Salt-losing nephropathy associated with severe hypothyroidism.

Here, we present a case of an older man presenting with worsening confusion. Laboratory tests showed serum sodium of 120 mmol/L with severe hypothyroidism and renal salt wasting that improved with treatment of hypothyroidism, normalising the serum sodium.

Spontaneous tumour lysis secondary to gastric adenocarcinoma.

We present a case of a man in his 70s who presented with worsening rectal and back pain associated with weight loss, dyspnoea and brownish discolouration of urine. Physical examination noted abdominal distention and epigastric tenderness. Laboratory investigations revealed acute kidney injury, hyperkalaemia, hyperphosphataemia and hyperuricaemia. Contrast CT of the abdomen/pelvis showed multiple, low-density masses throughout the liver, suspicious for metastatic disease. Oesophagogastroduodenoscopy demonstrated a large, fungating, infiltrative and ulcerated mass in the gastric body and lesser curvature of the stomach. Surgical pathology confirmed invasive moderately differentiated gastric adenocarcinoma. He met both the laboratory and clinical criteria for spontaneous tumour lysis syndrome (STLS) as per the Cairo-Bishop criteria. He was managed with aggressive fluid hydration, rasburicase and allopurinol, resulting in improvement in his renal function and laboratory findings. STLS of solid organ tumours, especially gastric adenocarcinoma, is rare and requires early detection with timely management to ensure favourable outcomes.

Recurrent severe hypernatraemia in a young patient: a disconnect between osmoreceptor function and drinking behaviour.

Chronic hypernatraemia is a rare clinical entity. In the younger population, hypernatraemia is often a consequence of failure to generate thirst in response to osmotic stimuli.We report the case of a male patient admitted with severe hypernatraemia (plasma sodium 175 mmol/L) on return from holidays. His urine was maximally concentrated at 894 mOsm/kg-suggestive of normal vasopressin reserve. MRI of the brain showed a large extra-axial cyst, with preservation of the posterior pituitary bright spot. Formal osmoregulatory studies demonstrated normal osmoregulated vasopressin secretion and normal thirst, but no appropriate drinking behaviour.This patient illustrates a unique pathophysiological disconnect between thirst appreciation and the central drive to drink, in the context of normal osmoregulatory function. It is likely that this disconnect is related to the patient's large intracranial cyst.The management challenge is to maintain appropriate fluid intake in order to prevent recurrent severe hypernatraemia.

Analgesia to acidosis: metabolic acidosis due to chronic acetaminophen (paracetamol) use.

This case describes a rare occurrence of high anion gap metabolic acidosis due to chronic acetaminophen (paracetamol) usage, which can be confirmed by measuring 5-oxoproline (pyroglutamate), an organic acid metabolite. As acetaminophen is an extremely common drug prescribed in both inpatient and outpatient settings, a high degree of clinical suspicion is required to isolate it as the aetiology for metabolic acidosis. Management includes discontinuation of acetaminophen use and at times the supplementation of oral bicarbonate. Metabolic acidosis due to a high anion gap is commonly described by the mnemonic 'MUDPILES' in daily practice. A newer mnemonic, 'GOLD MARK' is proposed to be a more inclusive tool to assist in determining the cause of high anion gap metabolic acidosis, especially with such cases being reported.

Unusual presentation of Wilson's disease as proximal renal tubular acidosis with isolated phosphaturia.

An adolescent girl presented with recurrent lower limb fractures and was managed as osteogenesis imperfecta. Low phosphate levels noted on routine investigation were the clue for the phosphaturia and subsequent diagnosis of proximal renal tubular acidosis (RTA). Further, with a history of jaundice, she was diagnosed with Wilson's disease, which was the underlying cause of proximal RTA with isolated phosphaturia and consequent fractures. Standard treatment for Wilson's disease along with supplementation of oral phosphate and bicarbonate led to complete recovery of fragile bones.

Salt-losing nephropathy associated with supraventricular arrhythmia.

We present a case of a young man with a new-onset supraventricular arrhythmia accompanied by polyuria and natriuresis with subsequent renal salt-wasting causing hypovolemic hyponatremia. Resolution of the electrolyte imbalance occurred only after successful atrial flutter ablation.

Bartter syndrome-like phenotype in a patient with type 2 diabetes mellitus.

Bartter syndrome (BS) is a rare genetic tubulopathy affecting the loop of Henle leading to salt wasting. It is commonly seen in utero or in the early neonatal period. Rare cases of acquired BS are reported in association with infections like tuberculosis, granulomatous conditions like sarcoidosis, autoimmune diseases and drugs. The mainstay of management includes potassium, calcium and magnesium supplementation. We report the case of a woman in her 50s with a history of type 2 diabetes mellitus for the last 10 years, who presented with diabetic foot ulcers and generalised weakness with ECG changes suggestive of hypokalaemia. She had severe hypokalaemia with high urine potassium excretion and hypochloraemic metabolic alkalosis. She poorly responded to intravenously administered potassium supplements and had persistent hypokalaemia. On further evaluation of the persistent hypokalaemia, a diagnosis of idiopathic Bartter-like phenotype was made. She responded well to tablet indomethacin and is presently asymptomatic and is being maintained on tablet indomethacin after 6 months of follow-up.

Rehabilitation after Hypoxic and Metabolic Brain Injury in a Mountain Climber.

A patient in her 50s presented with altered mental status and shortness of breath at 4600 m elevation. After descent to the base of the mountain, the patient became comatose. She was found to have bilateral pulmonary infiltrates and a serum sodium of 102 mEq/L. She was rapidly corrected to 131 mEq/L in 1 day. Initial MRI showed intensities in bilateral hippocampi, temporal cortex and insula. A repeat MRI 17 days post injury showed worsened intensities in the bilateral occipital lobes. On admission to acute rehabilitation, the patient presented with blindness, agitation, hallucinations and an inability to follow commands. Midway through her rehabilitation course, antioxidant supplementations were started with significant improvement in function. Rapid correction of hyponatraemia may cause central pontine myelinolysis or extrapontine myelinolysis (EPM). In some cases of hypoxic brain injury, delayed post-hypoxic leucoencephalopathy (DPHL) may occur. Treatment options for both disorders are generally supportive. This report represents the only documented interdisciplinary approach to treatment of a patient with DPHL and EPM. Antioxidant supplementation may be beneficial as a treatment option for both EPM and DPHL.

Polymyxin B-induced Bartter syndrome.

Bartter syndrome is a genetic disorder characterised by chloride-unresponsive metabolic alkalosis, hypokalaemia, hypomagnesaemia and hypercalciuria. While it commonly presents antenatally or in early infancy, sometimes, drugs can induce a state similar to Bartter syndrome in any age group, called acquired Bartter syndrome. Polymyxins and aminoglycosides are the most commonly implicated drugs. Polymyxin B and polymyxin E (popularly known as colistin) are the two chemically similar polymyxins that are commonly used clinically. While colistin is frequently associated with nephrotoxicity, polymyxin B is generally considered less nephrotoxic. This difference is due to the way these two drugs are handled by the kidneys. In this case report, we discuss a middle-aged male who developed Bartter syndrome due to polymyxin B, which resolved on discontinuation of the drug, and re-appeared after its re-introduction later. This case exemplifies the nephrotoxicity caused by polymyxin B and the need for vigilance when using this drug.

Familial renal glycosuria identified in an Indian family.

Glycosuria can be isolated or it can be associated with other tubulopathies like proximal renal tubular acidosis, Fanconi syndrome and endocrine conditions like diabetes mellitus. The SLC5A2 gene codes for the SGLT2 transporter, which is responsible for glucose reabsorption in the proximal tubule. Previously reported cases show that mutation in this gene is associated with intellectual disability, seizure disorder and renin and angiotensin system dysfunction. In his early childhood, a male child displayed persistently high urine glucose levels. We ruled out diabetes mellitus and other tubulopathies before diagnosing the child with familial renal glycosuria, with a novel mutation in the SLC5A2 gene, and screened family members for the same condition. Child's father was found to have isolated renal glycosuria and tested positive for mutation in the SLC5A2 gene.

Total colectomy for poorly controlled hypokalaemia due to Gitelman syndrome.

Gitelman syndrome (GS) is an autosomal recessive tubulopathy caused by dysfunction of the thiazide-sensitive sodium-chloride cotransporter, which leads to hypokalaemia, metabolic alkalosis, hypomagnesaemia and hypocalciuria. Patients with GS show varied clinical features due to hypokalaemia: tetany, muscle weakness, periodical paralysis and constipation, which is one of the most frequent ones. This paper presents the case of a woman in her 40s referred to our endocrinology department for severe hypokalaemia. After biochemical and genetic analyses, a diagnosis of GS was established. Concurrently, the patient suffered from refractory constipation due to hypokalaemia and underwent a total colectomy with ileorectal anastomosis, which cured both disorders without any medication for 3 years.

HNF1B variant without hyperglycaemia as a cause of isolated profound hypomagnesaemia.

A young man presented unconscious with severe hyponatraemia, hypokalaemia, hypomagnesaemia and metabolic alkalosis. After 4 months of treatment in hospital, the hypomagnesaemia persisted. The patient had no signs of diabetes mellitus, and radiology showed no abnormalities of the kidneys, pancreas or genitourinary tract. A parenteral magnesium load demonstrated renal wasting with increased fractional urinary excretion of magnesium. Genetic tests for Gitelman as well as Bartter syndromes were negative. However, a wider genetic panel revealed that the patient was heterozygous for a deletion on chromosome band 17q12, encompassing the whole HNF1B gene.This case highlights the importance of considering pathogenic HNF1B variants in isolated profound hypomagnesaemia caused by renal wasting. Pathogenic HNF1B variants may partly mimic hypomagnesaemia found in Gitelman and Bartter syndromes and may be present without other features linked to HNF1B variants, including diabetes mellitus.

Severe hypocalcaemia episodes in a patient of primary hypoparathyroidism precipitated by underlying stress due to haemophagocytic lymphohistiocytosis (HLH) secondary to pulmonary tuberculosis.

A man in his 20s who had previously experienced multiple episodes of transient loss of consciousness, majorly attributable to the seizures, presented with a 1-month history of increased seizure frequency, high-grade fever and weight loss. Clinically, he had postural instability, bradykinesia and symmetrical cogwheel rigidity. His investigations revealed hypocalcaemia, hyperphosphataemia, inappropriately normal intact parathyroid hormone, metabolic alkalosis, normomagnesemic magnesium depletion, and increased plasma renin activity and serum aldosterone concentration. CT scan of the brain revealed symmetrical calcification of the basal ganglia. The patient had primary hypoparathyroidism (HP). A similar presentation of his brother indicated a genetic cause, most likely autosomal dominant hypocalcaemia with Bartter's syndrome type 5. The patient's fever was caused by underlying haemophagocytic lymphohistiocytosis secondary to pulmonary tuberculosis, which triggered acute episodes of hypocalcaemia. This case represents a complex interplay of a multifaceted relationship between primary HP, vitamin D deficiency and an acute stressor.

Surviving cardiac arrest from severe metformin-associated lactic acidosis using extracorporeal membrane oxygenation and double continuous venovenous haemodialysis.

Metformin-associated lactic acidosis (MALA) is a serious condition with high mortality. This case describes a man in the mid-60s with diabetes mellitus type 2 treated with metformin developing MALA 4 days after coronary stenting for non-ST-elevation myocardial infarction. He presented acutely with severe abdominal pain, a lactate of 19 mmol/L and pH 6.74. Despite treatment for MALA, he went into refractory cardiac arrest and was connected to venoarterial extracorporeal membrane oxygenation (VA-ECMO). He suffered a massive haemothorax due to perforation of the right atrial appendage. It was repaired through a sternotomy while being given massive blood transfusions. The following days, he was on VA-ECMO and double continuous venovenous haemodialysis (CVVHD). He survived with only mild paresis of the left hand. VA-ECMO should be considered a rescue therapy alongside treatment with CVVHD in case of cardiac arrest due to severe MALA.

Severe lactic acidosis during tenofovir disoproxil fumarate and cobicistat combination for HIV patient.

Lactic acidosis is a rare but serious side effect in individuals receiving nucleoside reverse transcriptase inhibitors. An underweight woman with HIV was admitted to our hospital because of nausea and diffuse myalgia. Her antiretroviral regimen had been changed to tenofovir disoproxil fumarate (TDF)/emtricitabine and darunavir/cobicistat 3 months prior, after which her renal function had gradually declined. After admission, she was diagnosed with lactic acidosis, and a liver biopsy suggested mitochondrial damage. Her plasma tenofovir levels were elevated at the onset of lactic acidosis. We hypothesise that the patient's low body weight, combined with the addition of cobicistat, induced renal dysfunction and led to elevated plasma tenofovir concentrations, resulting in mitochondrial damage and lactic acidosis. Careful monitoring of renal function and lactic acidosis is required during use of TDF-containing regimens for underweight HIV patients, particularly when combined with cobicistat.

Extreme alkalaemia with mixed alkalosis due to suspected acute-on-chronic respiratory alkalosis.

Herein we present a case of severe alkalaemia (pH 7.81) due to suspected acute-on-chronic respiratory alkalosis in a patient with chronic anxiety and metabolic alkalosis secondary to emesis. The patient was managed in the intensive care unit with significant improvement and discharged in stable condition. The case report emphasises considering a broad differential of aetiologies that can cause acid-base status derangements and identifying the appropriate therapeutic approach.

Diabetic ketoacidosis in a patient known with Gitelman syndrome.

Gitelman syndrome is a rare hereditary nephropathy, which causes chronic metabolic alkalosis with low potassium and magnesium levels. There is no known coherence between Gitelman syndrome and Type-1 diabetes but patients with both diseases that develop diabetic ketoacidosis might present with normal acid status and receive incorrect treatment. In our case report the patient was known with both diseases and quickly diagnosed and treated but the condition is rare and previously only described in two other case reports.

Third-degree atrioventricular block associated with severe acute hyponatraemia.

Severe acute hyponatraemia, defined as a sodium concentration of less than 120 mEq/L, typically manifests with neurological manifestations, resulting in obtundation, coma, seizures, respiratory arrest and death. It very rarely is arrhythmogenic, with a literature review revealing seven cases of hyponatraemia-associated atrioventricular (AV) block of various degrees, of which only three were described as having third-degree AV block. The higher-degree AV blocks typically occurred at sodium levels closer to 115 mEq/L. We present a case of severe acute hypo-osmolar hyponatraemia-induced third-degree AV block in a patient without any other risk factors or aetiologies who initially presented with subdural haematoma and developed refractory bradycardia during his admission. The patient's third-degree AV block completely resolved after correction of his sodium. This case highlights the importance of working up the cause of new-onset third-degree AV block and the consideration of rarer electrolyte derangements such as hyponatraemia as a potential cause.

Zonisamide-induced distal renal tubular acidosis and critical hypokalaemia.

A woman in her 20s presented with rapidly progressive muscle weakness and a 1-month preceding history of fatigability, nausea and vomiting. She was found to have critical hypokalaemia (K+ 1.8 mmol/L), a prolonged corrected QT interval (581 ms) and a normal anion gap metabolic acidosis (pH 7.15) due to zonisamide-induced distal (type 1) renal tubular acidosis. She was admitted to the intensive care unit for potassium replacement and alkali therapy. Clinical and biochemical improvement ensued, and she was discharged after a 27-day inpatient stay.

Use of Venous Excess UltraSound (VExUS) score in hyponatraemia management in critically ill patient.

Hyponatraemia is the most prevalent electrolyte disorder in the neurocritical care setting and is associated with a significant morbimortality. Cerebral salt wasting and inappropriate antidiuretic hormone secretion syndrome have been classically described as the two most frequent entities responsible for hyponatraemia in neurocritical care patients. An accurate aetiological diagnosis of hypotonic hyponatraemia requires a proper volume status assessment. Nevertheless, determination of volume status based on physical examination, laboratory findings and imaging modalities have several limitations and can lead to improperly diagnosis and hyponatraemia mismanagement. Point-of-care ultrasound (POCUS), specifically Venous Excess UltraSound (VExUS) score, is a fast and valuable tool to evaluate venous congestion at the bedside and identify hypervolaemia, helping the physicians in therapeutic decision making in a patient with hyponatraemia. We report a case where the use of POCUS, and more specifically VExUS, can be helpful in volume status assessment, complementing the complex management of multifactorial hyponatraemia in a neurocritical patient.