Terlipressin-induced hyponatremic seizure in a child
A 7-year-old male child presented with two episodes of hematemesis (around 100 ml of fresh blood). There was no history of abdominal pain, malena, fever, drug intake, and bladder/bowel complaints. There was no history of blood transfusion or jaundice in the past. His family history and birth history was normal. On admission, blood pressure was 78/58 mmHg, heart rate was 110 beats/min, and respiratory rate was 24 breaths/min. Pallor was present. There was no icterus, edema, cyanosis, or jaundice. Spleen was palpable 3 cm below left costal margin. Liver span was 8 cm with soft consistency and smooth margins. After initial fluid resuscitation, patient was given 15 cc/kg of packed cell transfusion. His hemoglobin was 5.7 g/dl; white blood cell count 7200/cumm; platelet count 1.6 lac/cumm. His liver function tests, serum electrolytes, renal function tests, prothrombin time, plasma thromboplastin time, and bleeding time were normal. A provisional diagnosis of extra-hepatic portal vein obstruction with variceal bleeding was made. An esophagogastroduodenoscopy (EGD) showed two large esophageal varices with active bleeding. Endoscopic variceal ligation was planned in the patient. However, as the patient was not hemodynamically stable, a bolus of 2 mg of terlipressin was initiated, followed by 1 mg every 6 hourly. Color Doppler sonography revealed multiple collateral channels replacing the portal vein (portal cavernoma) and splenomegaly. The patient was stable until the third hospital day when he had a generalized tonic seizure and became drowsy. His sodium level had dropped from 142 mEq/L on admission to 110 mEq/L and serum osmolality had decreased to 240 mOsm/kg. Intravenous correction for hyponatremia was started. Computed tomography scan of brain, cerebrospinal fluid examination, and electroencephalography were normal. After 2 days of starting sodium correction, the sensorium had slightly improved but hyponatremia was persistent. On the fifth hospital day, terlipressin was stopped and serum electrolytes measured the next day showed a dramatic increase in sodium level, although not to a normal level. After 4 days of stopping terlipressin, the serum sodium was normal. This can be considered as a ‘probable’ adverse drug reaction as per causality assessment with Naranjo's Scale.[] shows the serial serum sodium values during the hospital stay. The patient underwent endoscopic ligation of the esophageal varices and was discharged on the tenth day of admission.