma osmolality. Clinicians should be aware that acute severe hyponatremia, including that due to water intoxication, may initially present as non-neurologic manifestations, and early detection of hemolysis is essential to prevent secondary life-threatening sequelae.
在急诊护理环境中，急性低钠血症可能因脑水肿等神经并发症而危及生命。虽然水中毒是急性严重低钠血症伴明显神经表现的一个公认原因，但血管内溶血等非神经并发症很少被报道。我们报告了一例罕见的急性低钠血症病例，最初表现为血管内溶血，原因是仅在两小时内发生了水中毒。一名67岁女性以烦躁状态（格拉斯哥昏迷量表评分为13分）就诊于急诊科。她有未经治疗的抑郁症状病史。她故意将自己关在浴室里约两小时，用一个500毫升的瓶子反复饮用自来水。在浴室被发现两小时后，她被送往急诊室。到达时，血清钠为111 mEq/L，血浆渗透压为233 mOsm/kg。最初的尿液呈红棕色，引起了对血红蛋白尿的怀疑。实验室检查结果显示肌酸激酶、乳酸脱氢酶水平显著升高，出现肌红蛋白尿，血清触珠蛋白检测不到。她被诊断为水中毒导致血管内溶血和横纹肌溶解。她在重症监护病房接受了液体限制治疗。随着血清钠恢复正常，她的精神状态完全恢复，溶血和横纹肌溶解没有复发。短期内的水中毒可能由于血浆渗透压突然下降而导致血管内溶血。临床医生应意识到，包括因水中毒引起的急性严重低钠血症，最初可能表现为非神经症状，早期发现溶血对于预防继发性危及生命的后遗症至关重要。
