Water intoxication

Water intoxication, also known as water poisoning is a potentially fatal disturbance in brain functions that results when the normal balance of electrolytes in the body is pushed outside safe limits by overhydration.

Under normal circumstances, accidentally consuming too much water is exceptionally rare. Nearly all deaths related to water intoxication in normal individuals have resulted either from water drinking contests in which individuals attempt to consume large amounts of water, or from long bouts of exercise during which excessive amounts of fluid were consumed.^[1] In addition, water cure, a method of torture in which the victim is forced to consume excessive amounts of water, can cause water intoxication.

Water, just like any other substance, can be considered a poison when over-consumed in a specific period of time. Water intoxication mostly occurs when water is being consumed in a high quantity without giving the body the proper nutrients it needs to be healthy, but even healthy people can get water intoxication.^[2]

Excess of body water may also be a result of a medical condition or improper treatment; see "hyponatremia" for some examples. Water is considered the least toxic chemical compound, with an LD₅₀ of over 90 ml/kg in rats.^[3]

Risk factors

Low body mass (infants)

It can be very easy for children under one year old to absorb too much water, especially if the child is under nine months old. Because of their small body mass, it is easy to take in a large amount of water relative to body mass and total body sodium stores.^[4]

Endurance sports

Marathon runners are susceptible to water intoxication if they drink too much while running. This is caused when sodium levels drop below 135 mmol/L when athletes consume large amounts of fluid. This has been noted to be the result of the encouragement of excessive fluid replacement by various guidelines. This has largely been identified in marathon runners as a dilutional hyponatremia.^[5] A study conducted on participants of the 2002 Boston marathon found that thirteen percent finished the race with hyponatremia. The study concluded that the strongest predictor of hyponatremia was weight gain while racing (over-hydration), and hyponatremia was just as likely to occur in runners who chose sports drinks as those who chose water.^[5] Medical personnel at marathon events are trained to suspect water intoxication immediately when runners collapse or show signs of confusion.

Overexertion and heat stress

Any activity or situation that promotes heavy sweating can lead to water intoxication when water is consumed to replace lost fluids. Persons working in extreme heat and/or humidity for long periods must take care to drink and eat in ways that help to maintain electrolyte balance. People using drugs such as MDMA (often referred to colloquially as "Ecstasy") may overexert themselves, perspire heavily, and then drink large amounts of water to rehydrate, leading to electrolyte imbalance and water intoxication – this is compounded by MDMA use increasing the levels of antidiuretic hormone (ADH), decreasing the amount of water lost through urination.^[6] Even people who are resting quietly in extreme heat or humidity may run the risk of water intoxication if they drink large amounts of water over short periods for rehydration.

Competitive eating training

Competitive eaters often train for their sport by drinking large amounts of water in a short period of time in an attempt to stretch their stomach to increase their food intake capacity.^[7]

Psychiatric conditions

Psychogenic polydipsia is the psychiatric condition in which patients feel compelled to drink large quantities of water, thus putting them at risk of water intoxication. This condition can be especially dangerous if the patient also exhibits other psychiatric indications (as is often the case), as the care-takers might misinterpret the hyponatremic symptoms.

Iatrogenic

When an unconscious person is being fed intravenously (for example, total parenteral nutrition) or via a nasogastric tube, the fluids given must be carefully balanced in composition to match fluids and electrolytes lost. These fluids are typically hypertonic, and so water is often co-administered. If the electrolytes are not monitored (even in an ambulatory patient), either hypernatremia or hyponatremia may result.^[8]

Some neurological/psychiatric medications (Oxcarbazepine, among others) have been found to cause hyponatremia in some patients.^[9] Patients with diabetes insipidus are particularly vulnerable due to rapid fluid processing.^[10]

Pathophysiology

At the onset of this condition, fluid outside the cells has an excessively low amount of solutes (such as sodium (hyponatremia) and other electrolytes) in comparison to that inside the cells causing the fluid to shift through (via osmosis) into the cells to balance its concentration. This causes the cells to swell. In the brain, this swelling increases intracranial pressure (ICP). It is this increase in pressure which leads to the first observable symptoms of water intoxication: headache, personality changes, changes in behavior, confusion, irritability, and drowsiness. These are sometimes followed by difficulty breathing during exertion, muscle weakness & pain, twitching, or cramping, nausea, vomiting, thirst, and a dulled ability to perceive and interpret sensory information. As the condition persists, papillary and vital signs may result including bradycardia and widened pulse pressure. The cells in the brain may swell to the point where blood flow is interrupted resulting in cerebral edema. Swollen brain cells may also apply pressure to the brain stem causing central nervous system dysfunction. Both cerebral edema and interference with the central nervous system are dangerous and could result in seizures, brain damage, coma or death.^[11]

Prevention

Water intoxication can be prevented if a person's intake of water does not grossly exceed their losses.^[12] Healthy kidneys are able to excrete approximately 0.8 to 1 litre of fluid water (0.21 - 0.26 gallons) per hour.^[12] However, stress (from prolonged physical exertion), as well as disease states, can greatly reduce this amount.^[12]

Treatment

Mild intoxication may remain asymptomatic and require only fluid restriction. In more severe cases, treatment consists of:

• Diuretics to increase urination, which are most effective for excess blood volume.
• Vasopressin receptor antagonists

Notable cases

• 1991, Andy Warhol: Five years after his death, Warhol's family publicly accused the hospital where he had had his gallbladder removed, of causing his death by water intoxication administered post-operatively. A claimed autopsy weight of 150 lbs, with his weight being 128 lbs when admitted, was cited as evidence that too much fluid had been given.^[13]
• October 24, 1995: Anna Wood, a 15-year-old Australian schoolgirl who died from the effects of water intoxication secondary to use of MDMA (commonly known as ecstasy).
• November 16, 1995: Leah Betts died as the result of drinking too much water, though in the media, her death was initially attributed to taking an ecstasy tablet at her 18th birthday party.^[14]
• September 12, 1999: US Air Force basic trainee Micah J. Schindler died of heat stroke, severely complicated by water intoxication, two days after becoming seriously ill during a 5.8 miles (9.3 km) march. The Air Force changed its recruit training procedures as a result.^[15]
• 2002: Boston Marathon competitor Cynthia Lucero.^[16]
• June 9, 2002: 4-year-old Cassandra Killpack of Springville, Utah died as a result of water intoxication when her parents forcefully fed her as much as one US gallon (3.8 l) of water in a short period while she was being disciplined. Her mother, Jennette Killpack, was convicted in 2005 of child abuse homicide.^[17]
• October 12, 2002: 3-year-old Rosita Gonzalez of Hollywood, Florida died of water intoxication when her babysitter Nancy Gayoso punished her by forcing her to drink three US quarts (2.8 l) of water in a four-hour period.^[18][19] Gayoso was arrested and charged with murder in the first degree on March 10, 2003. After being declared incompetent to stand trial in 2004 and 2005,^[20] Gayoso was ruled competent on March 26, 2007 by Broward Circuit Judge Martin Bidwill.^[21]
• 2003: British actor Anthony Andrews survived a case of water intoxication. He was performing as Henry Higgins in a revival of the musical My Fair Lady at the time, and consumed up to eight litres of water a day. He was unconscious and in intensive care for three days.^[22][23]
• 2003: Walter Dean Jennings, a freshman history major at SUNY Plattsburgh, was pledging the Psi Epsilon Chi "when he was forced to drink urine, stay awake for days and consume vast amounts of alcohol during a 10-day initiation and hazing process." According to PressRepublican.com, "On his last night of pledging the unrecognized fraternity, the 18-year-old was forced to drink gallons of water through a funnel, which caused his brain to swell from water intoxication and ultimately resulted in his death." Eleven members of the fraternity were charged with criminally negligent homicide.^[24]
• 2005: In a much-publicized case of fraternity hazing, four members of the Chi Tau House at California State University, Chico pleaded guilty to forcing 21-year-old student Matthew Carrington to drink excessive amounts of water while performing calisthenics in a frigid basement as part of initiation rites on February 2, 2005.^[25] He collapsed and died of heart failure due to water intoxication.
• August 9, 2005: Washington, D.C. police officer James McBride, died from water intoxication after riding 12 miles (19 km) during bicycle patrol training.^[26]
• On January 12, 2007, Jennifer Strange, a 28-year-old woman and a mother of three, from Rancho Cordova, California, was found dead in her home by her mother, hours after trying to win one of Nintendo's Wii game consoles. KDND 107.9 "The End" radio station's "Hold Your Wee for a Wii" contest involved drinking large quantities of water without urinating. A nurse called the radio station to warn them about the danger in which they were putting people, but the disc jockeys rejected the warnings. Lucy Davidson, the winner of the contest, was severely sickened while picking up her prize. Civil charges against the radio station were filed by Strange's family,^[27] and the family was eventually awarded $16.5 million in the ensuing wrongful death lawsuit.^[28] The FCC launched its own investigation to determine if the station violated the terms of its operating license.
• 2008: Jacqueline Henson, a 40-year-old British woman, died after drinking four liters of water in under two hours as part of her LighterLife diet plan.^[29]
• 2011: Jonathan Paul Dent, 29, became lost during a four-hour walk through Tasmania's Dial Range on April 19, 2011. He called his wife a number of times to say he was lost. Rescue crews found his body in bushland two days later. The coroner found that Dent most likely died from exercise-associated hyponatremia (EAH), a condition caused by drinking too much fluid during prolonged exercise.^[30]
• 2012: Alexa Linboom, a 5-year-old Tennessee girl, died after being forced to drink large amounts of grape soda and water as a punishment.^[31][32]
• 2012: Savannah Hardin, a 9-year-old Alabama girl, died after being forced to run for hours. 911 was called when she started suffering from seizures and became unresponsive. Three days later she died at the hospital. The cause of death according to her death certificate was "seizure disorder due to hyponatremia."^[33] Her grandmother was convicted of murder in May 2015, and sentenced to life imprisonment without the possibility for parole.^[34]
• 2013: Luana Priscyla Fernandes Soares, a 21-year-old Brazilian woman, died during a radio contest in Brazil, where her group drank 54 liters (14 gallons) of water mixed with Yerba Mate (a plant used in South America to make a tea-like beverage), an average of 5.4 liters/1.4 gallons per person. She collapsed one hour after the contest began. She suffered a stroke during the event and died two days later in the hospital.^[35]
• 2013: 20-year-old Dutch student Lisa Nooij died from water intoxication four days after using MDMA at a festival.^[36]
• 2014: 17-year-old Zyrees Oliver died from water intoxication after drinking 4 gallons of water and Gatorade before and during football practice.^[37]
• 2014: The death of 17-year-old Mississippi high school football player Walker Wilbanks three days after he fell ill during a game was due to swelling in his brain possibly triggered by overhydration. Both before and during the game, Wilbanks drank Gatorade and Pedialyte.^[38]

See also

• Electrolytes
• Dehydration
• Drowning
• Hyperkalemia / Hypokalemia
• Hypermagnesemia / Hypomagnesemia
• Hypernatremia / Hyponatremia
• Gastroenteritis
• Oral rehydration therapy
• Polydipsia
• Water urticaria
• Dihydrogen monoxide hoax
• Electrolyte imbalance
• List of unusual deaths
• Potomania
• The dose makes the poison

References

External links

• BBC news feature on water intoxication