Lowest potassium I've ever seen

[Sessamoid]

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I just had a lady with a potassium of 1.4. Interesting set of labs, which is pretty much all I had to go on since she came in with a variety of nonspecfic complaints (rlq abd pain, chest pain +/- pleuritic, "sick", etc.).

Elderly thin female. Only interesting physical finding was a fairly large pulsatile mid-abdominal mass.

Temp 98.0
Pulse 78
Resp 18
BP 113/78
O2 sat 98% RA

Na 136, K 1.4, CL 89, HCO3 40, BUN 15, Cr 1.7, Glu 108
WBC 8.4, Hgb 10.3, Hct 30.7, Plt 484
Tbili 0.4, AST 324, ALT 154, AlkPhos 66, Lip 146
CK 6601, MB 10.1, Trop 0.95
ABG pH 7.61, pO2 77, pCO2 34.5, HCO3 34, BE 11.9
CXR nothing acute
EKG suggestive of posterior MI (ST dep V1-V2 with large R waves)
PT/PTT normal

Any guesses as to etiology? Family later provided the crucial piece of history which brought it all together.

 

[DrQuinn]

adrenal insufficiency or leukemia.

Time to head to Biloxi to try my hand at craps. Hopefully when I get back Monday we'll have an answer. wheeeeeeeeeeeee.

 

[Sessamoid]

adrenal insufficiency or leukemia.

Adrenal insufficiency (Addisonian Crisis) would give you hyponatremia and hyPERkalemia.

Leukemia?

Time to head to Biloxi to try my hand at craps. Hopefully when I get back Monday we'll have an answer. wheeeeeeeeeeeee.

Best of luck!

 

[Seaglass]

Persistent vomicking and RTA.

 

[Sessamoid]

Persistent vomicking and RTA.

No vomiting at all by history. Renal tubular acidosis is a good thought but her pH as stated above was 7.61.

edit: nobody should feel bad if you don't figure it out. I was scratching my head until the patient's adult daughter gave me the one piece of information that lit the lightbulb over my head. What's more important is the thought process here.

 

[southerndoc]

Does she have some sort of primary endocrine abnormality (Conn's, pheo), or is this a secondary process?

What meds does she take?

 

[DrQuinn]

Adrenal insufficiency (Addisonian Crisis) would give you hyponatremia and hyPERkalemia.

Leukemia?


Best of luck!

oops, hah! that's what i get for drinking last night!
Q

 

[Sessamoid]

Does she have some sort of primary endocrine abnormality (Conn's, pheo), or is this a secondary process?

What meds does she take?

Norvasc, Diovan, Lipitor, Lotensin, were the meds she told us on arrival. No history of primary endocrine disorders. Curiously, overdoses/adverse effects of those medications would be normally associated with hyPERkalemia, typically.

 

[spyderdoc]

Norvasc, Diovan, Lipitor, Lotensin, were the meds she told us on arrival. No history of primary endocrine disorders. Curiously, overdoses/adverse effects of those medications would be normally associated with hyPERkalemia, typically.

I'm guessing contraction alkalosis...super dehydrated, probably from a diuretic since her K is so low. Bumped LFT's and slight rhabdo probably from Lipitor...

 

[Sessamoid]

I'm guessing contraction alkalosis...super dehydrated, probably from a diuretic since her K is so low. Bumped LFT's and slight rhabdo probably from Lipitor...

Oops, left out the vital signs. (Bad attending!)

Temp 98.0
Pulse 78
Resp 18
BP 113/78
O2 sat 98% RA

So not so terribly volume contracted as to be hypotensive nor tachycardic.

I'll let this run for a while before I give away the answer. It's bed time for me now anyway.

 

[fuegorama]

Mere second month of MSII here, but does this lady have a taste for garden soil? Especially those dirts with a high clay content...pica w/geophagia?

And just so this first zebra doesn't get lonely, has anybody else in her family been diagnosed with something similar e.g. Liddle's Syndrome?
F

 

[NateatUC]

My money's on loop diuretic overuse. Looks like a hypokalemic, hypochloremic metabolic alkalosis to me.

 

[dr.smurf]

i totally agree with the above.... too much lasix causing K wasting and a met alk. i would ck the urine for lytes and watch her in the ICU like a hawk..with a K like that she is very proarrythmic, but you cant correct the K too fast or that will be a disaster too. interesting case...let us know what you find out and DX.

 

[Sessamoid]

The pica suggestion is a good idea, and if this were a theoretical case could reasonably be the cause of the patient's problems. Loop diuretics similarly are a reasonable thought, although the patient's volume status wasn't really bad.

The actual story which I got from a family member is that the patient has what sounds like a rectal prolapse which comes on when she has solid stools. To the patient, the obvious solution was to make sure she doesn't have any solid stools. She's had this problem for about three years, the same period of time that she's been taking significant dosages of Senokot on a daily basis. Senokot (or senna) is a stimulative laxative which is known to cause gastrointestinal potassium loss in chronic use.

Diagnosis: Severe hypokalemia secondary to laxative abuse

The bumped hepatic enzymes and CPK could possibly be from the Lipitor, but along the principles explaining the whole syndrome with a single root cause, I'm more likely to ascribe it to diffuse myopathy from her hypokalemia. The electrolyte imbalance may have proven a bit too much for her heart to handle, thus the EKG suggestive of posterior MI. The changes on the EKG may just have been secondary to hypokalemia as well. On first glance the EKG didn't have any obvious U waves, but in the retrospectoscope the T waves looked a bit broader than normal which may represent U waves blending into the T waves.

I'm a bit surprised nobody suggested familial hypokalemic periodic paralysis (though she wasn't exactly paralyzed, just generally weak).

 

[roja]

ohhhhhhhhhhh, darn.. missed this one... I should have typed up a guess before reading the thread.


I would have said, merely based on low potassium NKHO in a diabetic but the glucose is normal (had a patient with a K of 1.1 which explained why he couldn't MOVE!) 😀 interesting...

puts laxatives in the garbage... 😉

 

[nachoDoc]

Diagnosis: Severe hypokalemia secondary to laxative abuse
.

nice case and dx!!!!
👍 👍

 

[southerndoc]

Like I said, what meds is she on?

 

[Sessamoid]

Like I said, what meds is she on?

?? I already replied to this question, didn't I? I didn't have the other information at first either, and it would have spoiled the fun giving away the punch line at the beginning.

 

[kungfufishing]

strangely enough, I just saw a Familial hypokalemic peroidic paralysis and it came to mind, but the lady wasnt paralyzed. I had forgotten it even existed until this 26 year old guy came in with severe generalized weakness and a K of 2. jumped out of bed after potassium replacement. weird!

 

[roja]

Like I said, what meds is she on?

silly! its not a medicine if you buy it over the counter! 😀

 

[Seaglass]

familial hypokalemic periodic paralysis

Man, that was right on the tip of my tounge. Go figure.

 

[Sessamoid]

silly! its not a medicine if you buy it over the counter! 😀

No kidding. I've found the most amazing things that people take that don't fall into "current medications". Chronic ASA and NSAID use often isn't mentioned. Herbal meds are usually not mentioned, including some fairly troublesome things (e.g. ma huang).