An adolescent with adnexal torsion presenting with severe hyponatremia

Abstract

Background: Adnexal torsion is the sixth most common pediatric surgical emergency, and one that requires high clinical suspicion and prompt surgical intervention in order to preserve adnexal function. Patients presenting with one or more additional acute medical concerns during an episode of torsion must be managed carefully and effectively to ensure both safe perioperative care and expeditious surgical management. Case Presentation: We review a case of adnexal torsion in a seventeen-year-old female who was found incidentally to have severe hyponatremia, with serum sodium concentration 117 mEq/L. Further workup was initiated for this significant electrolyte derangement. This demonstrated low serum osmolality and high urine osmolality, consistent with syndrome of inappropriate antidiuretic hormone (SIADH). This case represents the first case report of SIADH in the setting of adnexal torsion. Optimizing surgical management was uniquely challenging in this case. In order to preserve fertility in this young patient, urgent detorsion was needed. This had to be balanced with aggressive but safe preoperative normalization of sodium to minimize intraoperative risk. Although serum sodium improved with medical management, it only returned to normal range after the patient underwent surgical detorsion of the adnexa, and resolution of her pain. Conclusions: Although this represents the first reported case of SIADH in the setting of adnexal torsion, the linkage between pain afferents and SIADH has been well documented, suggesting that patients with severe pain from torsion may be at risk for hyponatremia via this mechanism. As such, providers should be aware of the management of SIADH, as well as potential perioperative risks. This case, along with our review of the literature, supports surgical intervention as integral to the definitive coffection of hyponatremia in patients with adnexal masses resulting in SIADH.

Keywords

• Adnexal torsion
• Tubal torsion
• Hyponatremia
• Syndrome of inappropriate antidiuretic hormone