The Case of Brittany
Passage 1
Susan, a new intern at the local hospital, was working the admissions desk one
Monday morning. It was a hot day. A man and a woman rushed through the
doors, carrying a second woman. “Help! Can you help us?” one called. Susan and
a nurse rushed them into an exam room.
“What happened?” Susan asked while examining the patient. “We don’t know!”
the female student sobbed. “I went to meet her to go to afternoon class, and
she did not show up outside her building, so I went inside. I found her on the
floor of her room. She seemed asleep, but was not able to wake up. She was
acting so weird we decided to bring her here.”
Susan carefully observed the woman lying on the table. She was dressed in
running shorts and a t-shirt. She was rolling her head and clearly seemed
confused. However, there were no obvious signs of trauma.
In your small group, answer the following questions:
 What could possibly be wrong with Brittany? Why do you think so?
 Being Susan, the intern, what would you do next? Why?
Math & Science Collaborative, © 2011. Life Science Institute, 2011. The Case of Brittany. Adapted from Norris Armstrong, University of GeorgiaAthens. Retrieved from National Center for Case Study Teaching in Science http://sciencecases.lib.buffalo.edu/cs/
1
Passage 2
Susan decided to order a series of blood tests, to get more information of what
could possibly be wrong with Brittany. The lab results came back as follows:
Item and measure
Heart Rate (beats/min)
Blood Pressure (mmHg)
Temperature (°F)
Glucose (mg/dl)
+
Sodium-Na (mM/L)
+
Potassium-K (mM/L)
-
Chloride-Cl (mM/L)
O (mmHg)
2
CO (mM/L)
2
Normal
60-100
90/50 - 140/90
98.6
60-109
135-146
Brittany
90
135/87
100.2
72
115
3.5-5.5
2.9
95-109
88
80-100
93
22-32
24
In your small group, answer the following questions:
 Which of the tests results look problematic?
 Based on these abnormal values, what might be wrong with Brittany?
Math & Science Collaborative, © 2011. Life Science Institute, 2011. The Case of Brittany. Adapted from Norris Armstrong, University of GeorgiaAthens. Retrieved from National Center for Case Study Teaching in Science http://sciencecases.lib.buffalo.edu/cs/
2
Passage 3
From analyzing the results of the blood tests, Susan suspected that Brittany
might be suffering from hyponatremia (water intoxication). Susan decided to
look up other cases of hyponatremia to find clues of what could have caused
Brittany’s hyponatremia. She came across the following article.
Marathon runner's death linked to excessive fluid intake
By Stephen Smith, Globe Staff, 8/13/2002
The 28-year-old runner who collapsed and died in this year's Boston Marathon was felled by a precipitous cascade of
medical events brought on in part by drinking too much fluid, the state medical examiner's office concluded yesterday.
Cynthia Lucero, who in the week before the April marathon completed her doctoral dissertation on how marathons help
runners grieve, died from a condition known as hyponatremic encephalopathy, which happens when the brain becomes
swollen because of a critical imbalance of sodium. She was only the second runner to die in the 106-year history of the race.
''This is a relatively rare catastrophic complication,'' said Dr. Ronenn Roubenoff, associate professor of medicine and
nutrition and director of human studies at the Jean Mayer USDA Human Nutrition Research Center at Tufts University. ''It
really is a tragedy because it's such a preventable thing.''
For the neighborhood jogger taking to the baking pavement in the August heat, the death of Lucero provides a graphic
illustration of the dangers of drinking too much water or even sports drinks. Runners have long known the importance of
replenishing fluids, but they may not know that it is also vital to maintain a balance in sodium levels to keep cells healthy. If
runners drink too much fluid, they can dangerously dilute their blood sodium levels.
That condition is called hyponatremia. Although people seldom die from hyponatremic encephalopathy, health-threatening
sodium deficiencies are more common among athletes than doctors once believed. Roubenoff cites one study, for example,
that tracked 18,000 marathoners and found that among those seeking medical care after the race, 9 percent suffered from
the condition. Deaths are sufficiently rare that specialists can recount them individually.
Until recently, hyponatremia was a little-known, even less-understood medical condition. But researchers, including Dr.
Arthur J. Siegel of McLean Hospital, are learning more about hyponatremia, known more commonly as water intoxication.
Siegel is deeply familiar with Lucero's case, having obtained with her parents' permission a blood sample drawn at Brigham
and Women's Hospital, where the runner was taken after she collapsed. He and other scientists are hopeful that, in death,
Lucero will yield medical evidence that can prevent other runners from the fate that befell her.
''We want as Cynthia's legacy a better understanding of this problem so that we can work out strategies to make it less
likely that these cases will happen in the future,'' said Siegel, director of internal medicine at McLean.
She also alerted the resident Kim to come and help her figure out what to do
with Brittany.
Math & Science Collaborative, © 2011. Life Science Institute, 2011. The Case of Brittany. Adapted from Norris Armstrong, University of GeorgiaAthens. Retrieved from National Center for Case Study Teaching in Science http://sciencecases.lib.buffalo.edu/cs/
3
In your small group, answer the following questions:
 Do you think Brittany might be suffering from hyponatremia? Why or why
not? What might have caused Brittany’s hyponatremia?
 What are some questions you would ask Brittany’s friends now, and why?
 What kinds of other tests/screenings might you run, and why?
Math & Science Collaborative, © 2011. Life Science Institute, 2011. The Case of Brittany. Adapted from Norris Armstrong, University of GeorgiaAthens. Retrieved from National Center for Case Study Teaching in Science http://sciencecases.lib.buffalo.edu/cs/
4
Passage 4
Susan talked with Kim about her suspicion that Brittany was suffering from
hyponatremia. She was wondering whether Kim might have been out running
and drinking too much water, before her friends found her. Kim shared some
other examples of cases of hyponatremia with Susan.






Brittney Chambers of Colorado (2001), Leah Betts of Great Britain (1995),
and Anna Wood of Australia (1995) died after reportedly taking Ecstasy
and drinking large amounts of water.
Fraternity hazing killed Matthew Carrington, a student at California State
Chico February 2005.
In Sacramento, Jennifer Strange died after a water-drinking contest "Hold
your wee for a Wii” sponsored by a local radio station, January 2007.
A 28-year-old female Boston marathoner died in 2002.
Artist Andy Warhol died after hospital staff accidentally administered
excess water after gall bladder surgery (1987).
Infants fed diluted formula for extended periods of time can suffer from
hyponatremia.
Kim and Susan decided to ask Brittany’s friends some more pointed questions to
find out what might have caused her condition.
“Did Brittany have much to drink last evening?” “Just one beer,” replied one.
“She had a test today and wanted to study. She did drink a lot of water. You’re
supposed to do that to prevent a hangover aren’t you? She seemed really
thirsty.”
“Has Brittany taken any drugs recently?” Susan asked. The two students
hesitated and looked at each other. Finally one of them nodded. “I think she
took some Ecstasy last night.”
Susan and Kim were not surprised by that answer. Ecstasy had been fairly
popular on the party scene for several years now.
Kim had seen people on the drug become somewhat confused, but not delirious.
Math & Science Collaborative, © 2011. Life Science Institute, 2011. The Case of Brittany. Adapted from Norris Armstrong, University of GeorgiaAthens. Retrieved from National Center for Case Study Teaching in Science http://sciencecases.lib.buffalo.edu/cs/
5
Susan and Kim decided to check her medical references to find out as much as
they could about how Ecstasy affected the body.
They consulted the Ecstasy (MDMA) Factsheet:
• MDMA (3,4 methylenedioxymethamphetamine) is a synthetic,
psychoactive drug chemically similar to the stimulant
methamphetamine and the hallucinogen mescaline. MDMA acts
as both a stimulant and psychedelic. It produces an energizing
effect, distorts both physical and cognitive sensations, and may
impair memory.
• MDMA affects a neuron’s ability to use the chemical serotonin.
Serotonin plays an important role in regulating mood, aggression,
sexual activity, sleep, and sensitivity to pain. Research in animals
indicates that MDMA is a neurotoxin. MDMA is potentially harmful to
health and, on rare occasions, may be lethal.
Susan remembered a video animation from medical school about how ecstasy
affects the body and showed it to Susan, also.
In the end, it all made sense to Kim and Susan now. Normally, Brittany’s kidneys
would respond to drinking a lot of water by producing large amounts of dilute
urine. However, Ecstasy acts as an anti-diuretic and forces the kidneys to make
concentrated urine instead. This would prevent Brittany’s body from getting rid
of excess water and could cause her electrolytes to fall. They needed to decide
how to treat her.
In your small group, answer the following questions:
 How would you treat Brittany? Why?
Math & Science Collaborative, © 2011. Life Science Institute, 2011. The Case of Brittany. Adapted from Norris Armstrong, University of GeorgiaAthens. Retrieved from National Center for Case Study Teaching in Science http://sciencecases.lib.buffalo.edu/cs/
6
Passage 5
Brittany was treated for hyponatremia. The treatment included giving her an IV
of fluids with normal or slightly higher sodium concentrations to correct the salt
imbalance in her tissues.
A problem associated with acute (sudden) hyponatremia, or water intoxication, is
swelling of tissues due to osmotic uptake of water by cells. Fortunately, because
she received treatment, Susan and Kim were able to reverse the swelling effects
before Brittany’s brain stem was damaged.
Hyponatremia can be very serious because of the possibility of brain damage.
Math & Science Collaborative, © 2011. Life Science Institute, 2011. The Case of Brittany. Adapted from Norris Armstrong, University of GeorgiaAthens. Retrieved from National Center for Case Study Teaching in Science http://sciencecases.lib.buffalo.edu/cs/
7