Hyperkalemic ascending paralysis

Trimethoprim-associated electrolyte and acid-base abnormalities

INTRODUCTION

The antimicrobial trimethoprim is structurally related to potassium-sparing diuretics and may consequently lead to derangements in electrolyte and acid-base balance. Since no report so far analyzed the literature documenting individual cases with electrolyte and acid-base derangements induced by trimethoprim, a systematic review was carried out.

EVIDENCE ACQUISITION

We retained 53 reports documenting 68 cases (42 males and 26 females 23 to 96 years of age) of electrolyte or acid-base derangements occurring on trimethoprim for about 5 days.

EVIDENCE SYNTHESIS

One hundred five electrolyte imbalances were detected in the 68 patients: hyperkalemia (>5.0 mmol/L) in 62 (91%), hyponatremia (<135 mmol/L) in 29 (43%) and metabolic acidosis (pH<7.38 and bicarbonate <19 mmol/L) in 14 (21%) cases. Following possible predisposing factors for electrolyte and acid-base abnormalities were found in 54 (79%) patients: high-dose trimethoprim, comedication with drugs that have been associated with electrolyte and acid-base derangements, preexisting kidney disease, age ≥80 years and diabetes mellitus.

CONCLUSIONS

High-dose trimethoprim, comedicated with drugs that have been associated with electrolyte and acid-base derangements, poor kidney function, age ≥80 years and diabetes mellitus predispose to trimethoprim-associated electrolyte and acid-base abnormalities. Clinicians must recognize patients at risk, possibly avoid drug combinations that may worsen the problem and monitor the laboratory values.

Tetraparesia: an unusual presentation of disseminated tuberculosis

A 48-year-old man with a 4 months history of asthenia, anorexia, 10 kg weight loss and 1 month of hematuria and dysuria was admitted to another hospital for sudden muscular weakness. He was found to have areflexic tetraparesis and was referred to our hospital.On admission, he was bradycardic, tachypneic, with flaccid tetraplegia. Laboratory results showed metabolic acidemia, severe hyperkalemia and hyponatremia, acute renal dysfunction and sterile pyuria. After hyperkalemia correction, the neurological symptoms resolved.On the second day, he became febrile and chest radiograph and CT images showed a pulmonary bilateral reticulomicronodular pattern, left hydronephrosis and diffuse bladder wall thickening. Disseminated tuberculosis was considered as diagnosis by the coexistence of this imagiologic alterations and sterile pyuria. Acid-fast test for Mycobacteriumtuberculosis was negative, but the urine culture became positive after 2 weeks.Antituberculosis treatment was started. One year later, he was asymptomatic and the structural urinary lesions had disappeared.

Neurologic complications of electrolyte disturbances and acid-base balance

Electrolyte and acid-base disturbances are common occurrences in daily clinical practice. Although these abnormalities can be readily ascertained from routine laboratory findings, only specific clinical correlates may attest as to their significance. Among a wide phenotypic spectrum, acute electrolyte and acid-base disturbances may affect the peripheral nervous system as arreflexic weakness (hypermagnesemia, hyperkalemia, and hypophosphatemia), the central nervous system as epileptic encephalopathies (hypomagnesemia, dysnatremias, and hypocalcemia), or both as a mixture of encephalopathy and weakness or paresthesias (hypocalcemia, alkalosis). Disabling complications may develop not only when these derangements are overlooked and left untreated (e.g., visual loss from intracranial hypertension in respiratory or metabolic acidosis; quadriplegia with respiratory insufficiency in hypermagnesemia) but also when they are inappropriately managed (e.g., central pontine myelinolisis when rapidly correcting hyponatremia; cardiac arrhythmias when aggressively correcting hypo- or hyperkalemia). Therefore prompt identification of the specific neurometabolic syndromes is critical to correct the causative electrolyte or acid-base disturbances and prevent permanent central or peripheral nervous system injury. This chapter reviews the pathophysiology, clinical investigations, clinical phenotypes, and current management strategies in disorders resulting from alterations in the plasma concentration of sodium, potassium, calcium, magnesium, and phosphorus as well as from acidemia and alkalemia.

Hyperkalemic Recurrent Bilateral Lower Extremity Weakness in a Patient on Hemodialysis

Hyperkalemia is a severe life-threatening electrolyte disorder that commonly affects the cardiac conductivity and contractility. Ascending paralysis affecting the extremities with focal neurological deficit as well as quadriparesis and a seizure associated with hyperkalemia has been reported in the literature. Here, we describe a case of isolated recurrent lower extremity paralysis and an episode of seizure in an 83-year-old patient with end-stage renal disease on hemodialysis.

Neurologic presentations of acid-base imbalance, electrolyte abnormalities, and endocrine emergencies

Accurate identification of nervous system dysfunction is vital in the assessment of any multisystem disorder. The neurologic manifestations of acid-base disturbances, abnormal electrolyte concentrations, and acute endocrinopathies are protean and typically determined by the acuity of the underlying derangement. Detailed history and physical examination may guide appropriate laboratory testing and lead to prompt and accurate diagnosis. Neurologic manifestations of primary and secondary systemic disorders are frequently encountered in all subspecialties of medicine. This article focuses on key neurologic presentations of respiratory and metabolic acid-base derangements and potentially life-threatening endocrinopathies.

Hyperkalemia-induced paralysis

Hyperkalemia is an electrolyte abnormality that can lead to severe consequences. Paralysis induced by hyperkalemia has been described in only a few reports. We describe a 60-year-old man who experienced paralysis presumably due to hyperkalemia. He presented to the emergency department with severe weakness in all extremities. The patient's serum potassium concentration was greater than 8 mEq/L and his serum creatinine concentration was 7 mg/dl. Findings on electrocardiography were abnormal. Of note, his drug therapy included lisinopril and naproxen. After treatment for hyperkalemia, the patient's symptoms resolved; however, he was admitted for further workup for renal failure. The patient was discharged after approximately 1 week with a diagnosis of end-stage renal disease. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 5) between the patient's paralysis and hyperkalemia. Although hyperkalemia as a cause of paralysis is extremely rare, clinicians should be aware of this potentially life-threatening, noncardiac toxicity.

[An unusual diagnostic of quadriparesia: hyperkalemic paralysis. Report of four non-familial cases]

INTRODUCTION

The classical cause of hyperkalemic paralysis is the hereditary hyperkalemic paralysis. Very rarely, secondary forms of hyperkalemic paralysis have been reported.

EXEGESIS

Four cases of acute paralysis mimicking Guillain-Barre syndrome in three cases and revealing severe hyperkalemia are presented. All the four patients had moderate chronic renal insufficiency. In two cases, the patients received spironolactone. One case was associated with lysis syndrome. All the 4 cases dramatically improved with the treatment of hyperkalemia.

CONCLUSION

These cases pointed out the possibility for acute peripheral paralysis to reveal severe hyperkalemia.