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Gitelman syndrome and goitrous hypothyroidism: case report A 16-year-old girl developed Gitelman syndrome during treatment with kanamycin, and goitrous hypothyroidism during treatment with ethionamide for multidrug resistant tuberculosis (MDR-TB). The girl presented with numbness and tingling sensations in the hand for 4 days, inability to hold neck for 1 day and progressive weakness of all four limbs for 7 days. Since two months, she had been receiving treatment for MDR-TB that comprised kanamycin, ethionamide [routes and dosages not stated], cycloserine, pyrazinamide, levofloxacin and ethambutol. At the current presentation, she was noted to have bradycardia. Systemic examination showed generalised hypotonia, a soft palpable goitre and right sided effusion. Investigations showed TSH of 84 mIU/L, metabolic alkalosis (pH 7.6, bicarbonate 35), hypomagnesaemia, hypocalcaemia and hypokalaemia. ECG revealed prolonged PR and QTc interval and U waves. She was treated with potassium chloride, magnesium sulphate and calcium gluconate. After 48 hours of intravenous replacement, the paralysis and carpopedal spasms improved. Subsequent investigations showed decrease in vitamin D levels and elevation in parathyroid hormone level. Vitamin D3 was therefore added on day 2. She had urinary chloride level of 83 meq/L with fractional excretion of magnesium of 13.9% and 24-hour urinary calcium creatinine ratio of 0.21. These clinical manifestations were attributed to kanamycin, and kanamycin was discontinued on day 3. Over the next 5 days, the girl improved, and intravenous replacements were switched to oral supplements. Additionally, she underwent thyroxine replacement for her hypothyroidism that was attributed to ethionamide. On day 8, kanamycin was re-initiated. On day 10, she was discharged in a haemodynamically stable condition. During follow-up at 1 and 2 months, her electrolytes were noted to be normal. She was on potassium, calcium and magnesium sulphate supplementation. Her TSH level was still 16 mIU/L, levothyroxine-sodium dose was increased. A Gitelman syndrome was strongly suspected [durations of treatments to reactions onsets not stated]. Author comment: "Drugs which can cause Gitelmans or Bartter like syndrome are aminoglycosides". "She also required thyroxine replacement for her hypothyroidism, which was attributed to ethionamide." Ravi C, et al. Treatment of Multi-drug Resistant Tuberculosis Causing Tubulopathy - Gitelman-like Syndrome. Indian Pediatrics 56: 976-977, No. 11, 15 Nov 2019. Available from: URL: http://doi.org/10.1007/s13312-019-1662-8 803443548 India

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Reactions 4 Jan 2020 No. 1785