Transient Bartter-like syndrome in a child with extensively drug-resistant tuberculosis: Answers
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CLINICAL QUIZ
Transient Bartter-like syndrome in a child with extensively drug-resistant tuberculosis: Answers Vishrutha Sujith Poojari 1 & Ira Shah 1 & Naman S. Shetty 1 & Akanksha Jaiswal 1 Received: 17 September 2020 / Revised: 18 September 2020 / Accepted: 5 October 2020 # IPNA 2020
Keywords Child . XDR TB . Electrolyte imbalance . Mixed hearing loss . Bartter-like syndrome . Aminoglycoside nephrotoxicity . Capreomycin
Answers 1. What is the most likely diagnosis for this patient? Capreomycin-induced transient Bartter-like syndrome with mixed hearing loss. 2. What are the most common findings in the suspected condition? The most common manifestation of Barrter-like syndrome with aminoglycoside use is non-oliguric acute kidney injury due to exclusive renal excretion of aminoglycosides. Investigations show deranged electrolytes which include persistent hypokalemia, hypomagnesemia, hypocalcemia, hypercalcuria, metabolic alkalosis-associated hypophosphatemia without kidney insufficiency. 3. What is the management strategy for this patient? Management of drug-induced acquired Bartter’slike syndrome condition is to withhold the offending agent and correct electrolyte imbalance. In our patient, capreomycin was stopped. She was given intravenous potassium correction in maintenance fluids (at 3 mEq/kg/day) for 1 day followed by oral
This refers to the article that can be found at https://doi.org/10.1007/ s00467-020-04813-y. * Vishrutha Sujith Poojari [email protected] Akanksha Jaiswal [email protected] 1
Department of Pediatrics, B J Wadia Hospital for Children, Parel, Mumbai 400012, India
potassium supplementation, parenteral magnesium replacement (intramuscular magnesium sulphate at 50 mg/kg/day for 3 days), phosphorus (orally at 30 mg/kg/day), and calcium correction orally at 60 mg/kg/day. She was started on salvage antituberculous therapy regimen consisting of meropenem with amoxicillin-clavulanic acid, clofazimine, ethionamide, high-dose moxifloxacin, and linezolid. Oral potassium, magnesium, and phosphorus replacement therapy was continued for around 6 weeks. Following the correction of dyselectrolytemia, delamanid was added in the regimen with regular electrocardiograph monitoring. Her prostaglandin E2 and parathormone levels could not be measured. She is on regular follow-up and is symptomatically better.
Discussion In the current era of increasing multidrug-resistant tuberculosis, its management in children includes aminoglycosides with other second-line agents depending on the drug sensitivity test pattern. The adverse effects associated with aminoglycosides of are nephrotoxicity, ototoxicity, and less often neuromuscular toxicity [1], are mainly associated with prolonged duration of treatment [2]. The tubular injury manifests as decreased reabsorption of filtered proteins, electrolytes, glucose, phospholipiduria, and cast excretion [3]. Renal tubular dysfunction causing electrolyte imbalance must be anticipated in multidrug-resistant tuberculosis patients who are on long-term aminoglyc
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