Hypernatremia with hypokalemia
| HOSP # | MRN86510387 | WARD | Internal medicine |
| CONSULTANT | Dr Jody Rusch | DOB/AGE | 35 year female |
Abnormal Result
Hypernatremia (sodium = 161 mmol/L)
Persistent Hypokalemia (potassium 1.9 mmol/L)
Presenting Complaint
Acute on chronic gastroenteritis
History
- 35 year old female. Known HIV positive on ARV with weight loss. GIT symptoms. To exclude villous atrophy/parasitic infestation.
- This is an HIV positive patient (CD4: 40 cells/uL; viral load: 54 869 copies/mL (4.74 log copies/ml))
- The patient has had a CD4 < 150 since 2018.
- HIV Viral load has never been suppressed <1000 copies / ml.
- There are concerns of ARV compliance
Examination
Not available
Laboratory Investigations
Two days earlier:
| Test | Result |
| Sodium mmol/L | 145 |
| Potassium mmol/L | 2.0 L |
| Chloride mmol/L | 124 H |
| Urea mmol/L | 7.9 H |
| Creatinine umol/L | 246 H |
Other Investigations
Histological examination requested after colonoscopy: Mild erythema of caecum. To exclude TB/CMVPatient has undergone a colonoscopy as well as an enteroscopy and mild erythema of the caecum was seen.
The terminal ileum showed: intestinal metaplasia with preserved villous architecture. There is no evidence of active inflammation, ulceration or increased intraepithelial lymphocytes seen. There is no evidence of ova, viral inclusions, granulomas or parasites, and no evidence of dysplasia or malignancy present, hence no pathologic diagnosis.
The caecum biopsy, which was macroscopically erythematous, showed fragments of colonic mucosa with areas of crypt branching and focal gland associated neutrophils.
Final Diagnosis
Mild chronic active colitis.
Take Home Message
This patient, who has laboratory findings of AIDS, likely has a combination of aetiologies accounting for the deranged electrolytes. The acquired immune deficiency likely is complicated by repeated infections with accompanying inflammation of the colonic mucosa – this seems to have been ongoing for months already.
This may well likely have been causing dehydration which recently have caused acute kidney injury, with creatinine rising from a baseline of 86, three weeks prior, to ~250 umol/L.
Some simple bedside laboratory tests may be helpful in aetiological evaluation. In cases where diarrhea has persisted for more than two weeks, testing the stool for glucose and pH can be helpful in identifying those patients with severe villous atrophy. This can be done easily at the bedside with a urine dipstick if available. Glucose test tape, nitrazine paper, and Clinitest tablets also have been used. A stool glucose of greater than 2+ or a pH of less than 5.0 suggests substantial villous atrophy.