Fatal acute hypernatremia resulting from a massive intake of seasoning soy sauce

Abstract

Background: Hypernatremia due to salt poisoning is clinically rare and standard care procedures have not been established. We report a case of salt poisoning due to massive intake of seasoning soy sauce.

Case presentation: A 40-year-old woman presented to the emergency department with seizures and remarkable hypernatremia with a serum sodium concentration of 183 mEq/L. The initial brain computed tomography scan showed brain shrinkage, which could occur during the acute phase of hypernatremia. We reduced her serum sodium level rapidly, rather than at the recommended slow rate. On day 3, the patient's brain computed tomography scan showed widespread low-density areas and edema. The patient died 8 days after admission.

Conclusion: After reviewing instances of resuscitation following salt intoxication, aggressive rapid correction of serum sodium concentration should only be considered in acute phases of hypernatremia within a few hours from ingestion, and 2-3 h could be one of the criteria.

Keywords: Brain CT; hypernatremia; salt poisoning; sodium chloride; sodium correction.

Fig. 1

Brain computed tomography in a 40‐year‐old woman on day 1 and day 3 of hypernatremia. Left panel: day 1, brain shrinkage is clearly visible. Right panel: day 3, brain edema and low‐density areas in the frontal lesion have appeared.

Fig. 2

Adaptation of brain cells to hypernatremia. In high osmotic pressure, brain cells lose intracellular fluid and shrink in size during the first 15–30 min. To recover in size, cells take up extracellular electrolytes and water within 30–90 min and completely replace their electrolytes with organic osmolytes in a matter of a few hours to days. As organic osmolytes cannot move in and out of cells rapidly, adaptation to the osmotic change in the extracellular fluid is slower. Hence, rapid correction of hypernatremia puts the patient at risk for brain edema (revised from Strange, 1992 ¹² ).