Chills without Fever - Causes and Treatment

Definition of Chills

Chills or rigor refers to the involuntary, continuous contractions of skeletal muscles with paroxysms of excessive shivering and teeth chattering. When the body attempts to produce heat to increase its temperature from within, the muscles contract and relax rapidly. In this way, the body is able to compensate and maintain the homeostasis with regards to temperature.

Chills relates to a feeling of being cold without a supposed cause. It normally occurs as a response to exposure to cold. Goose bumps show on the skin when it is cold and during times of stress. However goose bumps are not the same with chills. The mechanism of goose bumps is when the arrector pili muscle on the dermis contract, causing the hair to lie perpendicular to the skin [1, 2, 3].

 

What Causes Chills?

Being exposed to cold weather is a common and logical cause for chills without fever. Because of the low temperature, the body compensates by producing heat inside the body through continuous muscle contraction and relaxation [4].

 

What causes Causes of Chills without Fever

Having chills without fever may coincide with certain medical conditions such as the following [5, 6, 7]:

 

Influenza (Flu)

This commonly happens among children whose immune system is not yet sufficiently exposed to microorganisms so their body is not yet immune to several types of influenza virus. At first, the person may have chills without the fever yet. 1-2 days later, the fever starts to occur, i.e. when the virus becomes active.

 

Acute Bronchitis

Acute bronchitis refers to inflammation of the bronchi most commonly due to bacterial or viral infection. The bronchi swell because of the infection, causing chest pain, breathing problems, cough, and chills with or without fever. Chills without fever can also be seen in other respiratory tract infections.

 

Malnutrition

This happens when you are not getting enough nutrients that should be able to cater the needs of the body. There is a wide group of causes for malnutrition. Medical conditions, poor diet, and problems with absorption and digestion are the three main ones. Weight loss, dizziness, fatigue, and chills without fever are the main symptoms that seem to be present in the generality of the cases.

Having deficiencies in vitamin B, specifically vitamin B12, is bound to suffer from chills. The series of events that happens upon malnutrition depends entirely on the cause. Treatment includes stabilization of the underlying medical state which causes the malnutrition or replacing the missing nutrients.

 

Iron Deficiency Anemia

This is a condition characterized by low hemoglobin levels in the blood. The person feels cold even when if the weather is hot. Chills and fatigue also occur with the cold sensations. The hemoglobin in our red blood cells transports oxygen throughout our body.

The blood in itself provides warmth so with iron deficiency anemia, there is less transport of blood to the different parts of the body, especially on the distal parts like hands and feet, hence feeling cold especially on those areas.

 

Food Poisoning

Sudden chills without fever can occur due to food poisoning. Though some patients get fever and chills due to food illnesses, others do not experience an increase temperature of the body. They may also experience diarrhea, vomiting, and abdominal cramps aside from uncontrollable shivering or shaking.

 

Urinary Tract Infection

Persons suffering from urinary tract infection experience dysuria (painful urination) and a malodorous urine. Chills may occur periodically without fever in instances where the UTI is not that severe. If the infection ascends to the kidneys (pyelonephritis), a person may experience chills eventually with a fever.

 

Hypoglycemia

Hypoglycemia or low blood sugar level can also cause infrequent chills with diaphoresis (excessive sweating), headache, dizziness, and tachycardia (increased heart rate). A person who is diabetic and having insulin administrations are more likely to have hypoglycemia.

A rapid drop in blood sugar is also caused by an accidental take of excessive dose of insulin. Carefully following the schedule of medications but not eating regularly develops higher chances of hypoglycemia in patients with diabetes. Being an alcoholic, low carbohydrate diet and extreme exercises are other causes of hypoglycemia.

 

Drugs or Medications

If the prescription is incorrect or an individual is using them in an abusive manner, chills may occur as a side effect of some prescribed drugs. When you are besieged with uncontrollable muscle spasms, there will be chills in periodical sessions. These chills will be accompanied by vomiting, nausea, allergic reaction, insomnia, heart problems, drowsiness, and drug dependence.

 

Hypothyroidism

Thyroid is a small gland found in a person’s neck. It releases thyroid hormones to regulate your metabolism. When there is lacking production of the thyroid hormone, hypothyroidism occurs. One manifestation is chilling without fever.

It will result to chills because with this condition, you are more sensitive to cold. Some symptoms include depression, fatigue, constipation, joint pain, pale skin, heavy, weight gain, and brittle fingernails and hair. More symptoms may appear as the condition develops. Subsequent manifestations include decrease in sensation, slow speech, puffiness in the hands, feet and face, thickening of the skin, and thinning of the eyebrows.

 

Psychiatric Disorders

The sensation of coldness is not only experienced by a person with poor physical health. Panic disorders, anxiety problems, and other psychiatric diseases can have cold sensations regardless of the external environment. Chills without fever is a common response to anxiety.

 

Treatment

Medical Treatment

 Chills without fever is not a disease per se. It is a  [9].

  • Antibiotics/antibacterial for bacterial infections: Intravenous administration is recommended in more serious cases. 
  • Antiviral drugs for viral infections. However, antiviral drugs are not really necessary because influenza goes away on its own even without treatment. The patient is rather recommended to drink plenty of warm fluids and have a bed rest. 
  • Improve your diet by carefully planning what and what not to eat. Take vitamin supplements as necessary.
  • Seeking emergency call is necessary in cases of food poisoning.
  • Intravenous administration of fluids prevents dehydration.
  • Levothyroxine is the treatment of choice for hypothyroidism.
  • Iron supplements can correct the symptoms of iron deficiency anemia.
  • Physiological counseling, relaxation, and breathing techniques are recommended for anxiety or stress-related disorders.

Home Remedies

If your chills is not that severe, it may be controlled by having these home remedies [10]

  • Getting enough rest can comfort the chills. 8-9 hours is recommended to sleep at night. 
  • Do not skip your meal. Eat regularly and make sure not to go hours without getting any form of nutrition for the body. Keep some snacks with you in case of hunger. 
  • Exercises like brisk walking and quick swimming help in controlling the chills. 
  • Getting a vitamin B supplement can be a big help in the body. It can reduce your chills and boost your energy.
  • Drinking warm water every now and then can help in soothing your body and reducing chills. This helps is to keep the body hydrated very well, and maintaining also the heat in your body.
  • Relax through a soothing warm bath.


References: 
  1. Chills without Fever are Caused by Different Conditions. Available from:
  2. http://hubpages.com/health/Chills-without-Fever-are-Caused-by-Different-Conditions
  3. Rapid Assessment: A Flowchart Guide to Evaluating Signs and Symptoms by Lippincott Williams and Wilkins
  4. Chills. Available from: 
  5. http://www.nytimes.com/health/guides/symptoms/chills/overview.html
  6. Chills without fever. Available from:
  7. http://ic.steadyhealth.com/chills-without-fever
  8. Chills without fever. Available from: 
  9. http://www.buzzle.com/articles/chills-without-fever.html
  10. Chills without fever. Available from:
  11. http://www.medguidance.com/thread/Chills-Without-Fever.html
  12. Causes and Treatment for Uncontrollable Shivering. Available from:
  13. http://www.newhealthadvisor.com/Uncontrollable-Shivering.html
  14. Healthtap available from:
  15. https://www.healthtap.com/topics/chills-without-fever-during-pregnancy
  16. Chills without fever. Available from:
  17. http://mddk.com/chills-without-fever.html
  18. How to treat chills without fever. Available from: 
  19. http://basicfirstaid.ca/how-to-treat-chills-without-fever/


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How Long does Suboxone Stay in your System?

What is Suboxone?


Suboxone® is a prescription medicine that contains the active components buprenorphine and naloxone. These two combined medications in each dose of Suboxone are classified into two: Buprenorphine as a partial opioid agonist and Naloxone as an opioid antagonist.

It is indicated for treatment of opioid dependence in adults and should be used as part of a complete treatment plan including counseling and psychosocial support [1,2].




Picture 1: Suboxone Film (sublingual film)
Image Source: Restorative Solutions. Available from:http://restorative.solutions/dodson-directive/



Picture 2: Suboxone Tablets
Image Source: Restorative Solutions. Available from: http://restorative.solutions/dodson-directive/


What is Buprenorphine?


Buprenorphine (pronunciation: ‘bu-pre-‘nor-feen) is an opioid medication used to treat opioid addiction. It is a semi-synthetic opioid from an alkaloid of the poppy Papaver somniferum which is called thebaine.

Buprenorphine is a partial agonist, meaning it produces less side effects like respiratory depression that can only be seen with full agonist opioid.

Formulations of buprenorphine include Suboxone, Buprenex, Subutex, Cizdol, Bunavail, Temgesic, Zubsolv, Butrans, and Norspan available either as buprenorphine hydrochloride alone or a combination of buprenorphine and naloxone [3, 4].


What is Naloxone?


Naloxone (pronunciation: nə-läk-sōn) is a synthetic drug similar to morphine, which blocks the opiate receptors in the nervous system. It works by competitively antagonizing receptors for opioids.

To explain it simply, naloxone binds with the opioid receptors in the brain without stimulating them. It is a drug used to reverse the effects of opioids, especially in overdose. Naloxone is also useful in reducing respiratory or mental depression caused by opioids [5].


How Buprenorphine Works

  • Opioid receptor is empty. A person becomes less sensitive and requires more opioids to produce the same effect if they become tolerant to opioids. The patient feels discomfort whenever there is an insufficient amount of opioid receptors being activated. That is when withdrawal happens. 
  • Opioid receptors filled with full-agonist. Euphoria and the stop of withdrawal for a period of time (4-24 hours) are caused by the strong opioids of heroin and painkillers. To the point of an uncontrollable addiction, the brain starts to crave opioids and the cycle repeats accelerates.
  • Opioid replaced and blocked by Buprenorphine. Buprenorphine battles with the full agonist opioid for the receptor. It has a stronger affinity to receptors that eliminates existing opioids and blocks others from binding. As a partial agonist, buprenorphine has a restricted opioid effect, enough to stop withdrawal but not enough in causing intensive euphoria. 
  • Over time (24-72 hours) buprenorphine dissipates, but still creates restricted opioid effect that is enough to stop withdrawal and continues to block other opioids from binding to the opioid receptors.


Side Effects


The primary side effects of buprenorphine are similar to other opioid agonists, which include the following [6]:

  • Headache or other pain;
  • Tongue pain, inflammation inside your mouth;
  • Increased sweating (diaphoresis); or
  • Swelling of the extremities
  • Sleep problems (insomnia);
  • Diarrhea or dehydration


Duration of Buprenorphine + Naloxone (Suboxone)


The half-life of Suboxone is 20-70 hours, depending on the route of administration and interaction with other drugs administered to the body.

Furthermore, buprenorphine has the capability to stay and attach to opiate receptors for over 24 hours, effectively incapacitating the receptors to make use of other stronger opiates less appealing [4,7].


How Long does Saboxone Stay in the Body?


This drug has a relatively short half-life. 

In most people, it will be undetectable in the urine after 2-4 days of complete abstinence. In saliva, it only stays for 1-3 days. Hair drug tests usually have a longer detection time of 90 days. Suboxone would last in the blood stream the longest. Some people put it at around 17 days, others at longer periods of time.

How long it stays inside the body depends on the dosage, usage, body fat, and metabolism. If you are taking in 8mg of Suboxone, possibly it will take 5 days for the drug to be excreted from your system. With 4mg of Suboxone, it will take 30-72 hours; while it usually takes 24-36 hours for 2mg of Suboxone to be taken out of your body [8,9].


How Long does Suboxone Block Opiates?


Blocking of opiates depends on duration and dosage of the drug administered. A dose of 4 mg once would only block opiates for 1 to 3 days; a dose of 16 mg or more will block opiates for 3 to 5 days.


How Long does Suboxone Stay in our System for Drug Tests?


It depends on the amount of Suboxone taken and the metabolism of a person. Suboxone could stay 3 to 5 days or maybe a week in your system [10].

 

Withdrawal Symptoms


Buprenorphine withdrawal symptoms are unpleasant but it depends on the brand of drugs used wherein it could be milder with Subutex than Suboxone. Common withdrawal symptoms include:

  • Muscle, joint, and bone pain
  • Inability to sleep (insomnia)
  • Irritability
  • Diarrhea
  • Restless leg syndrome (RLS)
  • Excessive sweating (diaphoresis)
  • Involuntary shaking (tremors)
  • Nausea and vomiting
  • Raise blood pressure (hypertension)
  • Raised heart rate (tachycardia)
Suboxone withdrawal lasts for 3 months or 90 days. The process usually differs from person to person. 

Withdrawal with Suboxone is not going to be easy because of the factors that may influence on how the body gets rid of it. It may vary depending on the dosage and duration of drug intake. The longer you took the drug, the higher the amount of Suboxone in your system, the more difficult it is for you to withdraw. 

During the withdrawal process, it is important to engage with healthy activities [11,12].


How Long does the Treatment Last?


Opioid addiction is a manifestation of brain changes resulting from chronic opioid use and misuse. The patient’s recovery is in great part a struggle to overcome the effects of these changes. Brain adaptations take time to develop and reverse. 

Patients should remain in treatment long enough to reverse the brain changes to the extent possible and learn coping mechanisms for what cannot be reversed. This is accomplished through deliberate reconditioning effort. 6-12 months is not an unusual treatment time frame, but longer period may be required, depending on the progress of the patient [13].

Getting off of Suboxone needs a serious medical help. It will not be easy, but indeed, it is possible. However, it is highly recommended to stay as productive and healthy as you can during withdrawal because it brings about faster recovery.

References:
  1. http://www.suboxone.com/treatment/suboxone-film
  2. How is treatment differ from drug abuse. Available from: http://psychcentral.com/lib/how-is-suboxone-treatment-different-than-drug-abuse/
  3. The National Alliance of Advocates for Buprenorphine Treatment. Available from: http://www.naabt.org/
  4. Buprenorphine. Available from: https://en.wikipedia.org/wiki/buprenorphine
  5. Naloxone. Available from: http://www.naloxone.org.uk/index.php/naloxoneseperator/naloxoneinformation/whatisnaloxone
  6. Side Effects. Available from: http://drugs.com/sfx/buprenorphine-naloxone-side-effects.html
  7. How long does Buprenorphine stay in your system. Available from: http://www.passadrugtestingforall.com/long-does-buprenorphine-stay-your-system-a-72.html
  8. How long does buprenorphine last. Available from: http://prescription-drug.addictionblog.org/how-long-does-buprenorphine-last/
  9. Steadyhealth. Available from: http://www.steadyhealth.com/topics/how-long-does-suboxone-stay-in-your-body-stay-active
  10. Healthtap. Available from: https://www.healthtap.com/
  11. The Ugly Truth about Withdrawal. Available from: http://lighthouserecoveryinstitute.com/suboxone-withdrawal-symptoms/
  12. Withdrawal Symptoms. Available from: http://mentalhealthdaily.com/2014/04/24/suboxone-buprenorphine-withdrawal-symptoms-how-long -do-they-last/
  13. The National Alliance of Advocates for Buprenorphine Treatment Documents. NAABT brochures.
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      Hypokalemia - Symptoms, Causes, ECG and Treatment

      Hypokalemia

      Hypokalemia, is a medical condition that occurs when an individual has a lower than normal potassium level in their bloodstream.  For a healthy individual, the blood potassium level should be 3.6 to around 5.2 millimoles per liter. Getting low potassium levels such as 2.5mmol/L or below can be very dangerous. When a person gets these low levels, they should get medical attention immediately.[1,2]


      What is potassium and Its Uses? 

      The human body has several electrolytes that are crucial for cell function, and potassium is actually one of them. Potassium electrolytes are concentrated in the cells of the body, and they play a very important role. In the human body, only two percent of the total potassium is found in the blood stream.

      Any changes in the blood stream levels of potassium can greatly affect the functioning of the human body. Potassium has a great role of maintaining the electrical activities in the body cells. The body cells that have high electrical activity such as the nerves and muscles like the heart are seriously affected then the potassium levels in the body fall.[2,4]


      What are the causes of low potassium in the body?

      Many people believe that low potassium is commonly caused by poor dietary intake. However, this is not true.  The most common causes of hypokalemia is the loss of potassium from the gastrointestinal tract or from the kidney. Potassium levels in the body can fall from the GI tract due to the following reasons.
      • Diarrhea.
      • Vomiting
      • Ileostomy. Some patients who have had conditions that forced them to have a bowel surgery and get an ileostomy. Their stool output might sometimes contain huge amounts of potassium.
      • The use of laxative has also been linked to low potassium levels for some patients.
      • Villous adenoma is type of colon polyp, and it is said to cause hypokalemia in patients too. The polyp causes the patients colon to leak some amount of potassium.[4,7,9,10]

      Potassium can be lost from the kidney due to the following reasons.

      • Some diuretic medications, such as Hydrochlorothiazide and furosemide can cause the levels of potassium to fall.
      • When the levels of corticosteroids are elevated, the potassium levels go down. This can be caused by the use of medications such as prednisone or by some illnesses such as Cushing’s syndrome.
      • Elevated levels of aldosterone in the body can also lead to hypokalemia.  Aldosterone is a hormone in the human body that increases due to renal artery stenosis or due to adrenal tumors.
      • When the magnesium levels in the body are low, the levels of potassium go down too.
      • Renal tubular acidosis also causes hypokalemia.

      Hypokalemia can also be caused by the effects of the following medications.
      • Prednisone.
      • Aminoglycosides such as  gentamicin or tobramycin
      • Amphotericin B [4,10]

       

      Symptoms of Hypokalemia


      Potassium is an important element in the body.  Potassium greatly affects the manner your neuromuscular cells discharge energy and also how they regenerate this energy so that they can be able to fire again.  When your potassium levels are low, these cells are not able to repolarize and most of the time, they cannot fire repeatedly as expected.  When this happens, your muscles and nerves cannot function as usual, and the patient gets some symptoms.

      Most of the time, the symptoms of this condition are mild.  However, they can sometimes be vague. A patient might get one or more symptoms involving the GI, muscles, kidneys, nerves and the heart. Here are some of the most common symptoms
      • Some patients experience tiredness, weakness or even cramping in their legs or arm muscles. These cramping might be severe sometimes, causing the patient not to be unable to move their legs or arms.
      • Numbness or tingling is also common.
      • Vomiting and a lot of nausea might also be present.
      • Bloating and abdominal cramping.
      • Constipation.
      • Some patients complain about palpitations.
      • Feeling thirsty all the time and passing large amounts of urine.
      • Due to low blood pressure, some patients experience fainting.
      • Changes in psychological behavior in the patient. Some might get depression, delirium, psychosis, confusion or even hallucinations.[1,5]


      How is low potassium diagnosed? (with ECG (EKG) changes)


      It is very easy to measure your potassium levels during your normal routine blood tests. Hypokalemia is considered a potential complication when an individual is taking some medications. Patients who suffer from high blood pressure are mostly given some diuretics like hydrochlorothiazide or Lasix. This means that they have a high risk of getting hypokalemia, so their potassium levels should be monitored closely.

      If you have a patient who is ill, it is important to be extremely careful if they are vomiting or have diarrhea. These might lead to dehydration and weakness, common symptoms of hypokalemia. These patients should have their electrolyte levels monitored just to be sure that the potassium levels are good or whether they need to be replaced. 


      Difference between Normal ECG and Hypokalemia
       
      There are some EKG or ECG changes that are mostly associated with hypokalemia. Sometimes, the diagnosis of hypokalemia is done by getting the U waves in the EKG tracing. When the condition is serious, there can be severe disturbances in the heart rhythm. [1,6,8]

       Prominent U waves in Hypokalemia ECG 

      Also check Hyperkalemia ECG
         

      Treatment and Management of low potassium


      Patients who have serum potassium levels of above 3.0 mEq/liter have nothing to worry about.  These levels are not considered to be dangerous, and they can be given potassium replacements by mouth.

      However, patients with potassium levels that are lower than 3.0mEq/liter might require some intravenous replacement, depending on their current medical condition and symptoms.  Most of the time, the decision is patient –specific, and it depends on the diagnosis, the patient’s ability to tolerate fluid and the medication by mouth and the circumstances of the illnesses. 

      If the low potassium levels are short term or caused by self -limited diseases such as vomiting, diarrhea or gastroenteritis, the patients does not have to worry about medications. This is because the potassium levels can restore on their own.  If the hypokalemia is severe, or may be the doctor predicts that the potassium losses will be on going, potassium supplementation or replacement is very important.

      For individuals who get hypokalemia due to the use of diuretics, the doctor might recommend a small amount of oral potassium. This is due to the fact that the loss will continue as long as the diuretic is being used. The oral potassium supplementation is presented in liquid or in pill form. The dosages of these supplements are measured using mEg. The common dosage is 10-20mEq daily.

      Patients suffering from hypokalemia can also consume foods that are high in potassium.  This is always the first option given by the doctor to replace potassium, especially if the condition is not serious. Oranges, bananas, apricots and tomatoes are some of the food that are considered to be high in potassium content. 

      Potassium is extracted through the kidneys, and most of the time, the doctor will order blood tests that will monitor the patients kidney function. This way, it will be easier to monitor and predict the potassium levels from getting too high.

      If a patient will be getting their potassium supplements intravenously, the doctor should give it slowly. Potassium is very irritating to the veins, and it should only be given at a maximum rate of 10mEq.  Infusing potassium too fast in the veins can easily cause heart irritations and gradually promote potentially dangerous rhythms like ventricular tachycardia.[5,9]

       

      A Special Situation: Periodic Paralysis

      Although very rare, sometimes the potassium levels in the body moves from the blood stream in to the cells of the body. When this happens, the serum potassium levels drops to 1.0 mEq/liter or sometimes lower. This can be very serious to the patient. The muscles become very week to a point where the patient cannot move their body and become paralyzed.  The most affected parts are the legs and arms.  The breathing and swallowing muscles are also affected sometimes. 

      Periodic paralysis is said to be hereditary and sometimes, it might be precipitated by excessive exercising, consuming high carbohydrate or too salty meals, or even occur without any cause.  People who get periodic paralysis can be treated easy. They should be given potassium replacement intravenously. The recovery is expected to take place within the first 24 hours. [3,5]


      Prevention of low potassium

      The human body is able to maintain its potassium levels in the normal ranges as long as an individual takes foods that are rich in potassium.  When an individual gets any short time illnesses that can make the body to loose potassium levels, the body can easily compensate the loss. If the doctor says that the loss of the potassium is ongoing, it is crucial for a patient and the health care provider to anticipate this loss, and urgently consider the routine potassium replacement that will work effectively. Leaving the condition untreated can lead to serious problems. [4,6]


      References
      1. Diseases & Conditions - Medscape Reference [Internet]. Emedicine.medscape.com. 2016 [cited 2 May 2016]. Available from: http://emedicine.medscape.com
      2. Mayo Clinic [Internet]. Mayoclinic.org. 2016 [cited 2 May 2016]. Available from: http://www.mayoclinic.org
      3. National Library of Medicine - National Institutes of Health [Internet]. Nlm.nih.gov. 2016 [cited 2 May 2016]. Available from: https://www.nlm.nih.gov
      4. Marjorie Lazoff M, Cadogan M, Morgenstern J, Long N, Long N, Lynch D et al. LITFL: Life in the Fast Lane Medical Blog [Internet]. LITFL: Life in the Fast Lane Medical Blog. 2016 [cited 2 May 2016]. Available from: http://lifeinthefastlane.com
      5. The MSD Manuals - Trusted Medical Information [Internet]. Msdmanuals.com. 2016 [cited 2 May 2016]. Available from: http://www.msdmanuals.com
      6. [Internet]. 2016 [cited 2 May 2016]. Available from: http://Electrolyte Disorders
      7. The MSD Manuals - Trusted Medical Information [Internet]. Msdmanuals.com. 2016 [cited 2 May 2016]. Available from: http://www.msdmanuals.com
      8. Medical Information & Trusted Health Advice: Healthline [Internet]. Healthline.com. 2016 [cited 2 May 2016]. Available from: http://www.healthline.com
      9. [Internet]. Emedicinehealth.com. 2016 [cited 2 May 2016]. Available from: http://www.emedicinehealth.com
      10. [Internet]. 2016 [cited 2 May 2016]. Available from: http://healthy living az list
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      Hyponatremia - Causes, Pathophysiology, Algorithm, Correction, Treatment

      Facts about Hyponatremia : Definition

      This is a condition characterized by lower-than-normal levels of sodium in the blood. The normal serum sodium concentration in the body is between 135 and 145mEq/L. If the sodium serum levels go below 135mEq/L, you are considered to be suffering from hyponatremia. The condition is said to be severe if the serum levels go below 125mEq/L. The body uses sodium as an electrolyte to regulate water in and around the cells of the tissues. [1, 2, 3,5,8,9, 10, 13,]

      Pathophysiology 

      • The sodium concentration in the serum is regulated by secretion of the ADH (antidiuretic hormone), variations of the renal handling of filtered sodium, and the renin-angiotensin-aldosterone system.
      • If the serum osmolality increases over the normal range of 280-300mOsm/kg, there is the stimulation of hypothalamic osmoreceptors that cause an increase in thirst and circulate the ADH.
      • The ADH increase the reabsorption of the water from urine that results in low volume urine with high osmolality but returns the serum osmolality to normal.
      • Aldosterone is also released to curb hypovolemia through renin-angiotensin-aldosterone feedback system. The hormone causes the sodium absorption in the kidney’s renal tubule.
      • The sodium retention causes the retention of water that in turn corrects the hypovolemic problem. The kidney is able to balance the sodium-independent of these two hormones.
      • In a hypovolemic, state such as dehydration or hemorrhage increases the absorption of sodium in the proximal tubule of the kidney.
      • When the vascular volume is increased, tubular sodium reabsorption is suppressed and helps to restore the normal vascular volume. Thus, the sodium balance disorders can be traced to aldosterone, renal sodium transport, ADH, or disturbance water or thirst acquisition.
      • Hyponatremia is said to be physiologically significant when there is the indication of extracellular hyposmolality and the tendency of free water shifting from vascular space to the intracellular space.
      • The body tolerates cellular edema to a greater extent by not at the bony calvarium. Thus, hyponatremia clinical manifestations are primarily on cerebral edema. The rate at which the condition develops is critical to its treatment. [4,6,10, 11]

      Hypovolemic Vs Hypervolemic hyponatremia  

      A condition is considered hypovolemic hyponatremia if there is a decrease in total body water with the decrease in the total amounts of the body sodium.

      Hypervolemic hyponatremia occurs when there is an increase in total body sodium along with the increase in total body water.
      If the normal body sodium levels do not change with the increase in total body water, the condition is said to be euvolemic hyponatremia. [1, 2, 3,5,8,9]

      There are cases where water shifts from the intercellular to extracellularly environment and results in dilution of sodium. The total body water is not changed in this case.
      This condition occurs if one is suffering from hyperglycemia and is referred to as redistributive hyponatremia. [1, 2, 3, 5, 8, 9]

      Acute hyponatremia and chronic hyponatremia

      Acute hyponatremia is the case where sodium levels fall rapidly in less than 48 hours.
      The condition is more dangerous than hyponatremia that occurs over several day or weeks, commonly known as chronic hyponatremia. In the latter, the brain cells adjust to the condition, and there is minimal swelling. [1, 2, 3, 5, 8, 9]

      Signs and symptoms of hyponatremia

      • Vomiting
      • Short memory loss
      • Lethargy
      • Fatigue
      • Irritability
      • Loss of appetite
      • Nausea
      • Confusion and muscle weakness.
      • Some patients also complain muscle cramps, seizures, and decreased consciousness.
      • In severe cases, one may fall into a coma. 

      Neurological symptoms only occur when sodium levels get very low at quantities below 115mEq/L. At this level of sodium, water enters the brain causing the brain to swell.

      The condition later causes pressure in the skull, a condition called hyponatremic encephalopathy. If the condition is not checked at the point, there is squeezing of the brain across the structures of the skull. The physical symptoms of this condition are:

      • Confusion
      • Respiratory arrest
      • Non-cardiogenic fluid accumulation in lungs
      • Brain stem compression. 
      The condition is fatal if not treated at once.
      The severity of the symptoms is dependent on the severity of the sodium drop and show fast the condition happens. The body may tolerate gradual drop even to levels that are very low. As the body has a neurotic adaptation capability. However, the presence of neurological diseases, seizure disorders, and other non-neurological metabolic abnormalities influence the severity of the condition [1, 2, 3,5,8,9, 13]


      Causes of hyponatremia 

      Sodium in the body fluid is used to maintain electrolyte balance, blood pressure and for the working of muscles and nerves. If the level of sodium in the fluids outside the cells goes down, the fluids enter the cells causing the cells to swell. Here are the main causes of hyponatremia:

      • Diarrhea
      • The intake of diuretic medicines that increase the urine output
      • Burns that cover large areas of the body
      • Heart failure
      • Vomiting
      • Sweating
      • Vomiting
      • Heart failure
      • Kidney diseases
      • Liver cirrhosis
      • The Syndrome of Inappropriate antidiuretic hormone secretion (SIADH)
      • Hypothyroidism, a condition where there is underperformance of the pituitary glands
      • Deficiency of glucocorticoid, a steroid
      • Congenital adrenal hyperplasia that makes the adrenal glands unable to produce enough steroid 

      Hormones 

      • Exercise-associated hyponatremia from prolonged period of exercise while taking water alone
      • Certain medications such as Lasix for treating blood pressure and antidiuretics [1, 2, 3,5,8,9, 13]


      Workup : A clinical diagnosis chart used to determine the cause of hyponatremia

       

      Legionnaire’s disease workup

      Cases of pneumonia are caused by several pathogens that share similar laboratory findings. Hyponatremia that is secondary to SIADH is common in Legionnaires’ disease that that which is caused by pathogens. However, the condition is not specific to Legionnaires’ disease. [4, 5]


      Diagnosis 

      Hyponatremia is also classified according to effective osmolality. It can be said to be: 
      • Hypotonic hyponatremia
      • Hypertonic hyponatremia
      • Isotonic hyponatremia.
      During the diagnosis, the patients undergo three tests that when combined with physical examination and history, the doctor is able to establish the etiological mechanism as urinary sodium concentration, urine osmolality, serum osmolality. [1, 2, 5, 6, 9, 13]

      Urine osmolality 

      This osmolality test is used to differentiate primary polydipsia from free-water excretion. Osmolality that is greater than 100mOsm/kg shows that the kidneys are unable to dilute the urine. . [1,2,5,6,9,13]


      Serum osmolality 

      Serum osmolality is used for differentiating between pseudo hyponatremias and true hyponatremia. The earlier is secondary to hyperproteinemia or hyperlipidemia or could be hypertonic hyponatremia that is linked to elevated mannitol, glucose, and glycine maltose or sucrose. Symptoms do not appear until the plasma levels drop below 120 mmol per L . [1,2,5,6,9]

      The urinary sodium concentration

      This test is used to differentiate between the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and hyponatremia that is secondary to hypovolemia. The condition is considered SIADH hyponatremia when the urine sodium is greater than 20-40mEq/L. The typical measurements of urine sodium for hypovolemia patients are usually less than 25mEq/L. However, an SIADH patient taking low sodium will have the values falling below 25mEq/L.  . [1,2,5,6,9,11,13]

      Hyponatremia treatment 

      • The treatment of the hyponatremia condition is dependent on the underlying cause. Such a condition should be treated first to correct the condition.
      • Treatment starts with the examination of the condition to determine if one has euvolemic, hypervolemic or hypovolemic condition
      • If the patient is suffering from hypovolemia, the condition is corrected by an intravenous administration of normal salt in a saline solution.
      • Euvolemic hyponatremia is treated by restriction of fluid and abolishment of the stimuli that causes the secretion of the antidiuretic hormone such as nausea.
      • Any drug that the patient is taking that could be causing SADH is also discontinued.
      • Hypervolemic hyponatremia is treated by treating the disease that could be causing the condition. In most cases, the cause is usually liver or heart failure. If this is not resolved, the patient receives the same treatment as that of the euvolemic hypervolemic hyponatremia condition. 
      There is a risk of the patient developing severe neurological disorder called Central Pontine Myolysis that breaks down the sheaths covering parts of the nerve cells if hyponatremia is corrected rapidly. As a precautionary measure the salt level in blood, or called sodium serum, should not rise beyond 0.33mmol/l/h during the application of the saline solution. [1,2,4,5,6,8,9,13]

      Hyponatremia correction calculator

       Hyponatremia calculator is used for calculating the amount and the intensity of the saline solution that is needed to correct the serum hyponatremia. The formula for calculation of the infusateRate is; 

      Infusate Rate = (1000 * Serum Na Change Per Hr * ((Water Fract * Weight) + 1)) / (IVNa + IVK - SerumNa) 

      Serum Na Change Per Liter = (IVNa + IVK - SerumNa) / ((Water Fract * Weight) + 1) [12]

      ICD-9-CM Diagnosis Code 276.1 

      ICD-9-CM Diagnosis Code 276.1 is a billable medical code used to indicate that hyposmolality and hyponatremia were diagnosed for reimbursements. However, the code can only be used for claims for services rendered before October 1, 2015. For claims after the date, the code ICD-10-CM code is used. [7]


      References
      1. Merck Manuals Professional Edition. Hyponatremia - Endocrine and Metabolic Disorders [Internet]. 2015 [cited 22 December 2015]. Available from: http://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/hyponatremia#sec12-ch156-ch156d-714
      2. Melissa Conrad Stöppler M. Hyponatremia: Get the Facts on Symptoms and Treatment [Internet]. MedicineNet. 2015 [cited 24 December 2015]. Available from: http://www.medicinenet.com/hyponatremia/article.htm
      3. Goh K. Management of Hyponatremia - American Family Physician [Internet]. Aafp.org. 2015 [cited 24 December 2015]. Available from: http://www.aafp.org/afp/2004/0515/p2387.html
      4. Emedicine.medscape.com. Legionnaires Disease Workup: Approach Considerations, Histologic Findings, Laboratory Studies [Internet]. 2015 [cited 24 December 2015]. Available from: http://emedicine.medscape.com/article/220163-workup
      5. Updated by: David C. Dugdale a. Hyponatremia: MedlinePlus Medical Encyclopedia [Internet]. Nlm.nih.gov. 2015 [cited 24 December 2015]. Available from: https://www.nlm.nih.gov/medlineplus/ency/article/000394.htm
      6. Haralampos J. Milionis M. The hyponatremic patient: a systematic approach to laboratory diagnosis. CMAJ: Canadian Medical Association Journal [Internet]. 2002 [cited 24 December 2015];166(8):1056. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC100882/
      7. Icd9data.com. 2012 ICD-9-CM Diagnosis Code 276.1 : Hyposmolality and/or hyponatremia [Internet]. 2015 [cited 24 December 2015]. Available from: http://www.icd9data.com/2012/Volume1/240-279/270-279/276/276.1.htm
      8. Mayoclinic.org. Hyponatremia Symptoms - Mayo Clinic [Internet]. 2015 [cited 24 December 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/hyponatremia/basics/symptoms/con-20031445
      9. Healthline. Low Blood Sodium (Hyponatremia) [Internet]. 2015 [cited 24 December 2015]. Available from: http://www.healthline.com/health/hyponatremia
      10. Moritz M, Ayus J. The pathophysiology and treatment of hyponatraemic encephalopathy: an update. Nephrology Dialysis Transplantation. 2003;18(12):2486-2491.
      11. Encyclopedia Britannica. syndrome of inappropriate antidiuretic hormone (SIADH) | pathology [Internet]. 2014 [cited 24 December 2015]. Available from: http://www.britannica.com/science/syndrome-of-inappropriate-antidiuretic-hormone
      12. Reference.medscape.com. Hyponatremia Correction Infusate Rate [Internet]. 2015 [cited 24 December 2015]. Available from: http://reference.medscape.com/calculator/hyponatremia-correction-infusate-rate
      13. Updated by: David C. Dugdale a. Hyponatremia: MedlinePlus Medical Encyclopedia [Internet]. Nlm.nih.gov. 2015 [cited 24 December 2015]. Available from: https://www.nlm.nih.gov/medlineplus/ency/article/000394.htm
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