This case report identifies a very rare disease, choriocarcinoma in a male patient, causing another rare entity, an atraumatic rupture of the spleen.

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BackgroundWhilst mild neonatal hyponatraemia is common and relatively harmless, extreme hyponatraemia of 95 mmol per litre has never been reported in a premature baby and such a level could be associated with immediate as well as long-lasting detrimental effects on health.Case presentationTwenty-four days old baby boy born at 28 weeks gestation (triplet one) unexpectedly became moribund with hypovolaemic shock and was found to have blood sodium of 95 mmol per litre. Diagnostic work up revealed a combination of a urinary tract infection, inadvertently low sodium provision with donor breast milk, and weak renin-angiotensin-aldosterone response. Commencement of treatment with intravenous fluids and extra sodium led to unanticipated diuresis and faster than expected increase of sodium level. Ultimately, treatment resulted in clinical recovery and normalisation of sodium level, which subsequently remained normal with no additional sodium supplementation. Follow up revealed mild spastic diplegia.ConclusionContinuous monitoring and daily medical reviews may not be sensitive enough to recognise development of extreme hyponatraemia. Blood sodium levels should be monitored closely and any abnormalities promptly addressed. Treatment of hypovolaemic hyponatraemia should be centred on fluid resuscitation, anticipation of “paradoxical” diuresis, and blood sodium correction rate of 8 to 10 mmol per litre per day.

Purpose To describe the modes of death (MOD), the elements related to the decision to forgo life-sustaining treatments (LST) as well as the medical and parental environment surrounding time of death in our pediatric intensive care unit (PICU). Methods This is a retrospective, single-center study from a Swiss PICU. All patients between 30 days and 18 years of age who died in our PICU from 2006 to 2019 were eligible for inclusion. Data were collected from patients’ record and from a standardized death form containing information on circumstances surrounding end-of-life. Patients’ and families’ characteristics as well as trends over time of MOD were evaluated. Results Of 6930 PICU admissions during the whole study period, 121 (1.7%) died in our PICU. Mortality significantly decreased from 2.9% in 2006 to 1% in 2019 (p = 0.003). More than half of patients died after a decision to transition to comfort care (68.56%). Withdrawal and limitation of LST were the prevalent MOD (56%) with a significant increase in withdrawal over time. Primary diagnosis, limitation (vs. withdrawal) of LST, type of admission and families’ religious background are associated with longer latencies between admission to decision to comfort care and from decision to death. At least one parent was present in 94% of cases when LST were limited or withdrawn. Conclusions Most of the deaths follow LST limitation or withdrawal with increasing rates of withdrawal over time. We also showed that time latencies between admission and decision and from decision to death varies depending on MOD, patients’ characteristics and families ‘religious background.