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Recognizing Maltose-induced Hyponatremia
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IN RESPONSE:
I strongly agree that it is important for clinicians to distinguish maltose-induced hyponatremia from hypotonic hyponatremia [1]. The absence of central nervous system toxicity may be an important clinical finding pointing away from hypotonic hyponatremia. Unfortunately, our patient had an altered mental status before the onset of hyponatremia and was intermittently receiving doses of sedatives. Thus, her mental status was not a valid measure of the presence or absence of transcellular shifts in central nervous system fluid.
The cause of our patient's hyponatremia was initially unclear. No serum sodium concentration was measured immediately after the first infusion of intravenous immune globulin. Because her scheduled hemodialysis treatment immediately followed the completion of her second infusion of intravenous immune globulin, her depressed serum sodium concentration was not reported by the laboratory until after hemodialysis was initiated. I was skeptical of the development of severe hypotonicity based on her fluid balance, and after the postdialysis value had returned to baseline, I suspected a laboratory error.
When hyponatremia recurred after the third infusion with intravenous immune globulin, I became more curious and obtained a plasma osmolality on the same specimen, which showed the presence of hypertonic hypotonicity. A detailed review of her medications then showed that the intravenous immune globulin preparation that she was receiving was in 10% maltose (rather than 5% dextrose), leading us to the correct diagnosis. I had to dissuade her primary physician from treating her with hypertonic saline and from insisting that she be emergently dialyzed.
Paul M. Palevsky, MD
University of Pitts burgh School of Medicine; Pittsburgh, PA 15213
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
