Secondary or Transient Pseudohypoaldosteronism Associated With Urinary Tract Anomaly and Urinary Infection: A Case Report

Case report: Life threatening hyponatremia in infants with urinary tract infections: two cases of type III pseudohypoaldosteronism and review of the literature

We describe two female infants at the age of five and six months with urinary tract infections presenting with vomiting and reduced drinking behavior. On laboratory analysis, severe hyponatremia (106 mmol/L and 109 mmol/L) was seen with hyperkalemia and compensated metabolic acidosis. Endocrinological analyses revealed massively increased levels of aldosterone and renin, leading to the diagnosis of type III pseudohypoaldosteronism (PHA). A review of the current literature 2013-2023 revealed 26 type III PHA cases aged up to ten months with reduced drinking behavior, weight loss and/or failure to thrive being the most common clinical presentations. Given the severe presentation of PHA electrolyte measurements in infants with urinary tract infections and/or in infants with congenital anomalies of the kidney and urinary tract (CAKUT) are strongly recommended.

A Five-Month-Old Boy With Hypotonia, Electrolyte Derangements, and Failure to Thrive

Failure to thrive in the setting of profound hypotonia and multiple electrolyte derangements is a challenging constellation of findings that offers a broad differential diagnosis for providers to consider. Initial management should focus on the stabilization of the patient and correction of potential life-threatening electrolyte derangements. Once completed, the diagnosis should be sought, and in this case, many were considered and ultimately ruled out with thorough history and physical examination. Laboratory abnormalities revealed the final diagnosis of pseudohypoaldosteronism and connected the case. With proper treatment, our patient had a resolution of laboratory anomalies along with improved growth and tone.

Transient pseudohypoaldosteronism in infancy mainly manifested as poor appetite and vomiting: Two case reports and review of the literature

INTRODUCTION

Transient Pseudohypoaldosteronism (TPHA) is a very rare condition usually secondary to urinary tract malformations (UTM) and/or urinary tract infection (UTI). It is characterized by hyperkalemia, hyponatremia, metabolic acidosis, and elevated plasma aldosterone levels. Given that the predominant manifestations of TPHA patients are digestive tract symptoms, such as poor appetite, vomiting, and weight gain, it is easily misdiagnosed as digestive tract diseases.

CASE REPORTS

Two children with poor appetite and vomiting were admitted to the Department of Gastroenterology, Children's Hospital of Nanjing Medical University, from 2020 to 2021. Laboratory test results of these two children revealed hyponatremia (< 135.00 mmol/L), hyperkalemia (> 5.50 mmol/L), and hyperaldosteronism (> 180.00 ng/L). Moreover, genetic tests demonstrated no genetic variants highly associated with the phenotype in both cases. The two patients were subsequently treated with electrolyte correction. One of them also treated with antibiotics and one of them underwent surgery. They were followed for 8 and 4 months, respectively. No complications were observed during the follow-up period. This review aimed to outline both cases with parental consent.

CONCLUSION

Transient pseudohypoaldosteronism should be considered in children younger than 6 months, presenting with vomiting, poor appetite, unexplained hyponatremia, hyperkalemia, elevated aldosterone levels, and urethral malformation or urinary tract infection. Furthermore, attention should be paid to whether salt supplementation or anti-infection therapy is effective.

Association of Electrolyte Changes and Inflammatory Markers with Renal Involvement in Children with Febrile UTI

Background: We need some simpler, cheaper, and less burdensome tools to investigate the severity of renal parenchymal involvement in children with clinical pyelonephritis. Objectives: The present study was designed to investigate the relationship between electrolyte changes with renal involvement as documented by dimercaptosuccinic acid (DMSA) scan in children with febrile urinary tract infection (UTI). Methods: This is a retrospective cohort study, involving 158 children aged two months to 14 years with febrile UTI admitted to Taleghani Hospital in Gorgan from 2018 to 2019. Their documents in hospital were analyzed. They were divided into two groups with positive or negative defects on DMSA scan. Clinical and laboratory data were studied. Statistical analysis was performed using SPSS version 18. Data were analyzed using independent t-test with normal distribution of variables, otherwise chi-square test was used. The statistical significance level of the study was considered 0.05. Results: Among the 158 children, 78 patients (49.4%) had normal DMSA scan results, and 80 patients (50.6%) had an abnormal result. The mean age in month was not different between the two groups. In patients with positive renal cortical defects on DMSA Scintigraphy (group 2), ESR was significantly higher than the first group (P < 0.05). The mean serum Na level in the second group was lower than in the first group; however, it was only slightly significant (P = 0.058). The two groups showed no difference with respect to serum potassium, urine specific gravity (SG), WBC count, and the duration of fever (P > 0.05). The frequency distribution of proteinuria was not different between the two groups (P = 0.836). Conclusions: We suggest that increased ESR, positive CRP, and the presence of reflux can predict renal parenchymal involvement in children with febrile UTI as evidenced by a positive finding on DMSA scan, and the presence of hyponatremia has a little predictive value in this regard.

Secondary Pseudohypoaldosteronism Associated With Mild Hydronephrosis in a Newborn

Neonatal hyponatremia with hyperkalemia is a rare but potentially life-threatening occurrence. Aldosterone deficiency secondary to congenital adrenal hyperplasia (CAH) is often suspected in these cases, although it is not easy to accurately diagnose it initially. We report the case of a 12-day-old female infant presenting with poor sucking, hyperkalemia, and hyponatremia. Plasma renin activity (PRA) and aldosterone levels were markedly elevated, and mild hydronephrosis [Society for Fetal Urology (SFU) grade 1] was noted. We then suspected secondary pseudohypoaldosteronism (S-PHA); however, her serum potassium level remained elevated despite sodium infusion. Because we could not rule out a diagnosis of adrenal insufficiency caused by CAH, we cautiously initiated hydrocortisone. After reviewing the results of a mass screening test and a urine steroid profile analysis, adrenal diseases were ruled out and we diagnosed the patient with S-PHA. This report aims to illustrate that mild hydronephrosis can cause S-PHA by inducing renal tubular resistance to aldosterone. Because the symptoms of S-PHA are similar to those of CAH, we recognize that further studies are needed to clarify their differences.

Case Report: Newborns With Pseudohypoaldosteronism Secondary to Excessive Gastrointestinal Losses Through High Output Stoma

Life-threatening electrolyte imbalance is not uncommon in preemies. Differential diagnosis is important for immediate treatment. The syndrome of pseudohypoaldosteronism (PHA) is characterized by increased aldosterone secretion associated with clinical signs of hypoaldosteronism reflecting mineralocorticoid resistance. There are type I, type II, and secondary type of PHA. Most secondary PHA reported in the pediatric population result from urinary infection and obstructive uropathy and extremely rarely from gastrointestinal fluid loss. Seven preemies accepted jejunostomy or ileostomy, and they suffered from high output stoma. Electrolyte imbalance with bodyweight loss or cardiac event was noted. We found a high level of aldosterone and renin and diagnosed them with secondary PHA due to excessive gastrointestinal losses. After stomal reversal, aldosterone and renin level became normalized, and electrolyte was corrected. This study reports the finding of secondary pseudohyperaldosteronism (hyponatremia, hyperkalemia, and metabolic acidosis) in a series of cases with intestinal resection and ostomy of different causes. Early stomal reversal was recommended.

A rare cause of salt-wasting in early infancy: Transient pseudohypoaldosteronism

Three infants aged between 38 days and 43 days all presented with poor weight gain, hyponatremia, hyperkalemia, and were diagnosed as having urinary tract infections, which were accompanied by urinary tract malformations in our cases. Hydration and infection treatments were given. A few days after admission, hormonal studies revealed normal cortisol and 17-hydroxy progesterone levels and markedly high aldosterone levels, thus the patients were diagnosed as having transient pseudohypoaldosteronism. After the proper treatment was given, the transient pseudohypoaldosteronism resolved. In conclusion, when an infant with urinary tract infection or malformation has electrolyte abnormalities, pediatricians should consider the diagnosis of transient pseudohypoaldosteronism.

Transient pseudohypoaldosteronism: a potentially severe condition affecting infants with urinary tract malformation

BACKGROUND

Secondary pseudohypoaldosteronism (S-PHA) is a life-threatening condition affecting young children with urinary tract malformation (UTM).

OBJECTIVE

The aim of the study was to highlight the diagnosis of S-PHA in children with UTM and propose appropriate management.

STUDY DESIGN

The authors retrospectively reviewed cases of S-PHA related to UTM observed at the institution and searched the PubMed® database to review the literature.

RESULTS

A total of 116 cases of S-PHA associated with UTM, including the four cases from the institution, were reviewed. One hundred six cases (92.2%) were younger than 6 months, and 95 cases (81.9%) occurred in boys. Urinary tract infection was associated in 105 cases (90.5%). All types of UTM were observed. In the absence of urinary tract infection, S-PHA was related to bilateral UTM or solitary kidney. In 89 cases (76.5%), S-PHA resolved with medical treatment only. In cases of UTM requiring immediate surgery, electrolyte imbalance related to S-PHA also resolved after surgery. Children with associated urinary tract infection and bilateral UTM are at higher risk of developing S-PHA.

DISCUSSION

The pathogenesis of S-PHA has not been fully elucidated. Renal tubular immaturity may be one of the factors involved, in view of the young age of the population being affected. A high rate of bilateral UTM (or UTM on solitary kidney) was observed (50.9%), suggesting an association with S-PHA. In the absence of urinary tract infection (UTI), S-PHA appeared to occur more frequently in the presence of bilateral UTM. Although the indication for early surgery remains unclear, it may have a role in the prevention of UTI and prevention of recurrence of S-PHA. Serum electrolytes should be checked in children with UTM before urological surgery, and/or presenting urinary tract infection, before the age of 6 months. The results of this study must be interpreted cautiously because of its retrospective nature and the fact that data were derived from various articles. Few articles on S-PHA related to UTM have been published in the literature. To the best of the authors' knowledge, the study constitutes the largest series published to date.

CONCLUSIONS

S-PHA results in potentially severe electrolyte imbalance and affects children younger than 6 months with UTI and/or UTM. Electrolyte abnormalities related to S-PHA often resolve after administration of appropriate intravenous electrolyte solution and treatment of UTI and/or surgery.