Hypokalemic paralysis due to distal renal tubular acidosistype 1 in patient of mucormycosison amphotericin B: a case report

A 42-year-old male patient who is a known case of DM and mucormycosison treatment presented with sudden onset difficulty in moving all 4 limbs followed by decreased depth of respiration for 4 hours. The patient was known case of DM for 10 years and was on OHA for the same, he had history of biopsy diagnosed rhino mucormycosis 4 months ago and was on treatment for the same. On initial examination the tone was hypotonic in all4 limbs along with power of 3+, respiration was shallow and patient was bedridden unable to stand on his own, he was ambulatory 6 days before presentingto hospital. Potassium-1.7 mEq/l, ABGA pH-7.18, HCO3-10 Meq/l, urine osmolality 220 mOsm/l, urine pH-7.0, potassium-to-creatinine rstio (K/Cr)-3.9 mEq/ml, urine K-22 mEq/ml. Distal RTA (dRTA) is the classical form of RTA, being the first described. DistalRTA is characterized by a failure of H+ secretion into lumen of nephron by the alpha intercalatedcellsof themedullary collecting ductof thedistalnephron.This failure of acid secretion may be due to a number of causes, and it leads to an inability to acidify the urine to apHof less than 5.3.This case study enumerates the potentially dangerous side effects of amphotericin B in patients which canprecipitate RTA type 1 leading to severe hypokalaemia and acidosis, thus all patients receiving amphotericin B should be cautiously warned regarding side effect of hypokalaemia and prophylactic potassium syrup supplementation may be given in predisposed patients.

Intoxication à la réglisse révélée par une hypokaliémie sévère associée à une HTA Labile: à propos d'une observation et revue de la littérature / Licorice intoxication revealed by severe hypokalemia and labile hypertension: a case report with review of the literature

Cette observation illustre un tableau de pseudo-hyperaldostéronisme primaire par intoxication à la réglisse révélé par une hypokaliémie sévère chez un monsieur de 56 ans dans un contexte d'HTA de découverte récente. L'interrogatoire a retrouvé une notion de consommation régulière quotidienne de pastis sans alcool d'environ un litre et le bilan endocrinien a trouvé une activité rénine plasmatique effondrée et une hypoaldostéronémie. L'hypokaliémie et l'HTA ont régressé au bout de trois mois avec l'arrêt de la consommation du pastis et à distance de tout traitement antihypertenseur. Les abus de la réglisse sont rarement mentionnés spontanément par les patients ou sont ignorés d'eux, d'où l'intérêt d'une anamnèse minutieuse

This patient illustrates a case of primary pseudo-hyperaldosteronism due to licorice intoxication revealed by severe hypokalemia in a 56-year-old man with newly discovered hypertension. Past medical history revealed a notion of regular consumption of pastis without alcohol (about one liter per day) and hormonal assessment showed a collapsed plasma renin activity and hypoaldosteronemia. Hypokalaemia and hypertension resolved three months after cessation of pastis consumption, without any antihypertensive treatment. The abuse of licorice is rarely mentioned spontaneously by patients or is ignored by them, hence the interest of a careful medical history.

Diagnóstico de síndrome de Gitelman en paciente con condrocalcinosis / Diagnosis of gitelman syndrome in patient with condrocalcinosis

RESUMEN Introducción: El síndrome de Gitelman es una tubulopatía caracterizada por alcalosis metabólica hipopotasémica, hipomagnesemia e hipocalciuria. Sus efectos musculoesqueléticos son comunes, pudiendo provocar desarrollo de condrocalcinosis. Caso clínico: Paciente con condrocalcinosis de larga data asociada a hipomagnesemia crónica en tratamiento con calcio y magnesio. Tras la suspensión del tratamiento debido a una intervención quirúrgica presentó debilidad generalizada, alcalosis metabólica, hipopotasemia, hipomagnesemia e hipocalciuria con diagnóstico final de síndrome de Gitelman. Tras la instauración de tratamiento, mejoró clínica y analíticamente manteniendo cifras iónicas estables. Discusión y conclusiones: Resulta fundamental un adecuado diagnóstico de este tipo de tubulopatías, ya que un tratamiento adecuado evita complicaciones asociadas.

ABSTRACT Introduction: Gitelman syndrome is a renal tubule disease that involves hypokalaemic metabolic alkalosis, hypomagnesaemia and hypocalciuria. The musculoskeletal effects of Gitelman syndrome are common, including the development of chondrocalcinosis. Clinical case: A female patient with long-standing chondrocalcinosis associated with chronic hypomagnesaemia on treatment with calcium and magnesium. After the suspension of the treatment due to surgery, she presented with a generalised weakness, metabolic alkalosis, hypokalaemia, hypomagnesaemia and hypocalciuria, with final diagnosis of Gitelman syndrome. After re-introducing the treatment, she improved clinically, with electrolytes remaining stable. Discussion and conclusions: A proper diagnosis of this type of tubular diseases is essential because an adequate treatment avoids associated complications.

Thyrotoxic periodic paralysis: A retrospective, observational study from India

Background & objectives: Thyrotoxic periodic paralysis (TPP) is an endocrine emergency presenting with acute-onset flaccid paralysis in a patient having thyrotoxicosis accompanied by hypokalaemia. This study was conducted to evaluate the clinical profile of patients with TPP presenting to three centres in India. Methods: This retrospective, observational study was conducted at three tertiary care Armed Forces medical centres, located at Lucknow, Kolkata and Delhi. The history, clinical features, treatment details and outcomes were evaluated. Results: Of the 244 patients with thyrotoxicosis, 15 were diagnosed with TPP and included in the study. These 15 patients (14 male and 1 female) had 32 episodes of TPP which were analyzed. The mean age was 30.2�2 yr (range: 21-39), and overt thyrotoxicosis was seen in all patients except one who had subclinical hyperthyroidism. Graves' disease was the most common cause of thyrotoxicosis (13/15) and the remaining two patients had subacute thyroiditis and gestational thyrotoxicosis. Hypokalaemia (serum potassium <3.5 mmol/l) was seen in 12 patients, and the mean serum potassium was 3.2�9 mmol/l (range: 2.1-4.9). All patients had flaccid weakness, predominantly involving the lower limb with no bulbar, respiratory or cranial nerve involvement. The average duration of paralysis was 10.6�7 h (range: 3-28 h). Interpretation & conclusions: Our study demonstrated an early age of presentation and presence of clinical and biochemical thyrotoxicosis in majority of patients with TPP. Hypokalaemia may not always be evident in patients with TPP.

A novel heterozygous duplication of the SLC12A3 gene in two Gitelman syndrome pedigrees: indicating a founder effect

Gitelman syndrome is an autosomal recessive salt-wasting tubulopathy caused by mutations in the SLC12A3 gene. A female and a male sibling from two unrelated Greek-Cypriot families presenting with a severe salt-wasting tubulopathy dueto compound heterozygous mutations of a novel duplication and a previously reported missense mutation in the SLC12A gene are described. Sanger sequencing was used to identify possible mutations in the SLC12A3 gene. For the detection of duplications/conversions and deletions in the same gene, Multiplex ligation probe amplification (MLPA) analysis was performed. Direct sequencing and MLPA analysis of the SLC12A3 gene identified two compound heterozygous mutations in both unrelated probands. Both probands were identified to carry in compound heterozygosity the known p.Met581Lys and a novelheterozygous duplication of exons 9-14 (E9_E14dup). The diagnosis of Gitelman syndrome was made through clinical assessment, biochemical screening and genetic analysis. The identification of the novel SLC12A3 duplication seems to be characteristic of Greek-Cypriot patients and suggests a possible ancestral mutational event that has spread in Cyprus due to a possible founder effect. Testing for Gitelman syndrome probable variants can be performed before proceeding to a full gene sequencing dropping the diagnostic cost. In addition, this report adds to the mutational spectrum observed.

Changes in Serum Electrolyte Levels in Typhoid Fever Patients Attending Minna General Hospital, Nigeria.

Objective: This study was designed to evaluate the effect of Typhoid fever on the serum levels of electrolytes in patients attending Minna General Hospital, Nigeria. Materials and Methods: Blood samples were obtained from sixty patients with established typhoid fever attending General Hospital Minna, Nigeria. Serum sodium, potassium, chloride, and bicarbonate levels were determined in the samples using Spectrophotometric method. The case studies included 15 adult males and 15 adult females; 15 male and 15 female children of junior secondary school age (9 – 14 years). Widal test was carried out to ascertain the presence of Salmonella enterica serotype Typhi. Results: The mean ± standard deviations of serum Na+, K+, Cl-, and HCO3- in the sixty patients were 116.11±20.65 mmol/L; 3.40±0.90 mmol/L; 87.13±16.34 mmol/L; and 24.10±5.54 mmol/L respectively. When compared with the controls and the laboratory reported normal values, 50% of the patients were found to be hyponatraemic, 51% were hypochloraemic, 36% were hypokalaemic, while 11% had metabolic acidosis. Results based on sex showed insignificant differences between males and females for all electrolytes determined (p< 0.05). Insignificant differences were also observed between children and adult patients for all parameters determined (p< 0.05). In addition, weak positive correlations were observed between cations and anions determined in this study. Conclusion: The results obtained in this study showed that electrolytes’ abnormalities exist in patients with established typhoid fever attending General Hospital Minna, Niger state, Nigeria.

Severe Hypokalaemia as a Cause of Reversible Diabetes Mellitus.

Aims: To discuss the likelihood of severe hypokalaemia as a cause of reversible diabetes. Presentation of the Case: A 46 year old patient presented to the Accident and Emergency unit (A&E) with a history of polyuria and polydipsia of recent onset. He was severely hyperglycaemic (glucose = 40 mmol/L, HbA1c = 11%), hypokalaemic (serum potassium < 2.0 mmol/L) and hypertensive [Blood Pressure (BP) = 180/115]. Conn's syndrome was confirmed by finding a raised serum aldosterone (1650 pmol/L; normal value < 440 pmol/L), suppressed renin (< 0.2 ng/ml/h; normal range: 0.2-2.5 ng/ml/h) and a left sided adrenal tumour (2.0 x 2.0 cm) on CT scanning. He was managed initially with IV potassium and insulin (initially 100 units daily) together with oral potassium, spironolactone 100 mg daily, lisinopril 20 mg daily and amlodipine 10 mg daily. After six days his potassium was 3.4 mmol/L and the IV potassium infusion was stopped. Twelve days later his fasting blood glucose, serum potassium and BP's were normal and the insulin and antihypertensive medications, apart from spironolactone, were stopped. He was discharged on spironolactone alone for four months during which time his blood glucose, blood pressure, and serum potassium levels remained normal and his HbA1c had fallen from 11.0 to 5.2%. He then underwent successful laparoscopic adrenalectomy and his serum aldosterone came down to 127pmol/L (within normal range). Histology confirmed the diagnosis of a Conn’s tumour. Conclusion: Although hyperaldosteronism per se predisposes to diabetes we suspect that this patient’s rapidly reversible hyperglycaemia resulted primarily due to a failure of insulin secretion as a result of his severe potassium depletion.

Unusual cause of hypokalemia and paralysis in an elderly patient with Bronchial Asthma.

Asthma is a syndrome characterized by airflow obstruction that varies markedly, both spontaneously and with treatment. There are so many adverse effects of drugs which are used in the management of bronchial asthma in elderly. We report a case of sudden onset paralysis of both lower limbs after treatment of asthma with nebulized β2- agonists. The inappropriate and continuous use of such drugs may cause the hypokalaemic paralysis though lifesaving many times. Hypokalaemia is a common adverse effect of β2- agonists but hypokalaemic paralysis of both lower limbs is a rare entity.

An elderly woman with abdomen distension: Ogilvie?s or Chilaiditi syndrome? / Mulher idosa com distensão abdominal: síndrome de Ogilvie ou de Chilaiditi?

Embora a síndrome de Ogilvie ou pseudo-obstrução intestinaltenha sido poucas vezes relatada, não se trata decondição muito rara. Relata-se o estudo de caso de umamulher de 85 anos com hipocalemia em que os principaisaspectos são enfatizados, com o objetivo de aumentar oíndice de suspeita sobre essa entidade. O diagnóstico diferencialentre as síndromes de Ogilvie e de Chilaiditi érealçado, em virtude dos aspectos comuns a essas duascondições. A paciente recebeu suporte clínico geral e reposiçãohidroeletrolítica com bom resultado, após quatrodias de tratamento conservador. O diagnóstico precoce e a pronta correção de fatores predisponentes contribuírampara o sucesso do manuseio clínico da síndrome deOgilvie que afetou essa frágil paciente.

Although Ogilvie?s syndrome, or intestinal pseudoobstruction,has been scarcely reported, it is not arare condition. With the objective of raising awarenessabout this entity, the case study of an 85-yearoldwoman with hypokalaemia is reported and themain findings are emphasised. The differential diagnosisbetween Ogilvie?s and Chilaiditi syndromeis highlighted because of the features shared bythese conditions. The patient received general clinicalsupport and her hydro-electrolyte balance wasmaintained, with a good outcome after four days ofconservative treatment. Early diagnosis and promptcorrection of predisposing factors contributed tothe successful clinical management of the Ogilvie?ssyndrome affecting this fragile elderly patient.

Drug Utilization Review of Potassium Chloride Injection Formulations Available in a Private Hospital in Kuching, Sarawak, Malaysia

Background: The concentrated potassium chloride injection is a high-alert medication and replacing it with a pre-mixed formulation can reduce the risks associated with its use. The aim of this study was to determine the clinical characteristics of patients receiving different potassium chloride formulations available at a private institution. The study also assessed the effectiveness and safety of pre-mixed formulations in the correction of hypokalaemia. Methods: This was a retrospective observational study consisting of 296 cases using concentrated and pre-mixed potassium chloride injections in 2011 in a private hospital in Kuching, Sarawak, Malaysia. Results: There were 135 (45.6%) cases that received concentrated potassium chloride, and 161 (54.4%) cases that received pre-mixed formulations. The patients’ clinical characteristics that were significantly related to the utilization of the different formulations were diagnosis (P < 0.001), potassium serum blood concentration (P < 0.05), and fluid overload risk (P < 0.05). The difference observed for the cases that achieved or maintained normokalaemia was statistically insignificant (P = 0.172). Infusion-related adverse effects were seen more in pre-mixes compared to concentrated formulations (6.8% versus 2.2%, P < 0.05). Conclusion: This study provides insight into the utilization of potassium chloride injections at this specific institution. The results support current recommendations to use pre-mixed formulations whenever possible.

Hypophosphataemia among Severely-malnourished Children: Case Series.

Phosphorus is an essential substance in our body, and hypophosphataemia (HP) is well-described in rickets, refeeding syndrome, diabetic ketoacidosis (DKA), and in chronic alcohol-abuse. However, to our knowledge, HP among severely-malnourished children has not been studied in detail, and information on prevalence, severity, and treatment is scarce. Currently, there are only a few published case reports of HP. This case series describes three cases of HP that presented to Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Our first case required mechanical ventilation for respiratory distress associated with severe hypokalaemia (K 1.1 mmol/L) and moderate hypophosphataemia (P 2.1 mg/dL). The second case presented with severe sepsis which was associated with symptomatic hypocalcaemia (Ca 1.68 mmol/L), hypokalaemia (K 1.82 mmol/L), and severe hypophosphataemia (P 0.9 mg/dL). The third case presented with pneumonia and sepsis which were complicated by hypokalaemia (K 2.05 mmol/L) and severe hypophosphataemia (P 1.1 mg/dL). Marked lethargy and severe hypotonia were associated with HP in all of these cases. Manifestations of HP are diverse and can occur in association with other electrolyte imbalances, especially among malnourished children. Malnutrition, combined with sepsis, is one of the major killers of children younger than 5 years of age, and both malnutrition and sepsis can cause HP. It is concluded that the underlying causes of morbidity, including HP, should be actively sought and treated to reduce the mortality of children aged below five years.