Syndrome of inappropriate antidiuretic hormone secretion as an adverse reaction of ciprofloxacin: a case report and literature review

Antidiuretic hormone (ADH) is secreted by the posterior pituitary gland. Unsuppressed release of ADH leads to hyponatremia. This condition is referred to as syndrome of inappropriate antidiuretic hormone secretion (SIADH). Hereby, a case report is presented on ciprofloxacin-induced SIADH. A 67-year-old male patient was examined in the emergency room with symptoms of lethargy, headache, lack of attention, and a generally depressed mood lasting for three days. One week prior, empirical antimicrobial therapy involving ciprofloxacin for prostatitis was initiated. Laboratory analysis showed no relevant abnormalities except for hyponatremia (Na = 129 mmol/L). Chronic hyponatremia, thyroid dysfunction, and adrenal dysfunction were ruled out. Serum osmolality was 263 mOsmol/kg, urine osmolality was 206 mOsmol/kg, and urine sodium was 39 mmol/L. Given that all criteria for SIADH were met, ciprofloxacin was discontinued, and fluid restriction was advised. Four days later, the patient's serum sodium concentrations nearly normalized (Na = 135 mmol/L), and all symptoms resolved. The Naranjo Scale yielded a score of 8, supporting the likelihood of a probable adverse reaction to ciprofloxacin. This case is presented to raise awareness among clinicians about the potential of ciprofloxacin to cause even mild hyponatremia.

Syndrome of Inappropriate Antidiuretic Hormone Secretion and Lead Toxicity in a Child With Sickle Cell Disease and Pica

We describe the presentation and management of a three-year-old child with a history of pica, vitamin D deficiency, and sickle cell disease, who was admitted for pyelonephritis, and found to have elevated blood lead level (BLL) of 103.7 µg/dL, and who subsequently developed altered mental status and syndrome of inappropriate antidiuretic hormone secretion (SIADH). In consultation with Medical Toxicology, the patient was chelated with calcium disodium edetate (EDTA) and British Anti Lewisite (BAL). The patient's hyponatremia was managed with hypertonic saline infusion. The patient's encephalopathy improved throughout her hospital course, and she was discharged on hospital day 8. Following five days of EDTA and three days of BAL injections, her repeat BLL was 15.3 µg/dL. SIADH has been associated with severe lead poisoning and may be more likely to occur in high risk patients such as individuals with sickle cell anemia, particularly where medications are used that may cause iatrogenic hyponatremia.

Syndrome of Inappropriate Antidiuretic Hormone Secretion and Lead Toxicity in a Child With Sickle Cell Disease and Pica

We describe the presentation and management of a three-year-old child with a history of pica, vitamin D deficiency, and sickle cell disease, who was admitted for pyelonephritis, and found to have elevated blood lead level (BLL) of 103.7 µg/dL, and who subsequently developed altered mental status and syndrome of inappropriate antidiuretic hormone secretion (SIADH). In consultation with Medical Toxicology, the patient was chelated with calcium disodium edetate (EDTA) and British Anti Lewisite (BAL). The patient's hyponatremia was managed with hypertonic saline infusion. The patient's encephalopathy improved throughout her hospital course, and she was discharged on hospital day 8. Following five days of EDTA and three days of BAL injections, her repeat BLL was 15.3 µg/dL. SIADH has been associated with severe lead poisoning and may be more likely to occur in high risk patients such as individuals with sickle cell anemia, particularly where medications are used that may cause iatrogenic hyponatremia.

Adverse Effects of Fluoroquinolones: A Retrospective Cohort Study in a South Indian Tertiary Healthcare Facility

The Food and Drug Administration (FDA) safety review revealed that the use of fluoroquinolones (FQs) is linked with disabling and potentially permanent serious adverse effects. These adverse effects compromise the tendons, muscles, joints, nerves, and central nervous system of the human body. The purpose of the study was to investigate the incidence and risk factors for adverse drug reactions (ADRs) caused by FQs in comparison with other antibiotics used. A retrospective cohort study was conducted over seven months in Kasturba Medical College Hospital, Manipal, India. Patients who were prescribed with FQs were selected as the study cohort (SC; n = 482), and those without FQs were the reference cohort (RC; n = 318). The results showed that 8.5% (41) of patients developed ADRs in the SC, whereas 4.1% (13) of patients developed ADRs in the RC. With oral and parenteral routes of administration, almost a similar number of ADRs were observed. Levofloxacin caused the highest number of ADRs reported, especially with the 750-mg dose. Based on a multiple logistic regression model, FQ use (odds ratio (OR): 2.27; 95% confidence interval (CI): 1.18-4.39; p = 0.015) and concomitant steroid use (OR: 3.19; 95% CI: 1.31-7.79; p = 0.011) were identified as independent risk factors for the development of ADRs among antibiotics users, whereas age was found to be protective (OR: 0.98; 95% CI: 0.97-1.00; p = 0.047). The study found a higher incidence of ADRs related to FQs compared to other antibiotics. The study concludes a harmful association between FQ use and the development of ADRs. Moreover, FQs are not safe compared to other antibiotics. Hence, the use of FQs should be limited to the conditions where no other alternatives are available.

SIADH associated with ciprofloxacin

OBJECTIVE

To report a case of ciprofloxacin-induced syndrome of inappropriate antidiuretic hormone (SIADH).

CASE SUMMARY

A 68-year-old Caucasian woman presented on 2 separate occasions with generalized weakness. Both times, she was started on ciprofloxacin for a urinary tract infection. Prior to the first episode, she had also been on Augmentin for several days. On both occasions, her ciprofloxacin was discontinued on admission, and her sodium levels rose. On the first occasion, she was given 5% dextrose in water to slow the rate of rise, yet she still corrected faster than the recommended rate. After the second admission, she was briefly given hypertonic saline but remained off intravenous fluids, and her sodium again rose faster than the recommended rate.

DISCUSSION

An objective causality assessment using the Naranjo scale was done. A score of 8 revealed a probable causality between ciprofloxacin and SIADH. The likely mechanism of this reaction is ciprofloxacin crossing the blood-brain barrier and stimulating the γ-aminobutyric acid and N-methyl-D-aspartate receptors, which leads to the synthesis and release of antidiuretic hormone.

CONCLUSION

Fluoroquinolones have the potential to cause SIADH. In this case, ciprofloxacin probably caused SIADH.

Prevalence of hyponatremia on geriatric wards compared to other settings over four decades: a systematic review

Aim of the study was to analyze temporal trends in prevalence of hyponatremia over four decades in different settings. A systematic review of the literature from 1966 to 2009 yielded prevalences of hyponatremia, with standard errors (SE) and pooled estimated means (PEM), calculated by year and setting (geriatric, ICU, other hospital wards, psychiatric hospitals, nursing homes, outpatients). 53 studies were included. Prevalence of hyponatremia was stable from 1976 to 2006, and higher on geriatric wards accept for ICU: e.g. PEM prevalence of mild hyponatremia (serum sodium <135 mM) was 22.2% (95%CI 20.2-24.3) on geriatric wards, 6.0% (95%CI 5.9-6.1) on other hospital wards and 17.2% (SE 7.0) in one ICU-study; for severe hyponatremia (serum sodium<125 mM) these figures were 4.5% (95%CI 3.0-6.1), 0.8% (95%CI 0.7-0.8) and 10.3% (SE 5.6). In nursing homes PEM prevalence of mild hyponatremia was 18.8% (95%CI 15.6-22.2). The higher prevalence on geriatric wards could partly be explained by age-related changes in the regulation of serum sodium. Other underlying factors can be the presence of multiple diagnoses and the use of polypharmacy.