Forensic Science, Medicine, and Pathology

, Volume 4, Issue 3, pp 149–152 | Cite as

Hyponatremia at autopsy: an analysis of etiologic mechanisms and their possible significance

  • Angela Byramji
  • Glenda Cains
  • John D. Gilbert
  • Roger W. Byard
Review

Abstract

While electrolyte measurements after death may be confounded by a number of variables, vitreous humor sodium tends to remain stable for some time, enabling correlation between ante- and postmortem levels. Review of natural and unnatural causes of reduced vitreous humor sodium levels at autopsy was undertaken to demonstrate the range of diseases that may result in this finding. Natural diseases affecting the vasopressin–renin–angiotensin axis may cause reduction in sodium levels with associated hypovolemia, euvolemia, and hypervolemia. Low sodium measurements may also occur with redistribution of water, and artefactually when there are underlying lipid and protein disorders. Unnatural causes of hyponatremia at autopsy include water intoxication from psychogenic polydipsia, environmental polydipsia, ingestion of dilute infant formulas, beer potomania, endurance exercise, fresh water immersion (including water births) and iatrogenic causes including drug and parenteral fluid administration, and surgical irrigation. A knowledge of the range of conditions that may result in lowered postmortem sodium levels will help to exclude or confirm certain diseases at autopsy. In addition, significant vitreous hyponatremia may be a useful finding to help clarify mechanisms of unnatural deaths.

Keywords

Vitreous electrolytes Postmortem hyponatremia Polydipsia Immersion 

References

  1. 1.
    Madea B, Musshoff F. Postmortem biochemistry. For Sci Int. 2007;165:165–71.Google Scholar
  2. 2.
    Coe JI. Postmortem chemistry update-emphasis on forensic application. Am J Forensic Med Pathol. 1993;14:91–117.PubMedCrossRefGoogle Scholar
  3. 3.
  4. 4.
    Upadhyay A, Jaber BL, Madias NE. Incidence and prevalence of hyponatremia. Am J Med. 2006;119:S30–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Gill G, Huda B, Boyd A, Skagen K, Wile D, Watson I, et al. Characteristics and mortality of severe hyponatremia—a hospital-based study. Clin Endocrinol. 2006;65:246–9.CrossRefGoogle Scholar
  6. 6.
    Moritz ML, Ayus JC. Hospital-acquired hyponatremia—why are hypotonic parenteral fluids still being used? Nat Clin Pract Nephrol. 2007;3:374–82.PubMedCrossRefGoogle Scholar
  7. 7.
    Reynolds RM, Padfield PL, Seckl JR. Disorders of sodium balance. Brit Med J. 2006;332:702–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Singer GG, Brenner BM. Fluid and electrolyte disturbances, Ch 41. In: Kaspar D, Braunwald E, Hauser S, Longo D, editors. Harrison’s principles of internal medicine. McGraw-Hill; 2004.Google Scholar
  9. 9.
    Coe JI. Postmortem chemistries on vitreous humour. Am J Clin Pathol. 1969;51:741–50.PubMedGoogle Scholar
  10. 10.
    Balasooriya BAW, St Hill CA, Williams AR. The biochemistry of vitreous humor: a comparative study of the potassium, sodium and urate concentrations in the eye at the identical time intervals after death. Forensic Sci Int. 1984;26:85–91.PubMedCrossRefGoogle Scholar
  11. 11.
    Kelly J, Wassif W, Mitchard J, Gardner WN. Severe hyponatremia secondary to beer potomania complicated by central pontine myelinolysis. Int J Clin Pract. 1998;52:585–7.PubMedGoogle Scholar
  12. 12.
    Gardner JW. Death by water intoxication. Mil Med. 2002;167:432–4.PubMedGoogle Scholar
  13. 13.
    Dundas B, Harris M, Narasimhan M. Psychogenic polydipsia review: etiology, differential and treatment. Curr Psychiatry Rep. 2007;9:236–41.PubMedCrossRefGoogle Scholar
  14. 14.
    Hayashi T, Ishida Y, Miyashita T, Kiyokawa H, Kimura A, Kondo T. Fatal water intoxication in a schizophrenic patient—an autopsy case. J Clin Forensic Med. 2005;12:157–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Byard RW, Gilbert J, James R, Lokan RJ. Amphetamine derivative fatalities in South Australia - is “Ecstasy” the culprit? Am J Forensic Med Pathol. 1998;19:261–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Traub SJ, Hoffman RS, Nelson LS. The “ecstasy” hangover: hyponatremia due to 3, 4-methylenedioxymethamphetamine. J Urban Health. 2002;79:549–55.PubMedGoogle Scholar
  17. 17.
    Caldicott DGE, Edwards NA, Kruys A, Kirkbride KP, Sims DN, Byard RW, et al. Dancing with ‘death’; P-methoxyamphetamine overdose and its acute management. J Tox Clin Tox. 2003;41:143–54.CrossRefGoogle Scholar
  18. 18.
    Almond CS, Shin AY, Fortescue EB, Mannix RC, Wypij D, Binstadt BA, et al. Hyponatremia among runners in the Boston Marathon. N Engl J Med. 2005;352:1550–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Vucicevic Z, Degoricija V, Alfirevic Z, Vukicevic-Badouin D. Fatal hyponatremia and other metablic disturbances associated with psychotropic drug polypharmacy. Int J Clin Pharmacol Ther. 2007;45:289–92.PubMedGoogle Scholar
  20. 20.
    Arieff AI, Ayus JC, Fraser CL. Hyponatraemia and death or permanent brain damage in healthy children. Brit Med J. 1992;304:1218–22.PubMedCrossRefGoogle Scholar
  21. 21.
    Byard RW, Harrison R, Wells R, Gilbert JD. Glycine toxicity and unexpected intra-operative death. J Forensic Sci. 2001;46:1244–6.PubMedGoogle Scholar
  22. 22.
    Byard RW, Cains G, Simpson E, Eitzen D, Tsokos M. Drowning, haemodilution, haemolysis and staining of the aortic root–preliminary observations. J Clin Forensic Med. 2006;13:121–4.PubMedCrossRefGoogle Scholar
  23. 23.
    Byard RW, Zuccollo J. Forensic issues in cases of fatal water births. Am J Forensic Med Pathol. (in press).Google Scholar

Copyright information

© Humana Press 2008

Authors and Affiliations

  • Angela Byramji
    • 1
  • Glenda Cains
    • 2
  • John D. Gilbert
    • 2
  • Roger W. Byard
    • 1
    • 2
  1. 1.Discipline of Pathology, Level 3 Medical School North BuildingThe University of AdelaideAdelaideAustralia
  2. 2.Forensic Science SAAdelaideAustralia

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