A 63 year old lady born in Ghana was referred by her general practitioner for assessment of secondary hyperparathyroidism. She had corrected calcium of 1.93 (N: 2.182.47 mmol/L), PTH72.2 (N: 1.16.9 pmol/L) and alkaline phosphates of 324 (30100 IU/L). Her GP described her to be very conscious about her weight and she virtually lived on fruits and vegetables. She has history of hyper tension and was on alpha-blocker. Examination revealed BMI of 29 Kg/m2 with blood pressure of 155/98 and a pulse of 120/min. Investigation also showed her serum potassium was 3.3 (N: 3.54.7 mmol/L), Chloride 97 (N: 98109 mmol/L), bicarbonate 34 (N: 2232 nmol/L), phosphate 0.72 (N: 0.751.5 mmol/L) and 25(OH) Vit D <17 nmol/L.
On further questioning she admitted to binge eating disorder, intermittent self induce vomiting regular use of furosmide 40160 mg/day and senna 26 tablets/day. Further investigation showed normal aldosterone renin ratio, celiac screen was negative and CT abdomen showed bilateral bulky adrenals.
This picture of hypokalaemic hypocholraemic metabolic alkalosis suggest pseudo-bartters syndrome secondary to diuretic and laxative abuse. It is almost exclusive in women Leeds to prolonged volume depletion and hypokalemia. This can cause hypertrophy of juxtaglomeruar apparatus and autonomous renin secretion and permanent tubular atrophy.