Bartter-like Syndrome Induced By Tacrolimus in a Renal Transplanted Boy: A Case Report.

BACKGROUND: Losing-salt tubulopathies, such as Bartter syndrome, are rare and usually inherited due to mutations of tubular reabsorption channels of the nephrons. Despite its scarcity, some cases of acquired losing-salt tubulopathies have been described. In this case report, we discuss the main aspects of Bartter syndrome and present a rare pediatric case of probable tacrolimusinduced Bartter-like syndrome in a renal transplanted boy. CASE PRESENTATION: A ten-year-old male patient with end-stage renal disease due to endo and extra capillary glomerulonephritis was submitted to renal transplantation from a deceased donor. The post-operatory evolution was satisfactory with normalization of serum creatinine levels, mild hypertension, and the absence of metabolic disorders. The immunosuppression protocol included tacrolimus (0.3 mg/kg/day), mycophenolate (455 mg/m2/day) and prednisone (0.5 mg/kg/day). Two months later, the patient was hospitalized due to vomiting, dehydration, intense hypokalemia (1.3 mEq/L), hyponatremia (125 mEq/L), and hypochloremia (84 mmol/L). During hospitalization, he evolved with polydipsia (3000 mL/day) and polyuria (120-160 mL/m2/h) associated with major elevation of urinary potassium excretion, hypercalciuria, mild metabolic alkalosis, hyperfiltration, and proteinuria. The tacrolimus dose was reduced under the suspicion of tubular dysfunction, leading to a better metabolic profile. However, the patient developed a Banff IIb graft rejection, which required pulse therapy and elevation of tacrolimus and mycophenolate doses. Recovery of renal function parameters occurred, but the metabolic disorders worsened following tacrolimus dose elevation. The patient required chronic potassium, chloride, and sodium replacement. CONCLUSION: After administering immunosuppressive medications, physicians should be aware of the possibility of Bartter-like or other losing-salt tubulopathies syndromes that can affect metabolic homeostasis. The suspicion must always be considered in the case of a transplanted patient who presents dehydration and hydroelectrolytic disorders right after the commencement of nephrotoxic immunosuppressive drugs, including tacrolimus and cyclosporine.

Intoxicación por leche magnesia en una paciente pediátrica con constipación crónica: a propósito de un caso / Milk of magnesia intoxication in a pediatric patient with chronic constipation: case report

Resumen Las intoxicaciones accidentales siguen siendo un problema importante que genera gran cantidad de casos de autopsia médico legal, sobre todo cuando ocurren en pacientes pediátricos donde se deben descartar otras causas de muerte y que no se trate de un homicidio. La intoxicación con leche magnesia es un diagnóstico poco frecuente por lo que se hace necesario conocer sus características, evolución y las alteraciones metabólicas por las que se produce la muerte. La hipermagnesemia constituye una condición iatrogénica, generalmente secundaria a la administración de fármacos que contienen magnesio, entre ellos laxantes en pacientes con estreñimiento crónico, en muchas ocasiones sin supervisión médica; que puede producir depresión respiratoria, hipotensión, paro cardiorrespiratorio y la muerte. El diagnóstico de intoxicación con leche magnesia es clínico y se correlaciona con la concentración de magnesio detectada en análisis de muestras de sangre. A continuación se presenta un caso de intoxicación por leche magnesia en una paciente en edad pediátrica con antecedente de parálisis cerebral infantil y constipación crónica que desarrolló una hipermagnesemia posterior a la administración de dicho laxante por parte de sus padres.

Abstract Accidental intoxications continue to be an important problem in the Forensic Pathology field, mostly when they occur in pediatric patients where it is necessary to dismiss other causes of death and to rule out homicide. Milk of magnesia intoxication is a rare diagnosis, therefore it is important to know it´s characteristics, evolution and the metabolic disorders that lead to death. Hypermagnesemia is an iatrogenic condition, usually caused by the administration of medications that contain magnesium, such as laxatives in patients with chronic constipation, without medical supervision; that can lead to respiratory distress, hypotension, cardiac arrest and death. The diagnosis of milk of magnesia intoxication is clinical and can be correlated to the levels of magnesium found in blood sample analysis. We present a case of milk of magnesia intoxication in a 6-year-old girl with cerebral palsy and chronic constipation that was given laxatives by her parents and developed a fatal hypermagnesemia.