Membranes of left atrial appendage: real appearance or "pitfall"

The membranes of left atrial appendage (LAA) cavity are very rare entity. To date, only five cases of a membrane involving LAA have been described. In this report, we describe two different cases: in Case 1, we show image of a "real" nonobstructive membrane within the body of LAA, but in Case 2 we show a linear image, mimicking a membrane within the body of LAA. It really is a "pitfall" of transesophageal echocardiography (TEE).     

低钠血症诊断思路

低钠血症(血清钠<135 mmol/L)是临床最常见的电解质紊乱之一，临床表现主要包括神经系统和肌肉系统表现两个方面。首先应该查血渗透压水平除外假性低钠血症，尿渗透压检查可以鉴别大量饮用低渗液体或其他肾外失钠的情况，容量判断有助于进一步鉴别低钠血症原因。利尿剂过量、脑耗盐综合征和盐皮质激素减少都能造成低容性低钠血症。而等容或高容性低钠血症则常常因为抗利尿激素不适当分泌综合征、甲状腺激素不足、糖皮质激素缺乏或心、肝、肾功能不全引起。     

The silent epidemic of thiazide-induced hyponatremia

Hyponatremia is a recognized complication of treatment with thiazide diuretics, particularly in patients older than 70 years. Severe and symptomatic hyponatremia requires urgent management, usually requiring infusion of normal or hypertonic saline. Milder, asymptomatic, thiazide-induced hyponatremia requires steps to manage the hyponatremia as well as to prevent its future recurrence. This is a particular problem in patients who despite a history of thiazide-induced hyponatremia might require a diuretic in the management of their hypertension. In this review, the acute management of symptomatic and asymptomatic thiazide-induced hyponatremia is reviewed. Emphasis is also placed on the chronic management of patients who have experienced mild hyponatremia, in whom decisions about treatment with diuretic and nondiuretic antihypertensive agents must be made to satisfy the twin goals of controlling hypertension and avoiding recurrent hyponatremia.     

"Early repolarization". The diagnostic pitfall of an atypical form of ST elevation]

The authors report the case of a coloured man who was treated with intravenous thrombolysis for chest pain and "atypical" ST elevation related to early repolarisation. The interest of this case is to underline the electrocardiographic criteria of early repolarisation and to propose, in appropriate conditions of management, emergency coronary angiography in patients with an uncertain diagnosis of infarct-like chest pain associated with suspicious electrocardiographic changes.     

The management of ascites and hyponatremia in cirrhosis

Ascites is the most common complication of cirrhosis and is associated with an increased risk for the development of infections, dilutional hyponatremia, renal failure, and mortality. Cirrhotic patients who develop ascites and associated complications have a low probability of long-term survival without liver transplantation, and therefore should be referred for evaluation of liver transplantation. While the initial management of uncomplicated ascites with low-sodium diet and diuretic treatment is straightforward in the majority of patients, there is a group of patients who fail to respond to diuretics and develop refractory ascites. The development of specific associated complications such as dilutional hyponatremia may further challenge the management of patients with ascites. New pharmacological agents such as the V2 receptor antagonists, drugs that directly antagonize the effects of elevated plasma antidiuretic hormone levels, induce solute-free water diuresis and seem to be promising in the management of patients with cirrhosis, ascites, and dilutional hyponatremia. This article focuses on the pathophysiology, clinical consequences, current management, and new treatment modalities for ascites and dilutional hyponatremia in cirrhosis.     

Carbamazepine-induced hyponatremia

Treatment with some drugs may lead to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), the presence of which is more likely in some populations, including people who are elderly or who take diuretics. Resulting drug-induced hyponatremia is often mild and usually resolves following water restriction and withdrawal of the drug. In some patients, however, it may be a potentially fatal condition that is typically asymptomatic until it becomes severe. In this article, we describe the case of a 59-year-old man with arterial hypertension, already treated with hydrochlorothiazide, who presented with hyponatremia after starting administration of carbamazepine. After excluding other common causes of hyponatremia, a diagnosis of SIADH was established, carbamazepine was withdrawn and SIADH treatment introduced. Our study shows that routine assessment of blood electrolytes is reasonable not only in patients receiving diuretics but also in patients treated with other drugs affecting vasopressin secretion.     

Rickettsiosis-associated hyponatremia

Summary Two patients with hyponatremia (130 mEq/l and 122 mEq/l, respectively), and rickettsial disease are described. The causes of hyponatremia were attributed to rickettsial vasculitis and increased capillary permeability in the first patient and to the syndrome of inappropriate anti-diuretic hormone (ADH) secretion in the second patient. The differentiation between the mechanisms was established by measurement of urinary sodium excretion which was low in the first patient (7 mEq/l) and high in the second patient (60 mEq/l), and levels of ADH that were inappropriately high in the second patient (7–9 pg/ml) in the presence of low plasma osmolality. The differentiation between these causes of hyponatremia has important therapeutic implications.

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Hyponatriämie bei Rickettsiose

Zusammenfassung Es werden zwei Patienten beschrieben, die bei einer Rikkettsien-Infektion eine Hyponatriämie von 130 mÄq/l bzw. 122 mÄq/l entwickelten. Die Ursache für die Hyponatriämie wird beim ersten Patienten in einer Rikkettsien-Vaskulitis mit erhöhter Kapillarpermeabilität und beim zweiten in einer inadäquaten Sekretion von antidiuretischem Hormon (ADH) gesehen. Durch Messung der Natriumausscheidung im Urin war eine Differenzierung der beiden Pathomechanismen möglich: beim ersten Patienten war die Natriumausscheidung mit 7 mÄq/l niedrig und beim zweiten mit 60 mÄq/l hoch. Zudem waren die ADH-Spiegel beim zweiten Patienten mit 7–9 pg/ml bei geringer Plasmaosmolalität unangemessen hoch. Die Unterscheidung der Ursachen der Hyponatriämie hat wichtige therapeutische Konsequenzen.