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Hyponatremia, Cerebral Edema, and Noncardiogenic Pulmonary Edema in Marathon Runners

J. Carlos Ayus, MD; Joseph Varon, MD; and Allen I. Arieff, MD
[+] Article, Author, and Disclosure Information

From Baylor College of Medicine, Houston, Texas; and University of California, San Francisco, School of Medicine, San Francisco, California.

Presented in part at the annual meeting of the American Society of Nephrology, Miami, Florida, 4 November 1999, and published as an abstract in J Am Soc Nephrol. 1999; 10:119A.

Acknowledgments: The authors thank Dr. J. Gary Grant for his invaluable contribution to the database and Dr. David E. King for analysis of the neuroradiologic studies.

Requests for Single Reprints: J. Carlos Ayus, MD, Baylor College of Medicine, 4 Brompton Court, Houston, TX 77024.

Requests To Purchase Bulk Reprints (minimum, 100 copies): the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints@mail.acponline.org.

Current Author Addresses: Drs. Ayus and Varon: Baylor College of Medicine, 4 Brompton Court, Houston, TX 77024.

Dr. Arieff: University of California, San Francisco, School of Medicine, 299 South Street, Sausalito, CA 94965.

Author Contributions: Conception and design: J.C. Ayus, J. Varon, A.I. Arieff.

Analysis and interpretation of the data: J.C. Ayus, J. Varon, A.I. Arieff.

Drafting of the article: J.C. Ayus, A.I. Arieff.

Critical revision of the article for important intellectual content: J.C. Ayus, A.I. Arieff.

Final approval of the article: J.C. Ayus, J. Varon, A.I. Arieff.

Provision of study materials or patients: J.C. Ayus, J. Varon, A.I. Arieff.

Collection and assembly of data: J.C. Ayus, A.I. Arieff.

Ann Intern Med. 2000;132(9):711-714. doi:10.7326/0003-4819-132-9-200005020-00005
Text Size: A A A

Background: Noncardiogenic pulmonary edema is often associated with increased intracranial pressure and can be the initial manifestation of hyponatremic encephalopathy. Marathon runners tend to develop conditions that lead to hyponatremia.

Objective: To describe the development and treatment of noncardiogenic pulmonary edema in marathon runners that was associated with hyponatremic encephalopathy.

Design: Case series.

Setting: One university hospital and two community hospitals.

Patients: Seven healthy marathon runners who had a history of nonsteroidal anti-inflammatory drug use. The runners collapsed after competing in a marathon and were hospitalized with pulmonary edema.

Measurements: Plasma sodium levels, chest radiograph, electrocardiogram, cardiac enzyme levels, and magnetic resonance imaging or computed tomographic scans of the brain.

Results: Patients had nausea, emesis, and obtundation. The mean (±SD) plasma sodium level was 121 ± 3 mmol/L, and oxygen saturation was less than 70%. Electrocardiograms and echocardiograms were normal. Chest radiographs showed pulmonary edema with a normal heart. Creatine phosphokinase-MB bands, troponin levels, and pulmonary wedge pressure were not elevated. Scanning of the brain showed cerebral edema. All patients were intubated and mechanically ventilated. Treatment with intravenous NaCl, 514 mmol/L, increased plasma sodium levels by 10 mmol/L in 12 hours. Pulmonary and cerebral edema resolved as the sodium level increased. One patient had unsuspected hyponatremic encephalopathy and died of cardiopulmonary arrest caused by brainstem herniation. All six treated patients recovered and were well after 1 year of follow-up.

Conclusions: In healthy marathon runners, noncardiogenic pulmonary edema can be associated with hyponatremic encephalopathy. The condition may be fatal if undiagnosed and can be successfully treated with hypertonic NaCl.


Grahic Jump Location
Radiographs and scans obtained from patient 3, a 44-year-old woman who was admitted to the emergency department with a plasma sodium level of 121 mmol/L and oxygen saturation of 66%.A.B.C.D.

Bibasilar rales and copious pink frothy sputum were noted, and the respiratory rate was 38 breaths/min. Chest radiograph showing interstitial edema and apparent redistribution of pulmonary blood volume, with loss of distinct vascular margins. The heart size is normal. Chest radiograph obtained 24 hours after admission. The patient's plasma sodium level had been increased from 121 to 129 mmol/L in 9 hours. The patient was alert and responsive, with oxygen saturation of 97%. The chest radiograph is normal. Computed tomographic scan of the brain obtained within 1 hour of the chest radiograph shown in part A. Cerebral edema is evident, the cerebral ventricles are essentially obliterated, and the sulci are largely absent. Magnetic resonance image of the brain taken 24 hours after admission, at about the same time as the chest radiograph shown in part B. Cerebral edema has resolved, the cerebral ventricles are now clearly visible, and the sulci are more distinct.

Grahic Jump Location




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Summary for Patients

Serious Fluid Accumulation in the Brain and Lungs of Marathon Runners

The summary below is from the full report titled “Hyponatremia, Cerebral Edema, and Noncardiogenic Pulmonary Edema in Marathon Runners.” It is in the 2 May 2000 issue of Annals of Internal Medicine (volume 132, pages 711-714). The authors are J.C. Ayus, J. Varon, and A.I. Arieff.


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