SEVER SYMPTOMATIC HYPONATREMIA INDUCED BY HERBAL MEDICATION

Hyponatremia is of the  most common electrolyte disturbance in clinical practice . Hyponatremia may result from various etiologies .furthermore severe hyponatremia may associated with severe morbidities. Herbal preparations with diuretic properties are often perceived as safe; however, their use is not without risk. Sambong (Blumea balsamifera), recognized in the South Asia as an herbal with diuretic properties may cause hyponatremia  a few cases reported in the literature.

We reported A 75 years old femal from south asia . She presented to the emergency department with complaint of severe weakness, fatigue, dizziness and altered mental status. The blood work up showed that she had severe hyponatremia reported to be 112 men/L further work up for hyponatremia showed  low serum osmolarity, high urine osmolarity, urine sodium was relatively low. Her sugar and triglycerides were normal her TSH and cortisol both were normal .

on clinical examination BP was on lower side she was awake but disoriented there is no focal neurological sign,  clinically She was on dry side.

 Giving the fact that she had severe symptomatic hyponatremia patient was treated with 3% high concentrated saline initially,  there monitored closely and her sodium corrected slowly gradually as per European best practice protocol for hyponatremia  . 

Subsequently patient improved clinically her neurological manifestation improved Our diagnosis  , over all the picture was suggestive hypo osmolar hypovolemic symtomatic hyponatremia. 

 in regard to the cause , we looked thoroughly in to the patient medication. There were no anti psychotic  or anti-epileptic medications. However, we found that she is taking a herbal medication derivitive from sambong leaf. We looked and searched  for this herbal medication and we found that it  may exert  diuretic effect and it may cause hyponatremia, particularly if taken in high dose for prolong period like our patient.

Sambong leaf  is a herbal medication scintific  name: Blumea balsamifera a medicine plant containing active components: camphor, borneal, saponins, flavonoids, essential oils. used in south east countries commonly in Philippines, Thailand, and Indonesia . 

In some countries it’s officially recognized by DOH and  approved herbal medication’s. It’s used mainly as diuretic, for mild hypertension ,  kidney stones ,also as anti-inflammatory  coughs and colds .it have mild antiseptic effect  the leaves can be crushed and applied externally for minor wounds and cuts as it has Antibacterial properties. 

 This  medication  comes from a natural plant it has diuretic properties thought to be thized like .however The site of action is not precise defined, it can cause mild osmotic diuresis, this can cause electrolyte disturbance mainly  hyponatremia and also hypokalemia.

 has slow onset of effect ,but overuse with high dose for prolonged period it can cause excess fluid loss and severe electrolyte balance like severe hyponatremia .the pathophysiology it implies increases renal blood flow and glomerular filtration, Through it diuretic effect it allow  the kidney to secret more urine as well as sodium ,cause volume depletion therefore feel of thirst this  Will lead to  increase intake of plane water   .excessive fluid intake cause dilutional hyponatremia and further sodium worsening. 

 The risk of electrolyte imbalance and hyponatremia increased if patient take high doses for prolonged period mainly in elderly patient. Other contributing factors of hyponatremia it contains essential oils (borneol, falvonoids, camphor), which may lead to the inhibition of Sodium reabsorption in renal tubules. 

 Although there’s some series cases reporting hyponatremia there’s no epidemiological data report how frequently the hyponatremia is associated with sambong leaf. and unfortunately human studies are lacking. 

 In our reported case after exclusion of all causes of hyponatremia we think  sambong leaf is the main contributing factor for hyponatremia as the patient is taking a high doses for prolonged period furthermore she is elderly, congestive heart failure, with excessive water intake and low osmole solute intake which all consider a risk factor to produce hyponatremia in association with sambong leaf.

Hyponatremia is one of the commonest electrolyte disturbance. Associated with increase mortality and morbidity. There is different causes of hyponatremia. HCP should increase awareness of herbal that may induced hyponatremia .once suspension of any herbal may cause electrolytes disturbance careful monitoring is needed.further stydies needed to look for sambog leaf or other herbal as a cause of hyponatremia.