Persistent hyperkalemia in an otherwise healthy 4-month-old female: Questions
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CLINICAL QUIZ
Persistent hyperkalemia in an otherwise healthy 4-month-old female: Questions Grace Yu 1 & Faris Hashim 2 & Colleen Macmurdo 3 & Christian Hanna 4 Received: 3 April 2020 / Accepted: 6 April 2020 # IPNA 2020
Case summary A 4-month-old former term female infant born to a 36year-old healthy mother was admitted to the hospital for evaluation and management of right neck abscess and cellulitis. Outpatient treatment, including an incision and drainage done in clinic the day prior and two doses of oral antibiotics, resulted in no improvement. Past medical and surgical history was unremarkable. Family history was significant for an unspecified seizure and movement disorder in her older sister. She had appropriate growth for her age, with weight, length, and head circumference all measuring around the 20th percentile. Vitals were unremarkable on presentation and she remained normotensive during her stay at the hospital. Exam was within normal limits, aside from erythema and induration consistent with her abscess. Initial blood chemistry panel showed an alarmingly high potassium level of 8.4 mEq/L with slight hemolysis The answers to these questions can be found at https://doi.org/10.1007/ s00467-020-04575-7. * Grace Yu [email protected] 1
Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White McLane Children’s Medical Center, Temple, TX, USA
2
Division of Pediatric Nephrology, Baylor Scott & White McLane Children’s Medical Center, Temple, TX, USA
3
Division of Medical Genetics, Department of Internal Medicine, Baylor Scott &White Medical Center, Temple, TX, USA
4
Division of Pediatric Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
(normal for age is 4.1–5.3) with repeat of 7.3 without hemolysis. She had a low bicarbonate level of 10 mEq/L (normal for age is 19–24), high chloride level of 116 mEq/L (normal for age is 97–108), and elevated creatinine of 0.56 mg/dL (normal for age is 0.2–0.4). Anion gap was normal at 10 mEq/L. No electrocardiogram changes were noted. She was promptly transferred to the pediatric intensive care unit for care of her abscess and these incidental findings of hyperkalemia and non-gap metabolic acidosis. Intravenous calcium gluconate, sodium acetate, and Kayexalate (sodium polystyrene sulfonate) were given for hyperkalemia. The following morning, her potassium normalized to 5.8 mEq/L and then further to 4.7 mEq/L. Her bicarbonate level improved to 20 mEq/L, and her serum creatinine improved to 0.19 mg/ dL. Renal ultrasound revealed no abnormalities. After transfer to the general pediatrics floor, she again developed hyperkalemia of 7.5 mEq/L and nongap metabolic acidosis. A subsequent dose of Kayexalate was given. Additional lab work revealed urine potassium of 15 mEq/L, urine sodium of 90 mEq/L, and urine chloride of 65 mEq/L, resulting in a positive urine anion gap of 40 mEq/L. She had a normal serum aldosterone level of 22 ng/l (normal for age is 6–89) but low renin activity of 0.2 ng/ml/h (normal for age is 2–37). Renal tubular aci
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