Abstract| Volume 36, ISSUE 2, P183, April 2023

22. Adnexal Torsion and Syndrome of Inappropriate Antidiuretic Hormone – Coincidental or Causal? A Case Report of an Adolescent with Torsion Presenting with Severe Hyponatremia

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      Adnexal torsion is the sixth most common pediatric surgical emergency, and one that requires high 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.


      In this report 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 which demonstrated low serum osmolality and high urine osmolality, consistent with syndrome of inappropriate antidiuretic hormone (SIADH). Per our review of the literature, this represents the first case report of SIADH in the setting of adnexal torsion. Potential causes of and factors contributing to her hyponatremia were considered including SSRI use, pain, and possible relapse of prior anorexia nervosa. In this case, optimizing surgical management was uniquely challenging due to the need to balance preoperative normalization of sodium to minimize intraoperative risk with the necessity of urgent surgical detorsion to prevent lost or compromised fertility in a young patient. Although serum sodium improved with medical management, it only returned to normal range after the patient underwent surgery to de-torse her adnexa and relieve her pain.


      Through this case we review the presentation, evaluation, and management of ovarian torsion, a common but easily missed diagnosis in pediatric and adolescent patients with abdominal pain. Additionally, we discuss SIADH and its pathophysiology, symptoms, diagnosis, and potential sequelae. Further discussion includes the role of pain and surgery in SIADH, adnexal masses known to cause SIADH, medications commonly implicated in SIADH, and an overview of the types of hyponatremia commonly seen in patients with restrictive diets or anorexia nervosa. Although to our knowledge this represents the first reported case of SIADH in the setting of adnexal torsion, the linkage between pain afferents and SIADH has been 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 frequently integral to definitive correction of hyponatremia in patients with adnexal masses resulting in SIADH.
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