Introduction: We present 3 cases of the same severe electrolyte imbalance presenting with acute neurological symptoms.
Case descriptions: Case A, a 48 year old lady with severe CREST syndrome presented with prolonged vomiting and diarrhoea. Initial investigations showed: Sodium 141 mmol/l, Potassium 3.2 mmol/l, Creatinine 53 mmol/l, Glucose 4.3 mmol/l, Haemoglobin 13.9 g/dl, Albumin 38 g/l. 2 days after admission she developed seizures. Case B, a 75 year old residential home resident with Addisons disease who was admitted with an infection-precipitated Addisonian crisis, with increasing frailty during her 3 week in-patient stay, became acutely confused, drowsy and developed a seizure with temporary respiratory arrest. Baseline investigations: Sodium 143 mmol/l, Potassium 3.2 mmol/l, Creatinine 124 mmol/l, Glucose 5.3 mmol/l, Haemoglobin 11 g/dl, Albumin 30 g/l. Case C, a 42 year old man with hypoparathyroidism and poor adherence to alpha-calcidol was admitted with several self-limiting seizures. Baseline investigations: Sodium 140 mmol/l, Potassium 3.3 mmol/l, Creatinine 110 mmol/l, Glucose 4.8 mmol/l.
All 3 cases were found to have low calcium and magnesium levels.
Case A: 1.4 mmol/l and 0.2 mmol/l, Case B: 1.63 mmol/l and 0.28 mmol/l, Case C: 1.5 mmol/l and 0.25 mmol/l, respectively.
Discussion: Interestingly, the baseline blood tests were virtually normal, apart from the slightly low potassium. Despite these reassuringly normal baseline tests, the history of prolonged vomiting and diarrhoea (A) and prolonged poor nutrition (B) could have prompted an earlier full electrolyte screen. The history of poor adherence to medication (C) allowed prompt diagnosis of the hypocalcaemia and hypomagnesaemia.
Conclusion: These cases demonstrate the need to consider metabolic causes in acute neurological disturbances. They emphasise that patients with prolonged hospital stays with poor oral intake and patients with a prolonged history of possible decreased gastro-intestinal absorption and excess gut losses, as in severe diarrhoea, warrant a full electrolyte screen, including calcium and magnesium.
01 - 05 Apr 2006
European Society of Endocrinology