Review article
Forensic aspects of water intoxication: Four case reports and review of relevant literature

https://doi.org/10.1016/j.forsciint.2012.01.021Get rights and content

Abstract

Water intoxication (WI) is a rare condition that originates from over-consumption of water, with a potentially fatal outcome. Increased water intake (polydipsia) is followed by urination of high amount of diluted urine (polyuria) which are the main initial symptoms of WI. We present four case reports of WI. Two of them are unusual pediatric clinical cases using medical documentation and police case files, one of which is related to child abuse, and the other to a psychiatric disorder. The other two cases are fatal adult cases submitted to autopsy from a psychiatric hospital. Also, we present a diagnostic algorithm for polydipsia and polyuria before death. WI is usually seen in patients with psychiatric disorders, victims of child abuse or torture, drug abusers or it can be iatrogenically induced.

Introduction

Changes in osmotic gradient in blood, extracellular and cellular compartment due to increased loss, increased intake or retention of water in the body, followed by saline imbalance, causes the maldistribution of water among these compartments and general disorder in water metabolism. Hormone regulation of water metabolism includes vasopressin (ADH, antidiuretic hormone which increases the reabsorption of water from the renal tubules), aldosterone (which reabsorbs sodium and excretes potassium in the kidneys) and a group of natriuretic hormones (which excrete sodium and water).

Water intoxication (WI), hyperhydration or water poisoning, is a rare condition that originates from overconsumption of water, with a potentially fatal outcome. This primarily affects the brain function. Increased water intake (polydipsia) is followed by urination of high amount of diluted urine (polyuria) which are the main initial symptoms of WI.

Section snippets

Methods

We evaluate two unusual pediatric clinical cases of WI (polydipsia & polyuria) using medical documentation and police case files, and two fatal adult cases subjected to autopsy.

Case 1

A 5-year-old boy (112 cm, 22.5 kg) was admitted to a pediatric hospital due to strong thirst, excessive water intake (ca. 6 L a day) and frequent urination. The problems lasted for 10 days. He was the eldest child of the family, and was born 15 days premature. He had suffered from frequent bouts of bronchitis and atopic dermatitis, and two years previously he had infective mononucleosis. His mother had contact dermatitis to some metals and his grandfather had suffered from diabetes mellitus type II.

Discussion

Excessive water intake is compensated for by higher diuresis, but the kidneys of a healthy adult can process a maximum of 15 L a day, while the osmolarity of urine falls below 300–400 mosm/L. When the kidneys’ compensatory ability for water processing passes the limits, WI or hypotonic hyperhydration appears. It leads to the forming of concentration gradient between extracellular and intracellular compartments, especially in brain tissue and consequent brain swelling (edema). Brain damage occurs

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    1

    Institute of Forensic Medicine, “Milovan Milovanovic”, School of Medicine, University of Belgrade, Deligradska 31a, 11000 Belgrade, Serbia. Tel.: +381 63 8989 155.

    2

    School of Medicine, University of Belgrade, Deligradska 31a, 11000 Belgrade, Serbia. Tel.: +381 11 2682 522.

    3

    Present address: Susedgradska 41a/5, 11090 Belgrade, Serbia. Tel.: +381 63 8524 443.

    4

    Department for Endocrinology and Diabetes, Institute of Sick Children, Medical Faculty, University of Montenegro, Ljubljanska 1, 20000 Podgorica, Montenegro. Tel.: +382 67 548 861.

    5

    Department of Forensic Medicine, Clinical Centre of Vojvodina, Medical Faculty, University of Novi Sad, Hajduk Veljkova 1-7, 21000 Novi Sad, Serbia. Tel.: +381 21 454 927.

    6

    Institute of Forensic Medicine, “Milovan Milovanovic”, School of Medicine, University of Belgrade, Deligradska 31a, 11000 Belgrade, Serbia. Tel.: +381 11 2682 522.

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