- Renal Infiltration by Diffuse Large B-Cell Lymphoma as a Rare Cause of Fanconi's Syndrome: A Case Report. [Journal Article]
- CCureus 2016 Nov 30; 8(11):e904
- We report the case of a 16-year-old female patient with a known history of coeliac disease, who presented with the complaints of diarrhea, vomiting and generalized body weakness. On examination, she ...
We report the case of a 16-year-old female patient with a known history of coeliac disease, who presented with the complaints of diarrhea, vomiting and generalized body weakness. On examination, she was found to have dehydration, decreased power in all her limbs, cervical lymphadenopathy and hepatosplenomegaly. Investigations showed severe hypokalemia, hyponatremia, hypomagnesemia, hypoglycemia and mildly enlarged kidneys on ultrasonography. Biopsy of the duodenum confirmed the flare up of coeliac disease, while cervical lymph node biopsy was positive for atypical lymphoid infiltrate and a morphology suggestive of non-Hodgkin's lymphoma. The immune profile performed on this sample confirmed the presence of activated/non-germinal center type of diffuse large B cell lymphoma (DLBCL), which was morphologically aggressive in type. The bone marrow biopsy was hypocellular and was negative for any infiltration. The patient was suspected to have developed infiltration of one or both kidneys leading to a rare presentation of Fanconi's syndrome. She was given first dose of rituximab on the 14th day of her admission. Unfortunately, she developed cardiopulmonary arrest and expired on the next day. We recommend screening for a possible renal involvement in patients with DLBCL and in patients with unusually deranged serum electrolytes as seen in Fanconi's syndrome. Renal biopsy is considered the gold standard modality for diagnosis and if possible, an earlier sample in a patient with newly developed acute kidney injury can save future complications.
- Hypokalemia associated with acute colonic pseudo-obstruction in an ESRD patient. [Journal Article]
- CNClin Nephrol 2016 Dec 27
- Ogilvie's syndrome, or acute colonic pseudo-obstruction, is characterized by massive dilation of the colon without mechanical obstruction. Water and electrolytes often can be sequestered in the dilat...
Ogilvie's syndrome, or acute colonic pseudo-obstruction, is characterized by massive dilation of the colon without mechanical obstruction. Water and electrolytes often can be sequestered in the dilated intestinal loops resulting in profuse and watery diarrhea as well as hypokalemia. We report an anuric, end-stage renal disease (ESRD) patient undergoing peritoneal dialysis (PD) who developed acute colonic pseudo-obstruction causing a prolonged hospitalization. He also developed severe hypokalemia with a serum potassium (K+) as low as 2.4 mEq/L and required 180 - 240 mEq of potassium chloride per day for more than a month to correct it. While PD K+ losses often contribute to hypokalemia, the PD K+ loss was estimated to be only 39 mEq/day. Therefore, PD could only contribute modestly to the recalcitrant hypokalemia observed during the episode of pseudo-obstruction. It has been shown, however, that patients with colonic pseudo-obstruction have enhanced colonic K+ secretion. In addition, experimental studies in patients with chronic kidney disease (CKD) have demonstrated that colonic K+ excretion can be up to 3 times greater than in individuals with normal renal function. This increase may involve an upregulation of the large conductance K+ channel (maxi-K), also known as the BK channel, in the apical border of the colonocytes. We suggest that ESRD may have placed our patient at a greater risk of developing hypokalemia as his colon may have already adapted to secrete more K+. Clinicians should be aware of this extrarenal K+ wasting etiology in patients with colonic pseudo-obstruction, particularly in those with CKD where such a severe K+ deficit is not anticipated and, therefore, may inhibit more rigorous K+ replacement.
- Risk factors for QTc-prolongation: systematic review of the evidence. [Journal Article]
- IJInt J Clin Pharm 2016 Dec 23
- Background QTc-interval prolongation has been associated with serious adverse events, such as Torsade de Pointes and sudden cardiac death. In the prevention of QTc-prolongation, special attention sho...
Background QTc-interval prolongation has been associated with serious adverse events, such as Torsade de Pointes and sudden cardiac death. In the prevention of QTc-prolongation, special attention should go to high-risk patients. Aim of the review The aim of this review is to summarize and assess the evidence for different risk factors for QTc-prolongation (demographic factors, comorbidities, electrolytes, QTc-prolonging medication). Methods Potential studies were retrieved based on a systematic search of articles published until June 2015 in the databases Medline and Embase. Both terms about QTc-prolongation/Torsade de Pointes and risk factors were added in the search strategy. The following inclusion criteria were applied: randomized controlled trials and observational studies; inclusion of ≥500 patients from a general population (not limited to specific disease states); assessment of association between QTc-interval and risk factors. For the articles that met the inclusion criteria, the following data were extracted: study design, setting and study population, number of patients and cases of QTc-prolongation, method of electrocardiogram-monitoring, QTc-correction formula, definition of QTc-prolongation, statistical methods and results. Quality assessment was performed using the GRADE approach (for randomized controlled trials) and the STROBE-recommendations (for observational studies). Based on the number of significant results and the level of significance, a quotation of the evidence was allocated. Results Ten observational studies could be included, with a total of 89,532 patients [prospective cohort design: N = 6; multiple regression analyses: N = 5; median STROBE score = 17/22 (range 15-18)]. Very strong evidence was found for hypokalemia, use of diuretics, antiarrhythmic drugs and QTc-prolonging drugs of list 1 of CredibleMeds. Little or no evidence was found for hyperlipidemia, the use of digoxin or statins, neurological disorders, diabetes, renal failure, depression, alcohol abuse, heart rate, pulmonary disorders, hormone replacement therapy, hypomagnesemia, history of a prolonged QTc-interval/Torsade de Pointes, familial history of cardiovascular disease, and the use of only QTc-prolonging drugs of list 2 or 3 of CredibleMeds. Conclusion This systematic review gives a clear overview of the available evidence for a broad range of risk factors for QTc-prolongation.
- Hypokalemia associated with a solitary pulmonary nodule: A case report. [Journal Article]
- MMedicine (Baltimore) 2016; 95(50):e5046
- CONCLUSIONS: A 49-year-old woman presented with moderate hypokalemia. Further evaluation showed hypercortisolism due to ectopic ACTH secretion.Chest computed tomography (CT) revealed a peripheral solitary pulmonary nodule. Excision biopsy of the nodule showed carcinoid tumor. After excision biopsy, all of the patient's symptoms improved and electrolytes and ACTH levels also became normal.Carciniod tumors should be considered as a differential diagnosis in patients presenting with hypokalemia and ectopic ACTH syndrome. Carcinoid tumor often present as solitary pulmonary nodule and excision biopsy can be curative.
- A case of extreme hypokalaemia. [Journal Article]
- NJNeth J Med 2016; 74(9):406-409
- Hypokalaemia is a common clinical problem. It can lead to severe disturbances in cardiac, neurological and muscle function. We present the case of a 45-year-old woman who was transported to our hospi...
Hypokalaemia is a common clinical problem. It can lead to severe disturbances in cardiac, neurological and muscle function. We present the case of a 45-year-old woman who was transported to our hospital with cardiac arrest following ventricular fibrillation. Blood sampling revealed severe acidosis (pH 7.02) and extreme hypokalaemia (0.9 mmol/l). The low serum potassium level was most likely caused by the combination of a very deficient diet and use of a thiazide diuretic. She never reported any symptoms. An acute intracellular shift of potassium due to epinephrine and perhaps also the cathecholamines in Red Bull may have further decreased the serum potassium concentration. To our knowledge, this is the lowest potassium level reported in literature. Longer-lasting hypokalaemia might be asymptomatic but when combined with even minor triggers of acute hypokalaemia, serious morbidity or mortality can suddenly occur. Patients on diuretic treatment with suspected malnutrition or chronic gastrointestinal losses require regular monitoring of electrolytes.
- Hypoglycemia associated with refeeding syndrome in a cat. [Journal Article]
- JVJ Vet Emerg Crit Care (San Antonio) 2016; 26(6):798-803
- CONCLUSIONS: Hypoglycemia has not been reported previously as a complication of refeeding in a cat. Frequent monitoring of electrolyte, mineral, and blood glucose concentrations is essential to successful management of refeeding syndrome. The ideal refeeding strategy is unknown at this time. Evidence suggests that a diet low in carbohydrate decreases the likelihood of metabolic derangements commonly associated with refeeding.
- Successful treatment of severe hypokalemia in a dog with acute kidney injury caused by leptospirosis. [Journal Article]
- JVJ Vet Emerg Crit Care (San Antonio) 2016; 26(6):837-843
- CONCLUSIONS: This report identifies an unusually severe presentation of leptospirosis in a dog from a region where the disease is not considered common, which was successfully treated despite cardiopulmonary arrest on initial presentation.
- Serum level of scorpion toxins, electrolytes and electrocardiogram alterations in Mexican children envenomed by scorpion sting. [Journal Article]
- TToxicon 2016; 122:103-108
- The scorpion Centruroides limpidus limpidus (C.l.l.) is endemic in México, producing hundreds of accidents in humans; children being one of the most susceptible targets. Few studies reported that sev...
The scorpion Centruroides limpidus limpidus (C.l.l.) is endemic in México, producing hundreds of accidents in humans; children being one of the most susceptible targets. Few studies reported that severe envenoming by scorpion venom induces cardiac damage and electrolytes abnormalities in children, but the relationship of envenoming severity and toxic blood levels is unknown. The aim of this study was to determine the relationship among clinical status of envenoming, serum electrolyte, electrocardiographic abnormalities, and serum toxin levels in 44 children stung by scorpion over a period of 6 months in the State of Morelos, Mexico. The patients were said to be asymptomatic, when they presented just local symptoms, and were said to be symptomatic when showing local symptoms and at least one systemic symptom. The clinical status was evaluated at the admission at the emergency room of the Hospital, and 30 min after the administration of polyspecific F(ab')2 anti-scorpion therapy to symptomatic children. Forty-one percent of the children were asymptomatic and 59% symptomatic. Potassium and sodium imbalance and an elongation of the QT interval were detected; the rate of hypokalemia was higher in symptomatic than on asymptomatic children (50% and 6%, respectively). Hypokalemia persisted in 19% in symptomatic patients, whereas sodium reached normal levels 30 min after anti-venom therapy. The hypokalemia statistically correlated with elongation of the QT interval. The concentration of the toxic components of C.l.l in serum was significantly higher in symptomatic than asymptomatic children, and the serum levels of the toxic component significantly decreased to undetectable levels after the application of anti-venom therapy. Despite the small size of the sample, this study establishes that severity of envenoming was statistically related to potassium imbalance in serum, QT interval and the concentration of toxic components in serum, which decreased at undetectable levels after specific treatment with the anti-scorpion venom, correlating with clinical disappearance or greatly reduction of symptoms of envenomation.
- ED 08-4 DIAGNOSIS AND TREATMENT OF HYPERTENSIVE EMERGENCY IN CHILDREN. [Journal Article]
- JHJ Hypertens 2016; 34 Suppl 1 - ISH 2016 Abstract Book:e373-e374
- According to the seventh report of Joint National Committee (JNC 7), hypertensive emergency (HE), a kind of hypertensive crisis, is defined as a sudden and abrupt elevation in blood pressure so as to...
According to the seventh report of Joint National Committee (JNC 7), hypertensive emergency (HE), a kind of hypertensive crisis, is defined as a sudden and abrupt elevation in blood pressure so as to cause acute target organ dysfunctions, including central nervous system, cardiovascular system or kidneys. Patients with HE require immediate reduction in markedly elevated blood pressure. Currently, there are no international guidelines for children HE, so the JNC definition is commonly used. Hypertensive emergency in children is rare but a life-threatening emergency. Generally, secondary hypertension is the most common reason of hypertensive emergency. We analyzed clinical features of 16 patients with HE who were diagnosed as HE from Jan 2007 to Dec 2015 in our hospital. Results showed that all patients were diagnosed as secondary hypertension, including 10 cases associated with renal diseases, 3 cases with Takayasu arteritis,1case with hypercortisolism, 1 case with migraine, and 1 case with unknown reason. The pathophysiologic mechanisms of HE involve sympathetic hyperactivity and increasing of vasoconstricting substances, activation of renin-angiotensin system (RAS), decreasing in auto-regulation of target organs, and chronic endothelial damage and remodeling. There is strong evidence that the renin-angiotensin system plays an important role in the genesis of hypertensive crisis. Target organ dysfunctions may be manifested as hypertensive encephalopathy, acute left ventricular failure, acute renal failure and papilledema, etc. Hypertensive encephalopathy is the most common one with the symptoms of persistent headache, nausea, vomiting, altered mental status, convulsion and coma. Some patients may be revealed as reversible posterior leukoencephalopathy. Among 16 patients involved in our study, 13 patients had encephalopathy with 4 cases of reversible posterior leukoencephalopathy, 4 patients had acute heart failure with 1 case of fundus exudation, and 2 case of acute renal failure. 2 patients died with 3 target organ dysfunctions, including encephalopathy, acute heart failure, and acute renal failure, which showed that multiple organ dysfunction may increase the mortality of HE, so earlier identification of target organ dysfunction to take steps is important. As to the key points of diagnosis of HE, one is the level of blood pressure and its elevation speed, the other is to identify target organ dysfunction earlier. Detailed medical history and complete physical examination are important. Additionally, serum electrolytes, complete blood counts, blood urea nitrogen, creatine, urinalysis, chest radiography, electrocardiogram, enchocardiography, brain MRI and fundoscopy may be needed in some situation. It is worth mentioning that 8 patients had hypokalemia, and hypokalemia is associated with the activation of RAS. It indicates the possibility that hypokalemia may be a predictive factor of HE. The treatment of HE is based on the differentiation of acute, chronic or acute attack on chronic hypertension. Once HE is confirmed, intravenous drugs should be emergently applied. It is suggested that the targeted drop of mean arterial pressure in the first 6∼8 hours should reach 25% of the difference between the original value and the target value, and should be followed by a gradual reduction to the target value within 24∼48 hours. Safe and efficacious drugs with rapid onset of action are favorable. According to our experience, sodium nitroprusside and phentolamine are the most useful and effective in our hospital. It's notable that lowering intracranial pressure is more important than decreasing blood pressure for those patients with a high intracranial pressure who are diagnosed as encephalopathy. However, rapidly decreasing blood pressure levels may result in decreasing blood flow of brain, causing ischemia and infarction. To patients with acute left heart failure, management including sedation, oxygen supplement, cardiotonics, diuresis, and vascular dilation should be necessary. Long-acting oral anti-hypertensive medications should be introduced in conscious child after the blood pressure has been reasonably controlled within 24-48 hours. According to our experience, these patients with HE should need more than 2 kinds of anti-hypertensive drugs. In summary, the key points of diagnosis and treatment of HE are earlier identification and effective therapy to control the development of acute target organ dysfunctions.
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- Frequency of hyponatraemia and hypokalaemia in malnourished children with acute diarrhoea. [Journal Article]
- JPJ Pak Med Assoc 2016; 66(9):1077-1080
- CONCLUSIONS: Electrolyte disturbances among malnourished children may not be clinically evident, but diarrhoeal illness aggravated these imbalances.