A 12-year-old boy with
tuberculous meningitis and hydrocephalous, after undergoing revision of
ventriculo-peritoneal shunt had persistent impairment of sensorium and episodes of
hyponatremia (serum
sodium 104 to 125 mmol/l), accompanied by
polyuria, signs of poor peripheral, perfusion
hypotension and low CVP, and high urinary
sodium excretion (114-60 mmol/l). A diagnosis of cerebral
salt wasting syndrome (CSWS) was made and was treated with saline replacement and
fludrocortisone (10 microg/kg/day). Within next 3 days the sensorium, signs of
shock, urine output and serum and urinary
sodium returned to normal. The case illustrates that life-threatening
hyponatremia in a child with neurological illness could be caused by CSWS, which must be differentiated from Syndrome of inappropriate
antidiuretic hormone secretion (
SIADH), as CSWS requires rigorous
salt and volume replacement in contrast to fluid restriction in
SIADH.