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Otsubo Y, Kano Y, Suzumura H, Yoshihara S. Type 3 antenatal Bartter syndrome presenting with mild polyuria. BMJ Case Rep 2021; 14:e242086. [PMID: 33827883 PMCID: PMC8030685 DOI: 10.1136/bcr-2021-242086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 01/03/2023] Open
Abstract
Bartter syndrome (BS) is a well-recognised inherited tubular dysfunction that causes polyuria, metabolic alkalosis and hypokalaemia. Among BS cases, antenatal/neonatal BS (ABS) usually shows distinct polyhydramnios prenatally and presents features of BS in the early neonatal period. We encountered a premature infant with type 3 ABS presenting with mild polyuria and discuss the pathogenesis of mild polyuria in type 3 ABS. A male infant was born at 31 weeks' gestation. His mother received amniocentesis because of polyhydramnios. Hyponatraemia and hypokalaemia appeared within 3 days after birth. Metabolic alkalosis, hyperreninaemia and hyperaldosteronism were also identified. Temporary polyuria developed at 1 month after birth; however, the mean urine output during hospitalisation was within the normal range. CLCNKB compound heterozygous mutations were confirmed. Polyuria of type 3 ABS may be less severe than in other types of ABS. Lower urine sodium loss may be a characteristic feature of type 3 ABS.
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Isse N, Hashimoto M. Republished: Omeprazole-induced hypomagnesaemia, causing renal tubular acidosis with hypokalaemia, hypocalcaemia, hyperlactacidaemia and hyperammonaemia. Drug Ther Bull 2021; 59:60-63. [PMID: 33766923 DOI: 10.1136/dtb.2021.235385rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abraham S, Parekh J, Polisetty L, Gunasekaran K. Rapid resolution of life-threatening hyperkalaemia in diabetic ketoacidosis with intensive insulin therapy. BMJ Case Rep 2021; 14:e242536. [PMID: 33766978 PMCID: PMC8006825 DOI: 10.1136/bcr-2021-242536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2021] [Indexed: 11/03/2022] Open
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Marques-Sá J, Barbosa M, Fernandes V, Santos MJ. Nearly fatal hypokalaemia due to non-hypertensive primary hyperaldosteronism in the post partum. BMJ Case Rep 2021; 14:14/3/e240018. [PMID: 33753383 PMCID: PMC7986951 DOI: 10.1136/bcr-2020-240018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A previously healthy postpartum 33-year-old woman was admitted at the emergency department after two episodes of syncope. In the waiting room, she collapsed, ventricular fibrillation was detected, and she was reanimated by electric cardioversion. At admission, she was conscient, with blood pressure of 102/74 mm Hg and heart rate of 78 bpm. In the laboratory workup, severe hypokalaemia was found (K+ 1.77 mEq/L). Abdominopelvic CT revealed a 27 mm nodule in the right adrenal gland. High aldosterone and low plasma renin levels were detected, and the diagnosis of primary hyperaldosteronism was made, although she never had hypertension. Posteriorly, a cosecretion of aldosterone and cortisol was found. Two months after admission, the patient remained stable with normal K+ levels under spironolactone and a right adrenalectomy was performed. The cure of primary hyperaldosteronism and a partial adrenal insufficiency were confirmed. K+ levels and blood pressure remained normal without treatment and 10 months after surgery hydrocortisone was suspended.
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Alake O, Rana R, Jain A, Chakkarapani E. Therapeutic hypothermia and outcome in hyponatraemic encephalopathy secondary to maternal water intoxication. BMJ Case Rep 2021; 14:e237213. [PMID: 33731399 PMCID: PMC7978085 DOI: 10.1136/bcr-2020-237213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 11/03/2022] Open
Abstract
Misguided encouragement to consume large volumes of water during labour for pain relief results in dilutional hyponatraemia in mothers and their babies presenting with neurological dysfunction. We report three babies who were encephalopathic with seizures in the background of hyponatraemia secondary to maternal ingestion of large volumes of water and mild perinatal asphyxia. All babies underwent therapeutic hypothermia in addition to sodium supplementation with fluid restriction. Their neurodevelopment was appropriate for age. This case series highlights the dilemma that could arise with hyponatraemic encephalopathy and mild perinatal asphyxia in the first 6 hours of life, which is the window of opportunity for therapeutic hypothermia for hypoxic-ischaemic encephalopathy. It is important to educate pregnant mothers in labour on the adverse effects of excessive fluid ingestion.
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Araújo AN, Cunha M, Marques T, Bugalho MJGM. Multifactorial diabetes insipidus during pregnancy: a challenging diagnosis. BMJ Case Rep 2021; 14:14/3/e238410. [PMID: 33722910 PMCID: PMC7959218 DOI: 10.1136/bcr-2020-238410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Diabetes insipidus (DI) is characterised by thirst and polydipsia with hypotonic polyuria. Several forms exist, namely, central or pituitary, nephrogenic and gestational and must be differentiated for adequate treatment. We describe the case of a 41-year-old woman chronically infected with HIV who had been recently medicated with a tenofovir-based antiretroviral treatment and who, at 22 weeks of pregnancy, presented with transient gestational DI. Obstetric ultrasound revealed oligohydramnios and foetal growth restriction that did not improve despite serum sodium correction. The severity of the case suggested the presence of an underlying disorder and elevated copeptin levels indicated that an underlying subclinical form of nephrogenic DI, possibly induced by HIV-related nephropathy or tenofovir use, was present and rendered clinically overt during pregnancy.
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Yoshioka K. Patient with Bartter syndrome in whom chronic potassium depletion was considered one of the causes of hyponatremia. BMJ Case Rep 2021; 14:14/3/e240898. [PMID: 33692070 PMCID: PMC7949381 DOI: 10.1136/bcr-2020-240898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 53-year-old man was admitted to our hospital because of general fatigue and disorientation. He had been diagnosed with Bartter syndrome in his teens and had been taking potassium preparations since then. However, his serum potassium concentration (K+ s) remained persistently low. Ten days before admission, he developed fever. He was diagnosed as having bronchitis and was treated with antibiotics. Although his fever subsided, general fatigue worsened. Laboratory examination showed hyponatraemia (127 mEq/L), while K+ s was 2.3 mEq/L. C reactive protein was negative. On admission, laboratory examination revealed deterioration of hyponatraemia (125 mEq/L). Although his serum sodium concentration (Na+ s) was refractory to electrolyte replacement, the level increased towards normal after spironolactone administration, following normalisation of K+ s, suggesting that hyponatraemia was caused by K+ depletion. Physicians should be aware of the importance of the effects of exchangeable K+ (K+ e) on Na+ s.
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Mohamed H, Shorten G. Distinguishing cerebral salt wasting syndrome and syndrome of inappropriate ADH in a patient with traumatic brain injury. BMJ Case Rep 2021; 14:14/3/e237027. [PMID: 33692040 PMCID: PMC7949363 DOI: 10.1136/bcr-2020-237027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A previously healthy 48-year-old woman was referred to our intensive care unit (ICU) from a neurosurgical ward due to deterioration of her conscious level. She had a road traffic accident 6 days earlier. On admission to the hospital, a brain CT demonstrated subarachnoid haemorrhage which was considered not amenable to surgical intervention. A second CT brain performed shortly after admission to ICU showed no change in comparison to the initial CT. Serum sodium level on ICU admission was 108 mEq/L; serum and urine osmolalities were 223 mOsm/kg and 438 mOsm/kg, respectively. Her hyponatraemia was initially attributed to syndrome of inappropriate antidiuretic hormone. However, a clinical impression of low volume status raised the suspicion of cerebral salt wasting syndrome. She was managed by infusion of hypertonic saline and fluids for 5 days and discharged from ICU after improvement of her conscious level and normalisation of serum sodium.
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Shah HA, Madathil A, Routh C. Rare but serious cause for hypokalaemia and hypertension. BMJ Case Rep 2021; 14:e239955. [PMID: 33664034 PMCID: PMC7934740 DOI: 10.1136/bcr-2020-239955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 11/04/2022] Open
Abstract
Adrenocortical carcinoma is a rare tumour but hypertension conversely is very common. We present the case of a woman in her 30s, with poorly controlled hypertension on four antihypertensive agents. She was referred to the accident and emergency department with hypokalaemia. For a year, she had experienced oedema, weight gain, acne, hirsutism and oligomenorrhea. She had a classic Cushingoid appearance and marked striae. Cushing's syndrome was confirmed biochemically with an abnormal overnight dexamethasone suppression test. She was diagnosed with metastatic adrenocortical carcinoma following CT imaging. This was resected via a right adrenalectomy, nephrectomy and cholecystectomy. She also received mitotane. Unfortunately, she has a terminal prognosis having experienced a recurrence. This case demonstrates the value of a thorough clinical assessment. More importantly, it highlights the need to refer earlier patients under 40 with resistant hypertension to a specialist. Finally, it encourages clinicians to investigate hypokalaemia in the context of hypertension.
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Qureshi A, Rhee JH. Hyponatraemia due to hypothyroidism: a rare side effect from pomalidomide. BMJ Case Rep 2021; 14:14/3/e240168. [PMID: 33653858 PMCID: PMC7929826 DOI: 10.1136/bcr-2020-240168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pomalidomide is an immunomodulatory drug used for relapsed and refractory multiple myeloma (RRMM). Hypothyroidism is an uncommon side effect of pomalidomide. We present a 70-year-old male patient with RRMM on daratumumab, pomalidomide and dexamethasone, who presented with 2 weeks of fatigue. Laboratory values showed sodium of 120 mEq/L, plasma osmolarity of 256 mOsm/kg, urine osmolarity of 648 mOsm/kg and urine sodium of 93 mEq/L. Adrenocorticotropic hormone (ACTH) stimulation test was within normal limits. Thyroid-stimulating hormone (TSH) was 88.6 IU/mL (0.380-4.700 IU/mL), total triiodothyronine (TT3) <21 ng/mL (0.8-2 ng/mL), free thyroxine (fT4) 0.10 ng/dL (0.93-1.70 ng/dL) and free triiodothyronine (fT3) <0.5 pg/mL (2.3-4.2 pg/mL). Antithyroid peroxidase antibody was 726 IU/mL (<9 IU/mL). TSH 1 year ago was 2.88 IU/mL and TT3 was 1.06 ng/mL. He was started on levothyroxine with improvement in his symptoms, sodium level and thyroid functions. The most likely culprit was pomalidomide. Checking thyroid functions before and periodically while on pomalidomide is important in screening for this possible side effect.
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Kumar D, Nasim MZ, Shoukat BA, Shah SSA. Presentation of mixed diabetic ketoacidosis and metabolic acidosis due to ileal neobladder reconstruction. BMJ Case Rep 2021; 14:14/2/e223668. [PMID: 33622736 PMCID: PMC7903103 DOI: 10.1136/bcr-2017-223668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is one of the most serious acute metabolic complications of diabetes mellitus. It is characterised by the biochemical triad of hyperglycaemia, ketonemia/ketonuria, and an increased anion gap metabolic acidosis. In this case, a 40-year-old male patient presented to the emergency department, with vomiting, nausea, polydipsia, polyuria and weight loss. He was found to have an elevated plasma glucose, despite having no known history of diabetes mellitus. His medical history was significant for spina bifida and ileal neobladder reconstruction. The plasma glucose level was 38 mmol/L. Blood gas analysis showed normal anion gap metabolic acidosis with high chloride and low bicarbonate. His plasma ketone level was 4.5 mmol/L. No significant reason for hyperchloraemia was identified. On initiation of DKA regimen, his condition improved and serum ketones normalised. Due to persistent hyperchloraemic metabolic acidosis, bicarbonate infusion was administered and his metabolic acidosis resolved.
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Hussain A, Atlani M, Goyal A, Khurana AK. Type-5 Bartter syndrome presenting with metabolic seizure in adulthood. BMJ Case Rep 2021; 14:14/2/e235349. [PMID: 33597159 PMCID: PMC7893602 DOI: 10.1136/bcr-2020-235349] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Bartter syndrome is a very rare and heterogeneous disease with variable age of onset and symptom severity. Genotypically they have inherited disorders of the thick ascending limb in the renal tubular system, which manifest phenotypically as electrolyte imbalance due to loss of sodium, chloride and potassium. Gain of function mutations in the calcium-sensing receptor has been described in some patients with Bartter's syndrome (type-5 Bartter syndrome or autosomal dominant hypocalcaemia with Bartter syndrome) associated with hypocalcaemia and hypercalciuria differentiating it from Gitelman syndrome. This phenotype has been reported to present in adulthood with metabolic abnormalities. We present a case of a middle-aged woman who presented with metabolic seizures and on evaluation was found to have profound electrolyte abnormalities which were corrected with supplements and led to the resolution of symptoms.
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Hashim M, Athar S, Gaba WH. New onset adrenal insufficiency in a patient with COVID-19. BMJ Case Rep 2021; 14:14/1/e237690. [PMID: 33462013 PMCID: PMC7813399 DOI: 10.1136/bcr-2020-237690] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
SARS-CoV-2 is the cause of COVID-19. Since the outbreak and rapid spread of COVID-19, it has been apparent that the disease is having multi-organ system involvement. Still its effect in the endocrine system is not fully clear and data on cortisol dynamics in patients with COVID-19 are not yet available. SARS-CoV-2 can knock down the host’s cortisol stress response. Here we present a case of a 51-year-old man vomiting for 10 days after having confirmed COVID-19 infection. He had hypotension and significant hyponatraemia. Work-up was done including adrenocorticotropic hormone stimulation test. He was diagnosed as suffering from adrenal insufficiency and started on steroids with subsequent improvement in both blood pressure and sodium level. COVID-19 can cause adrenal insufficiency. Clinicians must be vigilant about the possibility of an underlying relative cortisol deficiency in patients with COVID-19.
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Veríssimo R, Leite de Sousa L, Carvalho TJ, Fidalgo P. Novel SLC12A3 mutation in Gitelman syndrome. BMJ Case Rep 2021; 14:14/1/e238097. [PMID: 33462018 PMCID: PMC7813350 DOI: 10.1136/bcr-2020-238097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Gitelman syndrome (GS) is an autosomal recessive disease characterised by the presence of hypokalaemic metabolic alkalosis with hypomagnesaemia and hypocalciuria. The prevalence of this disease is 1-10/40 000. GS is usually associated with mild and non-specific symptoms and many patients are only diagnosed in adulthood. The disease is caused by mutations in the SLC12A3 gene. We present the case of a 49-year-old man referred to a nephrology appointment due to persistent hypokalaemia and hypomagnesaemia. Complementary evaluation revealed hypokalaemia, hypomagnesaemia, metabolic alkalosis, hyperreninaemia, increased chloride and sodium urinary excretion, and reduced urinary calcium excretion. Renal function, remainder serum and urinary ionogram, and renal ultrasound were normal. A diagnosis of GS was established and confirmed with genetic testing which revealed a novel mutation in SLC12A3 (c.1072del, p.(Ala358Profs*12)). This novel mutation extends the spectrum of known SLC12A3 gene mutations and further supports the allelic heterogeneity of GS.
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O'Riordan K, Mohyuddin T, Moloney M. Unusual presentation of sarcoidosis, requiring a positron emission tomography/CT (PET/CT) for diagnosis. BMJ Case Rep 2021; 14:14/1/e237424. [PMID: 33414113 PMCID: PMC7797281 DOI: 10.1136/bcr-2020-237424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
A 43-year-old man presented to hospital after routine laboratory tests showed an acute kidney injury and hypercalcaemia. He had no relevant medical history and normal physical examination, other than a 6-week history of lower back pain for which he had been taking naproxen. Low parathyroid hormone (PTH) levels indicated a PTH-independent hypercalcaemia. Investigations including CT of thorax, abdomen and pelvis and subsequent bone biopsy and renal biopsy were unremarkable. Positron emission tomography/CT (PET/CT) scan was ultimately considered as a diagnostic test and showed abnormalities in the right subpectoral and portacaval region with intense fluorodeoxyglucose F 18 uptake in local lymph nodes. A biopsy of the right subpectoral node showed granulomatous change consistent with sarcoidosis. PET/CT scanning can play an important role in the investigation of suspected malignancy, infection and inflammatory disease and in this case, was required to diagnose an atypical presentation of sarcoidosis.
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Goonoo MS, Morris R, Raithatha A, Creagh F. Metformin-associated lactic acidosis: reinforcing learning points. BMJ Case Rep 2020; 13:13/9/e235608. [PMID: 32878828 DOI: 10.1136/bcr-2020-235608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Metformin-associated lactic acidosis (MALA) carries a high mortality rate. It is seen in patients with type 2 diabetes on metformin or patients who attempt suicide with metformin overdose. We present the case of a man in his early 20s with type 2 diabetes, hypertension and hypothyroidism who presented with agitation, abdominal pain and vomiting after ingesting 50-60 g of metformin; he developed severe lactic acidosis (blood pH 6.93, bicarbonate 7.8 mEq/L, lactate 28.0 mEq/L). He was managed with intravenous 8.4% bicarbonate infusion and continuous venovenous haemodiafiltration. He also developed acute renal failure (ARF) requiring intermittent haemodialysis and continuous haemodiafiltration. MALA is uncommon and causes changes in different vital organs and even death. The primary goals of therapy are restoration of acid-base status and removal of metformin. Early renal replacement therapy for ARF can result in rapid reversal of the acidosis and good recovery, even with levels of lactate normally considered to be incompatible with survival.
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Fraser J, Brook R, He T, Lewis D. Deferasirox-induced liver injury and Fanconi syndrome in a beta-thalassemia major male. BMJ Case Rep 2020; 13:e234542. [PMID: 32646935 PMCID: PMC7351284 DOI: 10.1136/bcr-2020-234542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2020] [Indexed: 11/03/2022] Open
Abstract
A 33-year-old male presenting with subacute abdominal pain was found to have hyperbilirubinaemia, hypokalaemia and hyponatraemia. This was in the setting of transitioning between deferasirox iron chelator formulations, from dispersible tablets to film-coated tablets for ongoing treatment of chronic iron overload secondary to transfusion requirement for beta-thalassemia major. A liver biopsy demonstrated acute cholestasis with patchy confluent hepatocellular necrosis and mild to moderate microvesicular steatosis. Based on the histological, biochemical and clinical findings, the diagnosis of hepatotoxicity and Fanconi-like syndrome was made. The patient improved clinically and biochemically with cessation of the deferasirox film-coated tablets and supportive management. To our knowledge, this is the first case report of hepatotoxicity and Fanconi-like syndrome occurring due to deferasirox film-coated tablets with previous tolerance of dispersible deferasirox tablets. It is important to raise clinical awareness of this potentially severe complication.
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Isse N, Hashimoto M. Omeprazole-induced hypomagnesaemia, causing renal tubular acidosis with hypokalaemia, hypocalcaemia, hyperlactacidaemia and hyperammonaemia. BMJ Case Rep 2020; 13:13/7/e235385. [PMID: 32641306 DOI: 10.1136/bcr-2020-235385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
A 72-year-old Japanese man treated with omeprazole for 11 years was admitted due to loss of consciousness and muscle weakness. Wolff-Parkinson-White syndrome-induced tachycardia was considered as the cause of syncope. His blood examination revealed rhabdomyolysis, hypokalaemia, hypomagnesaemia, hypocalcaemia, hyperlactacidaemia, hyperammonaemia and high-anion-gap metabolic acidosis. Hypomagnesaemia could be caused by magnesium malabsorption due to omeprazole use. Hypocalcaemia might be caused by the inhibitory effect of hypomagnesemia on the parathyroid gland hormone secretion. Hyperammonaemia might be caused by two reasons: (1) renal ammonium production induced by hypokalaemia; (2) inhibition of ammonium secretion by omeprazole. Both hypocalcaemia and hypokalaemia might cause chronic elevation of serum creatinine phosphokinase which ended up with rhabdomyolysis. Correction of serum electrolytes rapidly improved his muscle weakness. Discontinuation of omeprazole no longer caused these abnormalities. A physician should be aware of unexplained signs and symptoms of patients using proton-pump inhibitors to avoid life-threatening electrolyte and physiologic disturbances.
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Kumar S, McDermott H, Kamupira S, Agwu JC. Rare case of pseudohypoaldosteronism in a neonate secondary to congenital hydrometrocolpos. BMJ Case Rep 2020; 13:13/6/e234813. [PMID: 32595115 DOI: 10.1136/bcr-2020-234813] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pseudohypoaldosteronism (PHA) due to obstructive uropathy, urinary tract infections and congenital urogenital malformations has been reported in the literature; however, there are no reports of PHA associated with hydrometrocolpos due to a common urogenital tract. Hydrometrocolpos is a condition resulting in distension of the vagina and uterus due to accumulation of secretions (other than blood), caused by increased oestrogenic stimulation and vaginal outflow obstruction. We report on a neonatal case of PHA caused by recurrent hydrometrocolpos presenting with vomiting and poor weight gain. There was significant hyponatraemia, hyperkalaemia, and anaemia requiring medical stabilisation prior to surgery. The mechanism by which PHA occurs in obstruction involves renal tubular dysfunction due to pressure from hydronephrosis and the release of intrarenal cytokines. In addition, there is an immature or resistant renal tubular responsiveness to aldosterone during infancy. Clinicians should be aware of this uncommon but serious presentation.
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Evins C, Rao A. Point-of-care ultrasound to evaluate volume status in severe hyponatremia. BMJ Case Rep 2020; 13:13/6/e235304. [PMID: 32595119 DOI: 10.1136/bcr-2020-235304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
A 51-year-old man was hospitalised for severe hyponatremia. Initial history and physical examination suggested hypovolemia, and he was treated with normal saline at 100 mL/hour. After several days, his hyponatremia failed to improve, and then worsened without resolution of presenting ataxia and fatigue. He had no new complaints including no cough or orthopnea. He had no jugular venous distention or oedema, and his lungs were clear to auscultation. Point-of-care ultrasound was used, revealing a distended inferior vena cava, pulmonary oedema and pleural effusion, suggesting hypervolemia. Based on ultrasound findings, we treated with 60 mg oral torsemide two times per day. Hyponatremia resolved without complication within 48 hours. In this case, physical examination failed to recognise volume status change from hypovolemic to hypervolemic, increasing hospitalisation and morbidity. The point-of-care ultrasound proved to be an accurate tool for proper volume evaluation, and may be used as an adjunct to physical examination for hyponatremic patients.
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Lundin MS, Kaw B, Pahwa R. Syndrome of inappropriate antidiuretic hormone associated with eosinophilic granulomatosis and polyangiitis. BMJ Case Rep 2020; 13:13/3/e231249. [PMID: 32209573 DOI: 10.1136/bcr-2019-231249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 62-year-old man presented with classic signs and symptoms of eosinophilic granulomatosis and polyangiitis (EGPA, also known as Churg-Strauss syndrome)-mononeuritis multiplex, palpable purpura, hypereosinophilia, positive P-ANCA (perinuclear anti-neutrophil cytoplasmic antibodies) developed diffuse alveolar haemorrhage. The patient had longstanding mild hyponatraemia, but developed moderate and symptomatic hyponatraemia characteristic of the syndrome of inappropriate antidiuretic hormone. The patient's serum sodium returned to his baseline- mildly hyponatraemic, after initiation of treatment targeted towards EGPA.
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Nandoshvili E, Hyer S, Johri N. Republished: Partial nephrogenic diabetes insipidus associated with lithium therapy. Drug Ther Bull 2020; 58:45-47. [PMID: 31784466 DOI: 10.1136/dtb.2019.231093rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Abstract
A 62-year-old woman with chronic kidney disease stage 4, sleep apnoea on continuous positive airway pressure and recent admission for acute-on-chronic diastolic heart failure presented to emergency room with weakness. She was hypotensive and had symptomatic bradycardia in the 30 s secondary to hyperkalaemia and beta-blockers, raising concern for BRASH syndrome. Antihypertensives were immediately held. Potassium-lowering agents (with calcium gluconate for cardiac stability) were begun, as were fluids and dopamine for vasopressor support. The patient was admitted to intensive care unit and electrophysiology was consulted. Over the next 2 days, the patient clinically improved: she remained off dopamine for over 24 hours; potassium levels and renal function improved; and heart rate stabilised in 60 s. The patient was eventually discharged and advised to avoid metolazone, bumetanide and carvedilol, with primary care provider and cardiology follow-up.
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Tabish M, Mahendran M, Ray A, Vikram NK. Colistin-induced acquired Bartter-like syndrome: an unusual cause of meltdown. BMJ Case Rep 2020; 13:13/2/e232630. [PMID: 32029515 DOI: 10.1136/bcr-2019-232630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Colistin-induced nephrotoxicity is commonly associated with elevation of serum creatinine level or a reduction of urine output. Uncommonly, tubulopathy associated with colistin has been reported. Here we present a unique case of a 46-year-old man who developed polyuria, hypokalaemia, hypocalcaemia, hypomagnesemia and metabolic alkalosis after 3 days of therapy with intravenous colistimethate sodium. After ruling out other causes, a diagnosis of colistin-induced acquired Bartter syndrome was made. The patient required daily aggressive intravenous repletion of fluids and electrolytes. However, polyuria and metabolic abnormalities abated only after drug discontinuation.
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Al Banna R, Husain A, Al-Ghamdi B. Ventricular arrhythmia and tachycardia-induced cardiomyopathy in Gitelman syndrome, hypokalaemia is not the only culpable. BMJ Case Rep 2019; 12:12/12/e232086. [PMID: 31843774 DOI: 10.1136/bcr-2019-232086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Gitelman syndrome (GS) is an autosomal recessive tubulopathy recently implicated in cases with ventricular arrhythmias (VAs), the latter being considered linked to electrolytes' imbalance. However, a direct causal relationship is considered to be an oversimplification for a complex molecular dysfunction. Recent work has suggested a degree of microvascular dysfunction in patients with GS that might be attributed as a mechanism of arrhythmia. We report a case of GS presenting with VAs complicated by cardiomyopathy. The high load of premature ventricular contractions that were attributed to the hypokalaemia has masked the presence of the left ventricular (LV) outflow tract tachycardia. Her LV systolic function recovered after successful electrophysiology ablation procedure. Atrioventricular nodal re-entry tachycardia was discovered incidentally during the study and was ablated successfully.
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