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"He drank himself to death". 

Pathology of Water Intoxication

Dr Sampurna Roy MD                   July 2016

 


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Always remember: Never treat yourself by reading medical information from the internet or social media. Not all Medical Research findings are correct. Always consult your family physician if you feel unwell.

Sometimes drinking excessive "plain water" can also kill you.

 


A patient was found dead in the hospital room.

Autopsy was performed by the pathologist.

Internal examination revealed, large quantity of fluid in the stomach, the lungs had a boggy and edematous appearance.

The dark red blood in the heart appeared diluted.

               

There were no signs of external trauma or head injury. Neither macroscopic or histopathological lesion caused the death of the patient.

Postmortem biochemical examination revealed severe hyponatremia.

What was the cause of his death? 

His clinical history and biochemical finding solved the problem.

He had mental disorder and a history of excessive thirst (polydipsia).

He died from drinking excessive amount of water or water intoxication.

Psychogenic polydipsia (Compulsive water drinking) can lead to significant morbidity and mortality in psychiatric patients.

Water intoxication is a condition characterised by excessive consumption of water.


Drinking water is good for health only if the patient is physically healthy. 

Healthy individuals can safely drink very large volumes of water and respond to this by excessive production of urine.

The capacity of the kidney to excrete water when given without electrolytes is dependent upon many factors which include the rate of glomerular filtration and the power of the distal tubules to produce a dilute urine.

Many patients who are ill have ( for a variety of reasons) a restricted ability to dilute the urine when given large amounts of water.

These include:

Acute or chronic psychogenic polydipsia (Compulsive water drinking) is a common finding in psychiatric patients.

Water intoxication either results from the intake of large amounts of water within a short period of time and/or from a reduction of the renal "free water clearance".

- Athletes participating in endurance sports

- Those who use MDMA (3,4-methylenedioxymethamphetamine), referred to as ecstasy or molly.

It is a popular recreational psychoactive drug.

- Patients suffering from acute and chronic renal disease,

- Severe heart failure,

- Hypopituitarism,

- Adrenocortical insufficiency,

- Severe hypothyroidism and

- Hepatic cirrhosis or liver failure. 

- Occasionally tumours of the lung, pancreas or ovaries secrete a polypeptide with antidiuretic properties which leads to water intoxication.

- Post-operative patients are also incapable of diluting the urine because of the liberation of antidiuretic hormones by the stress of the operation.

- A number of drugs induce water retention by releasing pituitary vasopressin and can lead to water intoxication.

These include carbamazepine and morphine.

Chlorpropamide, phenylbutazone and indomethacin exert a similar effect by enhancing the action of the hormone on the distal nephron. 

In all these circumstances even moderate water intake reduces the plasma osmolality and the concentration of sodium and produces symptoms which are primarily those of disordered cerebral function.

These are partly due to cerebral oedema and include dizziness, headache, nausea and mental confusion. Severe water intoxication can produce convulsions, coma and death.

Diagnosis depends upon being aware of the circumstances in which water intoxication is likely to occur and the demonstration of a plasma sodium concentration below 130 mmol/l.

Hyponatraemia is defined as a plasma sodium level below 135 mmol/L.

Symptoms such as lethargy, restlessness, and disorientation usually occur when plasma levels drop to 115120 mmol/L.

Symptoms of hyponatraemia rarely occur unless patients continue to drink excessive amounts of water (>10 litres/day) after maximum urine dilution is reached.

Note: According to Dr Gill et al since psychogenic polydipsia is a common condition routine enquiry should be made into excessive water intake.

Paramedical staff, who observe patients continuously in the ward, should be educated about the importance of detection and management of the condition.

The differential diagnosis of symptoms of polyuria and polydipsia includes diabetes insipidus and mellitus, Addisonian crisis, Conn's syndrome, and chronic renal failure.

One should be cautious while treating hyponatraemia as rapid correction can cause central pontine myelinolysis.

Suggesting someone to drink plenty of water without knowing the medical history can be dangerous.

 

Further reading:

Fatal Water Intoxication and Cardiac Arrest in Runners During Marathons: Prevention and Treatment Based on Validated Clinical Paradigms.

Psychogenic polydipsia: the result, or cause of, deteriorating psychotic symptoms? A case report of the consequences of water intoxication.

Severe water intoxication secondary to the concomitant intake of non-steroidal anti-inflammatory drugs and desmopressin: a case report and review of the literature.

Water intoxication presenting as maternal and neonatal seizures: a case report.

Water intoxication-a dangerous condition in labor and delivery rooms.

Forensic aspects of water intoxication: four case reports and review of relevant literature.

Polydipsia: review of the literature.

Psychogenic adipsia presenting as acute kidney injury: case report and review of disorders of sodium and water metabolism in psychiatric illness.

Psychogenic polydipsia, hyponatremia and osmotic myelinolysis.

Psychogenic polydipsia review: etiology, differential, and treatment.

Hyperhydration and dialysis in acute kidney failure

Water intoxication--a little known complication in the course of mental diseases .

 

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Dr  Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)

 

                                                                                                           


 

 

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