scholarly journals Pseudohyperkalaemia in essential thrombocytosis: an important clinical reminder

2021 ◽  
Vol 2021 ◽  
Author(s):  
Jean Marc Mizzi ◽  
Christopher Rizzo ◽  
Stephen Fava
Keyword(s):  
Venous Blood ◽  
Elevated Serum ◽  
Plasma Potassium ◽  
List Type ◽  
Limb Weakness ◽  
Clinical Reminder ◽  
Bilateral Lower Limb ◽  
Venous Blood Gas ◽  
Learning Points ◽  
Rule Out

Summary An 82-year-old female was admitted to a general hospital due to progressive bilateral lower limb weakness. A T8–T9 extramedullary meningioma was diagnosed by MRI, and the patient was referred for excision of the tumour. During the patient’s admission, she was noted to have persistent hyperkalaemia which was refractory to treatment. Following a review by an endocrinology team, a diagnosis of pseudohyperkalaemia secondary to thrombocytosis was made. This case demonstrates the importance of promptly identifying patients who are susceptible to pseudohyperkalaemia, in order to prevent its potentially serious consequences. Learning points Pseudohyperkalaemia should be considered in patients with unexplained or asymptomatic hyperkalaemia. It should also be considered in those patients who are resistant to the classical treatment of hyperkalaemia. A diagnosis of pseudohyperkalaemia is considered when there is a difference of >0.4 mmol/L of potassium between serum and plasma potassium in the absence of symptoms and ECG changes. In patients who are presenting with consistently elevated serum potassium levels, it may be beneficial to take venous blood gas and/ or plasma potassium levels to rule out pseudohyperkalaemia. Pseudohyperkalaemia may subject patients to iatrogenic hypokalaemia which can be potentially fatal. Pseudohyperkalaemia can occur secondary to thrombocytosis, red cell haemolysis due to improper blood letting techniques, leukaemia and lymphoma.

scholarly journals Concurrent Guillain-Barré syndrome and myositis complicating dengue fever

2020 ◽  
Vol 13 (2) ◽  
pp. e232940 ◽  
Author(s):  
Manisha Gulia ◽  
Preeti Dalal ◽  
Monica Gupta ◽  
Daljinderjit Kaur
Keyword(s):  
Creatine Kinase ◽  
Dengue Fever ◽  
Elevated Serum ◽  
Guillain Barre Syndrome ◽  
Uneventful Recovery ◽  
Motor Neuropathy ◽  
Limb Weakness ◽  
Guillain Barré Syndrome ◽  
Bilateral Lower Limb ◽  
Guillain Barré

Dengue is an arboviral infection that classically presents with fever, headache, joint pain, skin flush and morbilliform rashes. Neurological manifestations are well recognised but their exact incidence is unknown. Though myalgias are common in dengue virus infection, myositis and/or elevated serum creatine kinase is an uncommon complication. Guillain-Barré syndrome is another rare neurological manifestation associated with dengue fever. Here, we report the case of a 21-year-old man with serologically confirmed dengue fever presenting with severe myalgia, bilateral lower and upper limb weakness with raised creatine kinase, MRI suggestive of myositis and myonecrosis and nerve conduction velocity showing bilateral lower limb and axillary sensory motor neuropathy. He was managed conservatively and made an uneventful recovery.

scholarly journals Acute milk-alkali syndrome

2018 ◽  
Vol 2018 ◽  
Author(s):  
Bidhya Timilsina ◽  
Niranjan Tachamo ◽  
Prem Raj Parajuli ◽  
Ilan Gabriely
Keyword(s):  
Renal Failure ◽  
Metabolic Alkalosis ◽  
List Type ◽  
Over The Counter ◽  
Excess Calcium ◽  
Severe Hypercalcemia ◽  
History Of ◽  
High Index Of Suspicion ◽  
Learning Points ◽  
Rule Out

Summary A 74-year-old woman presented with progressive lethargy, confusion, poor appetite and abdominal pain. She was found to have non-PTH-mediated severe hypercalcemia with renal failure and metabolic alkalosis. Extensive workup for hypercalcemia to rule out alternate etiology was unrevealing. Upon further questioning, she was taking excess calcium carbonate (Tums) for her worsening heartburn. She was diagnosed with milk-alkali syndrome (MAS). Her hypercalcemia and alkalosis recovered completely with aggressive hydration along with improvement in her renal function. High index of suspicion should be maintained and history of drug and supplements, especially calcium ingestion, should be routinely asked in patients presenting with hypercalcemia to timely diagnose MAS and prevent unnecessary tests and treatments. Learning points: Suspect milk-alkali syndrome in patients with hypercalcemia, metabolic alkalosis and renal failure, especially in context of ingestion of excess calcium-containing supplements. Careful history of over-the-counter medications, supplements and diet is crucial to diagnose milk-alkali syndrome. Milk-alkali syndrome may cause severe hypercalcemia in up to 25–30% of cases.

Child with acute weakness: don’t forget the salts

2020 ◽  
pp. edpract-2019-318286
Author(s):  
Kathryn Boyle ◽  
Ben McNaughten ◽  
Andrew Thompson ◽  
Stephen Mullen
Keyword(s):  
Qt Interval ◽  
Venous Blood ◽  
Vital Signs ◽  
Conversion Disorder ◽  
Periodic Paralysis ◽  
Term Treatment ◽  
List Type ◽  
Blood Gas ◽  
Long Term Treatment ◽  
Venous Blood Gas

Case summaryA 10-year-old boy presented with severe progressive generalised weakness on a background of 3 days of diarrhoea and vomiting. Vital signs were normal. Peripheral neurological examination revealed grade 1–2 power in all limbs, hypotonia and hyporeflexia. Sensation was fully intact. Cranial nerve examination and speech were normal. The ECG (figure 1) and initial venous blood gas (figure 2) are shown.Figure 1ECG.Figure 2Venous blood gas.Question 1What abnormalities are present on the ECG?Peaked T waves, prolonged PR segment and loss of P waves?Shortening of the QT interval and Osborn waves (J waves)?T wave flattening/inversion, prominent U waves and long QU interval?Prolonged QT interval with multiple atrial and ventricular ectopics?Question 2How would you manage this patient’s hypokalaemia?Question 3What is the likely diagnosis?Conversion disorder.Myasthenia gravis.Periodic paralysis.Guillain-Barré syndrome.Botulism.Question 4What interventions can be considered for long-term treatment of this condition?Answers can be found on page 2.

scholarly journals Exophthalmos and multinodular goitre, an unusual combination

2019 ◽  
Vol 2019 ◽  
Author(s):  
Kingsley Okolie ◽  
Daniel Chen ◽  
Raf Ghabrial ◽  
Robert Schmidli
Keyword(s):  
Thyroid Stimulating Hormone ◽  
Eye Disease ◽  
List Type ◽  
Multinodular Goitre ◽  
Diagnostic Dilemma ◽  
Graves Orbitopathy ◽  
Eye Symptoms ◽  
Possible Cause ◽  
Learning Points ◽  
Rule Out

Summary Multinodular goitre is not associated with eye disease, unless in a rare case of Marine–Lenhart syndrome where it coexists with Grave’s disease. Therefore, other causes of exophthalmos need to be ruled out when the eye disease is seen in a patient with multinodular goitre. Confusion can arise in patients with features suggestive of Graves’ ophthalmopathy in the absence of thyroid-stimulating hormone receptor autoantibodies and no evidence of other causes of exophthalmos. We present a case of multinodular goitre in a patient with exophthalmos which flared up after iodine contrast-based study. A 61-year-old Australian presented with a pre-syncopal attack and was diagnosed with toxic multinodular goitre. At the same time of investigations, to diagnose the possible cause of the pre-syncopal attack, computerised tomographic (CT) coronary artery angiogram was requested by a cardiologist. A few days after the iodine contrast-based imaging test was performed, he developed severe eye symptoms, with signs suggestive of Graves’ orbitopathy. MRI of the orbit revealed features of the disease. Although he had pre-existing eye symptoms, they were not classical of thyroid eye disease. He eventually had orbital decompressive surgery. This case poses a diagnostic dilemma of a possible Graves’ orbitopathy in a patient with multinodular goitre. Learning points: Graves’ orbitopathy can occur in a patient with normal autothyroid antibodies. The absence of the thyroid antibodies does not rule out the disease in all cases. Graves’ orbitopathy can coexist with multinodular goitre. Iodine-based compounds, in any form, can trigger severe symptoms, on the background of Graves’ eye disease.

scholarly journals Reverse pseudohyperkalemia in a newly diagnosed pediatric patient with acute T-cell leukemia and hyperleukocytosis: a case report and literature review

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Muneera Alabdulqader ◽  
Hanaa Al Alawyat ◽  
Mohammed F. Kasem ◽  
Abdelfattah Ibrahim ◽  
Abdelwahab Omara
Keyword(s):  
Case Report ◽  
Potassium Level ◽  
Medical Condition ◽  
Incidental Finding ◽  
Venous Blood ◽  
Elevated Serum ◽  
Clinical Manifestations ◽  
Plasma Potassium ◽  
Newly Diagnosed ◽  
Blood Potassium

Abstract Background Hyperkalemia is a serious medical condition that requires immediate intervention. However, pseudohyperkalemia and reverse pseudohyperkalemia are misleading clinical manifestations that can result in incorrect diagnosis and consequent harmful intervention. Case presentation An 11-year-old girl manifested an incidental finding of hyperleukocytosis (WBC > 400 × 109/L), with 90% blast cells during routine pre-operative investigations for adenotonsillectomy. Initial investigations demonstrated elevated serum potassium levels (7.5 mmol/L), despite concomitantly normal levels in venous blood gas samples (3.9–4.4 mmol/L) and being clinically stable with normal 12-lead ECG. Surprisingly, plasma potassium level was exacerbated, in comparison to the serum level by > 1 mmol/L. This finding is consistent with reverse pseudohyperkalemia that is associated with hyperleukocytosis in acute leukemia that does not require any active intervention. Conclusion This case report emphasizes the significance of interpreting potassium levels accurately, preferably utilizing whole-blood potassium level over serum and plasma level in newly diagnosed leukemia cases with hyperleukocytosis. Additionally, having a high index for the possibility of reverse pseudohyperkalemia, secondary to leakage from fragile leukocytes, avoids unnecessary treatment that might cause harm to the patient.

scholarly journals Use of plasma metanephrine to aid adrenal venous sampling in combined aldosterone and cortisol over-secretion

2015 ◽  
Vol 2015 ◽  
Author(s):  
Rémi Goupil ◽  
Martin Wolley ◽  
Jacobus Ungerer ◽  
Brett McWhinney ◽  
Kuniaki Mukai ◽  
...  
Keyword(s):  
Venous Blood ◽  
Adrenal Venous Sampling ◽  
Pathological Examination ◽  
List Type ◽  
Venous Sampling ◽  
Contralateral Suppression ◽  
Aldosterone Production ◽  
Cortisol Levels ◽  
Dexamethasone Suppression ◽  
Learning Points

Summary In patients with primary aldosteronism (PA) undergoing adrenal venous sampling (AVS), cortisol levels are measured to assess lateralization of aldosterone overproduction. Concomitant adrenal autonomous cortisol and aldosterone secretion therefore have the potential to confound AVS results. We describe a case where metanephrine was measured during AVS to successfully circumvent this problem. A 55-year-old hypertensive male had raised plasma aldosterone/renin ratios and PA confirmed by fludrocortisone suppression testing. Failure of plasma cortisol to suppress overnight following dexamethasone and persistently suppressed corticotrophin were consistent with adrenal hypercortisolism. On AVS, comparison of adrenal and peripheral A/F ratios (left 5.7 vs peripheral 1.0; right 1.7 vs peripheral 1.1) suggested bilateral aldosterone production, with the left gland dominant but without contralateral suppression. However, using aldosterone/metanephrine ratios (left 9.7 vs peripheral 2.4; right 1.3 vs peripheral 2.5), aldosterone production lateralized to the left with good contralateral suppression. The patient underwent left laparoscopic adrenalectomy with peri-operative glucocorticoid supplementation to prevent adrenal insufficiency. Pathological examination revealed adrenal cortical adenomas producing both cortisol and aldosterone within a background of aldosterone-producing cell clusters. Hypertension improved and cured of PA and hypercortisolism were confirmed by negative post-operative fludrocortisone suppression and overnight 1 mg dexamethasone suppression testing. Routine dexamethasone suppression testing in patients with PA permits detection of concurrent hypercortisolism which can confound AVS results and cause unilateral PA to be misdiagnosed as bilateral with patients thereby denied potentially curative surgical treatment. In such patients, measurement of plasma metanephrine during AVS may overcome this issue. Learning points Simultaneous autonomous overproduction of cortisol and aldosterone is increasingly recognised although still apparently uncommon. Because cortisol levels are used during AVS to correct for differences in dilution of adrenal with non-adrenal venous blood when assessing for lateralisation, unilateral cortisol overproduction with contralateral suppression could confound the interpretation of AVS results Measuring plasma metanephrine during AVS to calculate lateralisation ratios may circumvent this problem.

scholarly journals Role of MRI evaluation in acute secondary inability to walk in children

2021 ◽  
Vol 52 (1) ◽  
Author(s):  
K. H. Sedeek ◽  
K. Aboualfotouh ◽  
S. M. Hassanein ◽  
N. M. Osman ◽  
M. H. Shalaby
Keyword(s):  
Transverse Myelitis ◽  
High Sensitivity ◽  
Acute Disseminated Encephalomyelitis ◽  
Limb Weakness ◽  
Non Invasive ◽  
Highly Sensitive ◽  
Common Causes ◽  
Bilateral Lower Limb ◽  
Severity Of The Disease

Abstract Background Acute bilateral lower limb weakness is a common problem in children which necessitates a rapid method for diagnosis. MRI is a non-invasive imaging technique that produces high-quality images of the internal structure of the brain and spinal cord. Results MRI was very helpful in reaching rapid and prompt diagnosis in children with acute inability to walk. Acute disseminated encephalomyelitis (ADEM), Guillain–Barré syndrome (GBS), and acute transverse myelitis (ATM) were the most common causes in our study. MRI proved to be of high sensitivity in detecting the lesions and reaching the diagnosis in ADEM and GBS; however, there was no significant relation between the lesions’ size, enhancement pattern, and severity of the disease or prognosis, yet in ATM the site of the lesion and number of cord segment affection were significantly related to the severity of the disease and prognosis. Conclusion MRI is a quick tool to reach the diagnosis of children with acute secondary inability to walk, and to eliminate other differential diagnosis which is essential for proper treatment and rapid full recovery. It is highly sensitive in detecting the lesions, their site and size.

scholarly journals Surgical management outcome of cerebral schistosomiasis: a case report and review of the literature

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Moayad Moawia ZainElabdin Ahmed ◽  
Haytham Hussein Mohammed Osman ◽  
Alaa Hatim Ameer Mohamed ◽  
Alaaeldin Ginawi
Keyword(s):  
Surgical Resection ◽  
Clinical Laboratory ◽  
Parasitic Infection ◽  
Differential Diagnoses ◽  
Limb Weakness ◽  
General Test ◽  
Bilateral Lower Limb ◽  
Laboratory Investigations ◽  
The Right ◽  
Antiparasitic Agents

Abstract Background Schistosomiasis is a parasitic infection that commonly affects the gastrointestinal and genitourinary tracts. Cerebral schistosomiasis is rare, and few operative cases have been reported in the literature. Diagnosis is usually challenging due to the similarity of the lesion to many other brain conditions. Treatment usually requires surgical resection combined with the use of antiparasitic agents, which often results in good outcomes and excellent prognosis. Case presentation A 24-year-old, previously healthy Afro-asiatic man presented to our neurosurgical outpatient clinic complaining of headache and an attack of convulsions. On examination, he had bilateral lower limb weakness more on the right side. Laboratory investigations including stool and urine general test results were unremarkable. Magnetic resonance imaging of the brain was performed and showed an intra-axial left parietal mass; a granulomatous lesion was suggested in the differential diagnoses. The patient underwent craniotomy and total resection of the lesion. Histopathology confirmed the presence of active cerebral Schistosoma mansoni infection. Orally administered praziquantel was initiated at a dose of 20 mg/kg twice a day for a total of 3 days along with oral administration of corticosteroids for 2 weeks. The patient improved postoperatively without residual weakness and with no further convulsions. Conclusion Cerebral schistosomiasis is a rare but important consideration in the list of differential diagnoses of cerebral space-occupying lesions. This is of particular importance in in endemic areas like Sudan. In order to reach a diagnosis, careful social and occupational history need to be obtained and correlated with the clinical, laboratory, and radiological findings. Surgical resection along with the use of proper antiparasitic agents usually provides the best clinical outcomes.

Reference intervals for venous blood gas measurement in adults

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Kirsty L. Ress ◽  
Gus Koerbin ◽  
Ling Li ◽  
Douglas Chesher ◽  
Phillip Bwititi ◽  
...  
Keyword(s):  
Partial Pressure ◽  
Meta Analysis ◽  
Venous Blood ◽  
Reference Interval ◽  
Reference Intervals ◽  
Published Data ◽  
Blood Gas ◽  
Arterial Blood Gas ◽  
Arterial Blood ◽  
Venous Blood Gas

AbstractObjectivesVenous blood gas (VBG) analysis is becoming a popular alternative to arterial blood gas (ABG) analysis due to reduced risk of complications at phlebotomy and ease of draw. In lack of published data, this study aimed to establish reference intervals (RI) for correct interpretation of VBG results.MethodsOne hundred and 51 adult volunteers (101 females, 50 males 18–70 y), were enrolled after completion of a health questionnaire. Venous blood was drawn into safePICO syringes and analysed on ABL827 blood gas analyser (Radiometer Pacific Pty. Ltd.). A non-parametric approach was used to directly establish the VBG RI which was compared to a calculated VBG RI based on a meta-analysis of differences between ABG and VBGResultsAfter exclusions, 134 results were used to derive VBG RI: pH 7.30–7.43, partial pressure of carbon dioxide (pCO2) 38–58 mmHg, partial pressure of oxygen (pO2) 19–65 mmHg, bicarbonate (HCO3−) 22–30 mmol/L, sodium 135–143 mmol/L, potassium 3.6–4.5 mmol/L, chloride 101–110 mmol/L, ionised calcium 1.14–1.29 mmol/L, lactate 0.4–2.2 mmol/L, base excess (BE) −1.9–4.5 mmol/L, saturated oxygen (sO2) 23–93%, carboxyhaemoglobin 0.4–1.4% and methaemoglobin 0.3–0.9%. The meta-analysis revealed differences between ABG and VBG for pH, HCO3−, pCO2 and pO2 of 0.032, −1.0 mmol/L, −4.2 and 39.9 mmHg, respectively. Using this data along with established ABG RI, calculated VBG RI of pH 7.32–7.42, HCO3− 23 – 27 mmol/L, pCO2 36–49 mmHg (Female), pCO2 39–52 mmHg (Male) and pO2 43–68 mmHg were formulated and compared to the VBG RI of this study.ConclusionsAn adult reference interval has been established to assist interpretation of VBG results.

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