Fingertip numbness and appetite loss followed 5 weeks later. Her initial symptoms comprised lower extremity weakness that developed 6 weeks before admission. Our patient had renal dysfunction and had been prescribed with angiotensin-II receptor blockers, RAS inhibitors, and β-blockers for years. 1 Because RAS inhibitors suppress angiotensin-II and aldosterone secretion, consequently inhibited potassium excretion leads to hyperkalemia. 3, 4 Risk factors associated with hyperkalemia comprise renal dysfunction, diabetes, and medication with RAS inhibitors. However, hyperkalemia has been typically diagnosed from a few to several days from the onset of symptoms. This experience raised two important clinical issues.Įlderly patients with renal dysfunction who are under treatment with RAS inhibitors for hypertension might develop slowly progressive symptoms associated with hyperkalemia over several weeks. Antihypertensive drugs were replaced with a calcium antagonist. Abdominal CT and upper/lower gastrointestinal endoscopy revealed no significant findings. Her symptoms of lower extremity weakness, fingertip numbness and appetite loss disappeared. By hospital day 4, her serum potassium improved to 4.5 mEq/L, ECG findings showed a normal sinus rhythm and an improved tented T wave (Figure 1B). Her general condition gradually improved. Furthermore, sodium bicarbonate, calcium gluconate and glucose-insulin therapy was added.
We considered that chronic kidney disease (CKD) and medication with telmisartan, spironolactone, and metoprolol tartrate had caused the hyperkalemia. B, Electrocardiography findings on hospital day 4 show normal sinus rhythm and improved T wave Laboratory findings show serum potassium 9.2 mEq/L. A, Electrocardiography upon admission shows bradycardia (heart rate 37 bpm), decreased P-wave amplitude, and tented T wave in limb and chest leads. Five months before admission, her serum creatinine was 1.5 mg/dL and eGFR was 26.2 mL/min/1.73 m 2.Įlectrocardiography and laboratory findings. Laboratory findings revealed serum sodium 134 mEq/L, potassium 9.2 mEq/L, chloride 113 mEq/L, blood urea nitrogen 45 mg/dL, creatinine 2.2 mg/dL, and eGFR 17.7 mL/min/1.73 m 2. Electrocardiography (ECG) in the emergency room revealed bradycardia, with a heart rate of 37 beats/min, decreased P-wave amplitude, normal QRS width and a tall, tented T wave in limb and chest leads (Figure 1A). She was conscious, with a temperature of 35.7☌ heart rate, 37 beats/min, and blood pressure, 185/54 mm Hg. Aspirin 81 mg/d, telmisartan 40 mg/d, spironolactone 25 mg/d, allopurinol 100 mg/d, metoprolol tartrate 60 mg/d, and pravastatin sodium 10 mg/d were prescribed. The patient had been diagnosed with hypertension, hyperuricemia, and dyslipidemia. Five weeks later, she developed fingertip numbness followed by appetite loss 3 days before admission. She had a 6-week history of lower extremity weakness and had presented at an orthopedic clinic, where cervical and lumbar MRI findings were unremarkable. 2 CASEĪ 77-year-old woman walked into the emergency department with an episode of syncope and vomiting. We describe a patient who presented with slowly progressive symptoms and atypical electrocardiographic (ECG) findings. 1, 2 However, a diagnosis can be complicated when patients present with atypical clinical symptoms. Factors associated with hyperkalemia include advanced age, decreased renal function, diabetes, and renin-angiotensin system (RAS) inhibitors. Hyperkalemia is a life-threatening condition that requires immediate treatment in an emergency situation.
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