BMJ Case Reports 2018; doi:10.1136/bcr-2017-223021
  • Learning from errors

Iatrogenic water intoxication in a female adolescent with hypopituitarism

  1. Ana Antunes2
  1. 1Department of Endocrinology, Hospital de Braga, Braga, Portugal
  2. 2Pediatric Endocrinology Unit, Hospital de Braga, Braga, Portugal
  1. Correspondence to MD Ana Margarida Monteiro, anamargaridacmonteiro{at}, ana.m.monteiro{at}
  • Accepted 8 February 2018
  • Published 9 March 2018


The authors report a case of a 15-year-old girl with hypopituitarism due to pituitary stalk interruption syndrome diagnosed in the neonatal period. The patient was admitted to the emergency room with impaired consciousness and hypoglycaemia. The day before, she increased her water intake to about 1.5 L to perform a pelvic ultrasound. In the following hours, she developed vomiting and food refusal. Blood analysis revealed hypoglycaemia, hyponatraemia, decreased serum osmolality and normal urinary density. Hyponatraemia and adrenal crisis were managed with a gradual but slow resolution of consciousness and electrolytic balance. This case describes an episode of iatrogenic water intoxication in a patient under desmopressin treatment. Although uncommon, dilutional hyponatraemia is the main complication of desmopressin treatment. We reinforce the importance of patients and caregivers’ long-life education for the potential complications of an increase in fluid intake in patients treated with desmopressin.


  • Contributors AMM did the literature review, article drafting and final approval of the version to be published. OM and SM revised it critically for important intellectual content and final approval of the version to be published. AA was the primary treating physician and actively involved in the subsequent revision of the article. All authors read and approved the final manuscript.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Guardian consent obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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