Erratum

It has come to the editors’ attention (personal communication with Scott Montain PhD, Research Physiologist, United States Army Research Institute of Environmental Medicine) that a few statements in Bennett, Hew-Butler, Hoffman et al, paper “Wilderness Medical Society Practice Guidelines for Treatment of Exercise-Associated Hyponatremia”¹ warrant correction. While one previously published paper entitled “Death by Water Intoxication” details four fatal cases of dilutional hyponatremia in military personnel,² whether or not all four of these fatalities were primarily associated with exercise-associated hyponatremia (EAH) has been called into question. One fatality, in the 18-year-old Eskimo soldier, has been reported in three separate papers and clearly results from EAH with encephalopathy.²^–4 Another fatal case, in a 20-year-old female reported in two separate manuscripts,^2,5 questions the contributions of “exercise,” as she was drinking copious amounts of fluid for a urine drug test while “…required to perform frequent vigorous exercises, including push-ups, side straddle hops, flutter kicks, and running in place to facilitate producing a urine sample.”⁵ The third reported fatality, in a 19-year-old male air force recruit, had competing diagnoses of both heat stroke and hyponatremia with the primary etiology undermining subsequent mortality remaining unclear.² Thus, while it has been widely propagated that there have been four military deaths associated with EAH as the primary pathogenic mechanism, there appears to be additional factors (such as in the 20-year-old female and 19-year-old male, above) which may reduce the number of EAH military deaths from four to maybe one or two.² ^–5

It has also been pointed out that “Wilderness Medical Society Practice Guidelines for Treatment of Exercise-Associated Hyponatremia” reports that between 1999 and 2011 there were 1329 incident diagnoses of EAH (incidence of 12.6 per 100,000 person years) among active-duty members. However, this incidence actually reflects only one year (2010) instead of three. New data (1999 to 2012) released in March 2013 may provide a more accurate EAH incident rate of 6.7 cases/100,000 person years in US military services. These new data suggest that the annual incidence of EAH may have actually decreased by almost 50 percent from 2010 to 2012.⁶

References

Bennett

B.L.

Hew-Butler

Hoffman

M.D.

et al. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia. Wilderness Environ Med 2013; 24(3), 228–240.

Gardner

J.W.

Death by water intoxication. Mil Med 2002; 167(5), 432–434.

Garigan

Case Report: death from hyponatremia as a result of acute water intoxication in an army basic trainee. Mil Med 1999; 164(3), 234–238.

O’Brien

K.K.

Montain

S.J.

Corr

W.P.

et al. Hyponatremia associated with overhydration in U.S. army trainees. Mil Med 2001; 166(5), 405–410.

Gardner

J.W.

Fatal water intoxication of an army trainee during urine drug testing. Mil Med 2002; 167(5), 435–437.

O’Donnell FL, ed. Army Medical Surveillance Activity. Update: exertional hyponatremia, active component, U.S. armed forces, 1999–2012. Medical Surveillance Monthly Report. 2013;20:23–28..