TB with hypokalemia, hyponatremia, metabolic alkalosis?

[CaptKirk]

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Just curious if anyone has any thoughts... we diagnosed a patient with TB this week. Patient presented malnourished; temporal wasting, somewhat distended abdomen, albumin of 2.3. Can't remember everything but I can say liver enzymes were not elevated. Hyponatremia (129), hypokalemia (2.9), elevated bicarb (33)... ABG ordered today to see what the pH actually is but we're presuming a metabolic alkalosis. We ran with SIADH, and the patient became slightly hypervolemic but improved after fluid restriction. I think it's kind of an unusual constellation; don't normally see hypokalemia in SIADH... so now wondering if there is adrenal insufficiency on top of SIADH? Just wondering if anyone else has some insights. If you've got questions ask and I'll try to say what I can without HIPAA violations.

 

[SBlanc]

Personally i wouldn't overanalyze these electrolyte disturbances much... Patients who come in all malnourished and wasted can have all sorts of problems with their lytes that are generally multi-factorial. (Make sure the Mg is nl b/c hypomag can cause hypoK).

If you need this for a discussion, just go through the causes of hypokalemia and say what goes for or against each cause in this particular pt.

Adrenal insufficiency can easily be r/o with a nl cortisol.

 

[OmahaMX80]

Cool case.

 

[fang]

Just curious if anyone has any thoughts... we diagnosed a patient with TB this week. Patient presented malnourished; temporal wasting, somewhat distended abdomen, albumin of 2.3. Can't remember everything but I can say liver enzymes were not elevated. Hyponatremia (129), hypokalemia (2.9), elevated bicarb (33)... ABG ordered today to see what the pH actually is but we're presuming a metabolic alkalosis. We ran with SIADH, and the patient became slightly hypervolemic but improved after fluid restriction. I think it's kind of an unusual constellation; don't normally see hypokalemia in SIADH... so now wondering if there is adrenal insufficiency on top of SIADH? Just wondering if anyone else has some insights. If you've got questions ask and I'll try to say what I can without HIPAA violations.

Adrenal insufficiency would cause hyponatremia, hyPERkalemia, and metablic ACIDosis, so that's not it.

Vomiting could explain hypokalema and met alk, and slight hyponatriemia if he were drinking a lot of water. Malnutrition and SIADH from stress would also explain it-- extremely low K from malabsorbtion leading to met alk. Is refeeding syndrome a possibility? What's the phos?

Let us know if you find anything else!