lnapprepriete Secretion of
CASE
REPoRT
A 17-year-old white recruit in his second week of training was admitted to the Naval Hospital, Orlando, Florida, on November 24, 1972. He presented with a sore throat, cough, malaise, headache, fever, and nausea of several days' duration. His temperature was 104°F (40.0°C) orally and there were right lower lung rhonchi. Chest x-ray film obtained the following morning demonstrated an early right lower lobe infiltrate. Laboratory data is displayed in Table 1. The day after admission he was entered into an ongoing, prospective study of pneumonia in recruits. Nasal washings for virus isolation, throat and sputum cultures, and sera were obtained as a routine part of this study. Because of continuing fever of 104°F daily, penicillin was begun on the fourth hospital day. Intravenous fluids were administered starting on day 6. A chest x-ray film taken on the eighth hospital day revealed an increase in the right lower lobe pneumonia and the appearance of a small right pleural effusion. The evening of the same day he was noted to look quite ill and was confused. Review of the data at that time revealed that senun sodium level that day was 123 mEq/L. His state of hydration was clinically thought to be normal and his urinary output during the preceding 24 hours was greater than 3000 ml with an intake of approximately 4000 ml. The possibility of inappropriate secretion of ADH was thought likely and he was begun on a program of fluid restriction. The next morning he was transferred to the intensive care unit (leU). Initial leu laboratory studies on December 6, were compatible with inappropriate ADH secretion and except for fluids necessary for IV medications, he was placed on strict fluid restriction. The electrolytes gradually returned to normal over the next 48 hours. Blood gas analysis on arrival in the ICU revealed P02 of 40 and nasal oxygen therapy was begun. Lumbar puncture was nonnal. The ·white blood cell count had decreased to 2,000 by the eighth hospital day, with a relative lymphopenia. It was decided to treat the pneumonia with gentamicin, carbenicillin and methacillin, but this regimen was later changed to gentamicin and erythromycin. Sputum cultures grew out varied organisms with none predominating and many blood cultures gave negative findings. Cold agglutinins were 1:2. He slowly improved and normal mental status returned as the hyponatremia and hypoxia improved. His temperature rose to at least 104°F daily for nine days. Review of the x-ray films showed the infiltrate to be maximum on the 11th hospital day (Fig 1 ). There was a transient drop in hematocrit with associated guaiac-positive stools thought to be secondary to a stress ulcer. By December 20, he was discharged home for convalescent leave and was returned to active duty on January 15, 1973.
Antidiuretic Hormone Associated with Adenovirus Pneumonia"
u.s.
Richard B. Pollord~ M.D.
MetaboHc abnonnalities compatible with inappropriate secretion of ADH developed during the course of severe viral pneumonia in a 17-year-old Navy recruit. With a regimen of strict fluid restriction, nonnaBzation of these abnonnaUties occurred. Marked leukopenia 8Dd hypoxia were Do present, but gradually improved with resolution of the pneumonia. Inappropriate ADH secretion has been .-ociated mO't often with bacterial pneumonia and th8 patient represents one of the few with viral pneumonia compHcateel by this syndrome. WhDe the previous cases were .-ociated with inftuenza virus, dtis patient was infected with adenovtm.7 which is endemic in the military recndt population. secondary to inappropriate secretion of H yponatremia antidiuretic hormone (ADH) was first described by
Schwartz et a1 in 1957. 1 , 2 Since that time, this syndrome has been found to complicate many conditions involving the lungs, ie bacterial pneumonia, tuberculosis, fungal infections and neoplasms. In a recent review by . Rosenow and colleagues," the typical clinical picture was described and three patients with pneumonia and hyponatremia were presented. Two of these patients had pneumonia associated with A2 influenza and at least one of these had the typical findings of inappropriate secretion of ADH. This was the first reported case of viral pneumonia associated with this syndrome. During a large epidemiologic study of pneumonia among Navy recruits training in Orlando, F1orida, a patient with severe adenovirus pneumonia was noted to have findings consistent with inappropriate ADH secretion. ·From the Component Research Laboratory, Naval Medical Research Unit No.4, Naval Hospital, Orlando, Florida and Naval Medical Research Unit No.4, Great Lakes, Illinois. The opinions expressed herein are those of the authors and cannot be construed as reflecting the views of the Naval Service at large or the Department of Defense. Reprint requests: Dr. Pollard, Division of Infectious Diseases, Stanford University Medical Center, Palo Alto~ California 94305
Table I-Laboratory Data
Date
Bet. %
WBC
DifJ.
11-28 12-5 12-6 12-7 12-8 12-9 12-10 12-14
40
11,600 2,000 4,100 3,300 3,900 5,900 7,200 9,400
84S/14L
38 40 36 33 35
86S/10L
75S/25L
CHEST, 68: 4, OCTOBER, 1975
Serum CI Glucose K Na mEq/L mEq/L mEq/L Mg% 123 125 133 138 138 139 137
4.0 3.8 3.7 3.5 3.8 3.8 5.1
86 95 94 98 95 99 97
BUN
122
10 8 8.9 10.5
75
9.7
102
Urine Osmolality IJ N K S mEq/L mEq/L mOsm/L mOsm/L
35 71 66
43 59 40
259
685
61 146
16 73
281
400
INAPPROPRIATE SECRETION OF ANTIDIURETIC HORMONE 589
magnitude of resp onse to th is non isola ted virus is felt to be a c ross rea cti on co nsist ent wi th th e heterotypic respo nse described b y Grayston e t al.? There was no se rologic response d et ected to any of th e other an tigens tested, excep t to 1B rhi novirus (4 hi he ) . Rhinovims was not isolated an d th e significa nce of th is titer rise is unknown . The occurrence of m ulti ple seroeo nversions w as not an u nco m mo n finding durin g th is study of p ne um on ia in recrui ts ; however, th e possibility of d ual infec tio n must be considered. DISCUSSION
FIGURE 1. PA chest film tak e n on 11th hosp ital d ay reveals a co nsolidatin g right lower lobe infiltrate wh ich was maximal on th is d at e. VIROLOGIC AN D SEROLOGIC TESTING
Serum and nasal wash ing specimens wer e frozen and se nt to Naval Medical Resear ch Un it 4, Great Lakes, Illinois, for test in g. Xasal wash in gs for viral isolation were inoculated in to HeLa, prim a ry rhesus mo nke y kidney tubes and HEP-2 mi cropl ates. Ad enoviruses we re typed in microplates b y neutralization test, using 20 unit, of type-specific an tibody. Acute a nd co nv a les ce nt sera wer e tested for complem ent fixing ( C F) antihody to adenovirus, Mycoplasma pn eu moniae, respiratory syncytia l virus, and psittacosis. Hemagglutination inhibition tests for parainfluenza virus antibody were performed in microplates usin g standard methods." Ne utr ali zati on an ti body for adenov irus types, 3, 4 and 7 , and rh inovirus types l A, 1B, 2, 64, and 7407 were performed by the micromethod pr e viou sly descrtbed. s-? Aden ovirus type 7 was isol at ed from the nasal was h ing obtained No vem ber 29 ( Tab le 2 ) . The re was CF se roeonversion to ad enovirus and specific neutraliz ati on antibody rises to ade nov irus-? ( 128 -fo ld) and adenov irus -4 ( 16- fold). The rise in neutralization ti te r to adenovi m s-4 with a low er Table 2-1.olation and Serology Data
N8.,11.1 Washing Serology Titer s
M ycoplasma pneumonia e C F · Ade novirus C F Adenovi rus- t N·· Ad en ovirus-7 N Rhinov irus N "Complem ent fixa ti on tests
··N eutralizaj.ion tests
590 RICHARD B. POLLARD
l sol ation -Ad en ovirus-7 Conval (21 d ays) Acute
CASE
REPoRT
A 17-year-old white recruit in his second week of training was admitted to the Naval Hospital, Orlando, Florida, on November 24, 1972. He presented with a sore throat, cough, malaise, headache, fever, and nausea of several days' duration. His temperature was 104°F (40.0°C) orally and there were right lower lung rhonchi. Chest x-ray film obtained the following morning demonstrated an early right lower lobe infiltrate. Laboratory data is displayed in Table 1. The day after admission he was entered into an ongoing, prospective study of pneumonia in recruits. Nasal washings for virus isolation, throat and sputum cultures, and sera were obtained as a routine part of this study. Because of continuing fever of 104°F daily, penicillin was begun on the fourth hospital day. Intravenous fluids were administered starting on day 6. A chest x-ray film taken on the eighth hospital day revealed an increase in the right lower lobe pneumonia and the appearance of a small right pleural effusion. The evening of the same day he was noted to look quite ill and was confused. Review of the data at that time revealed that senun sodium level that day was 123 mEq/L. His state of hydration was clinically thought to be normal and his urinary output during the preceding 24 hours was greater than 3000 ml with an intake of approximately 4000 ml. The possibility of inappropriate secretion of ADH was thought likely and he was begun on a program of fluid restriction. The next morning he was transferred to the intensive care unit (leU). Initial leu laboratory studies on December 6, were compatible with inappropriate ADH secretion and except for fluids necessary for IV medications, he was placed on strict fluid restriction. The electrolytes gradually returned to normal over the next 48 hours. Blood gas analysis on arrival in the ICU revealed P02 of 40 and nasal oxygen therapy was begun. Lumbar puncture was nonnal. The ·white blood cell count had decreased to 2,000 by the eighth hospital day, with a relative lymphopenia. It was decided to treat the pneumonia with gentamicin, carbenicillin and methacillin, but this regimen was later changed to gentamicin and erythromycin. Sputum cultures grew out varied organisms with none predominating and many blood cultures gave negative findings. Cold agglutinins were 1:2. He slowly improved and normal mental status returned as the hyponatremia and hypoxia improved. His temperature rose to at least 104°F daily for nine days. Review of the x-ray films showed the infiltrate to be maximum on the 11th hospital day (Fig 1 ). There was a transient drop in hematocrit with associated guaiac-positive stools thought to be secondary to a stress ulcer. By December 20, he was discharged home for convalescent leave and was returned to active duty on January 15, 1973.
Antidiuretic Hormone Associated with Adenovirus Pneumonia"
u.s.
Richard B. Pollord~ M.D.
MetaboHc abnonnalities compatible with inappropriate secretion of ADH developed during the course of severe viral pneumonia in a 17-year-old Navy recruit. With a regimen of strict fluid restriction, nonnaBzation of these abnonnaUties occurred. Marked leukopenia 8Dd hypoxia were Do present, but gradually improved with resolution of the pneumonia. Inappropriate ADH secretion has been .-ociated mO't often with bacterial pneumonia and th8 patient represents one of the few with viral pneumonia compHcateel by this syndrome. WhDe the previous cases were .-ociated with inftuenza virus, dtis patient was infected with adenovtm.7 which is endemic in the military recndt population. secondary to inappropriate secretion of H yponatremia antidiuretic hormone (ADH) was first described by
Schwartz et a1 in 1957. 1 , 2 Since that time, this syndrome has been found to complicate many conditions involving the lungs, ie bacterial pneumonia, tuberculosis, fungal infections and neoplasms. In a recent review by . Rosenow and colleagues," the typical clinical picture was described and three patients with pneumonia and hyponatremia were presented. Two of these patients had pneumonia associated with A2 influenza and at least one of these had the typical findings of inappropriate secretion of ADH. This was the first reported case of viral pneumonia associated with this syndrome. During a large epidemiologic study of pneumonia among Navy recruits training in Orlando, F1orida, a patient with severe adenovirus pneumonia was noted to have findings consistent with inappropriate ADH secretion. ·From the Component Research Laboratory, Naval Medical Research Unit No.4, Naval Hospital, Orlando, Florida and Naval Medical Research Unit No.4, Great Lakes, Illinois. The opinions expressed herein are those of the authors and cannot be construed as reflecting the views of the Naval Service at large or the Department of Defense. Reprint requests: Dr. Pollard, Division of Infectious Diseases, Stanford University Medical Center, Palo Alto~ California 94305
Table I-Laboratory Data
Date
Bet. %
WBC
DifJ.
11-28 12-5 12-6 12-7 12-8 12-9 12-10 12-14
40
11,600 2,000 4,100 3,300 3,900 5,900 7,200 9,400
84S/14L
38 40 36 33 35
86S/10L
75S/25L
CHEST, 68: 4, OCTOBER, 1975
Serum CI Glucose K Na mEq/L mEq/L mEq/L Mg% 123 125 133 138 138 139 137
4.0 3.8 3.7 3.5 3.8 3.8 5.1
86 95 94 98 95 99 97
BUN
122
10 8 8.9 10.5
75
9.7
102
Urine Osmolality IJ N K S mEq/L mEq/L mOsm/L mOsm/L
35 71 66
43 59 40
259
685
61 146
16 73
281
400
INAPPROPRIATE SECRETION OF ANTIDIURETIC HORMONE 589
magnitude of resp onse to th is non isola ted virus is felt to be a c ross rea cti on co nsist ent wi th th e heterotypic respo nse described b y Grayston e t al.? There was no se rologic response d et ected to any of th e other an tigens tested, excep t to 1B rhi novirus (4 hi he ) . Rhinovims was not isolated an d th e significa nce of th is titer rise is unknown . The occurrence of m ulti ple seroeo nversions w as not an u nco m mo n finding durin g th is study of p ne um on ia in recrui ts ; however, th e possibility of d ual infec tio n must be considered. DISCUSSION
FIGURE 1. PA chest film tak e n on 11th hosp ital d ay reveals a co nsolidatin g right lower lobe infiltrate wh ich was maximal on th is d at e. VIROLOGIC AN D SEROLOGIC TESTING
Serum and nasal wash ing specimens wer e frozen and se nt to Naval Medical Resear ch Un it 4, Great Lakes, Illinois, for test in g. Xasal wash in gs for viral isolation were inoculated in to HeLa, prim a ry rhesus mo nke y kidney tubes and HEP-2 mi cropl ates. Ad enoviruses we re typed in microplates b y neutralization test, using 20 unit, of type-specific an tibody. Acute a nd co nv a les ce nt sera wer e tested for complem ent fixing ( C F) antihody to adenovirus, Mycoplasma pn eu moniae, respiratory syncytia l virus, and psittacosis. Hemagglutination inhibition tests for parainfluenza virus antibody were performed in microplates usin g standard methods." Ne utr ali zati on an ti body for adenov irus types, 3, 4 and 7 , and rh inovirus types l A, 1B, 2, 64, and 7407 were performed by the micromethod pr e viou sly descrtbed. s-? Aden ovirus type 7 was isol at ed from the nasal was h ing obtained No vem ber 29 ( Tab le 2 ) . The re was CF se roeonversion to ad enovirus and specific neutraliz ati on antibody rises to ade nov irus-? ( 128 -fo ld) and adenov irus -4 ( 16- fold). The rise in neutralization ti te r to adenovi m s-4 with a low er Table 2-1.olation and Serology Data
N8.,11.1 Washing Serology Titer s
M ycoplasma pneumonia e C F · Ade novirus C F Adenovi rus- t N·· Ad en ovirus-7 N Rhinov irus N "Complem ent fixa ti on tests
··N eutralizaj.ion tests
590 RICHARD B. POLLARD
l sol ation -Ad en ovirus-7 Conval (21 d ays) Acute
