a case of bartter's syndrome
TRANSCRIPT
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Case of Case of HypokalemiaHypokalemia
Dr.K.VidhyaDr.K.VidhyaUnit VII, Dept of medicineUnit VII, Dept of medicine
Prof.Dr.P.VijayaragavanProf.Dr.P.Vijayaragavan
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venkatesh, venkatesh, 41 yr old male 41 yr old male , , Welder by occupationWelder by occupation
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……admitted withadmitted with
C/O Weakness of all 4 limbs for the C/O Weakness of all 4 limbs for the past 3 days…past 3 days…
Acute onset, initially felt as Acute onset, initially felt as limbs becoming heavy and then was limbs becoming heavy and then was unable to move his limbs : gets unable to move his limbs : gets severe pain when attempting to use severe pain when attempting to use the muscles the muscles
H/O inability to turn in bed H/O inability to turn in bed from side to side +from side to side +
H/O difficulty in lifting head H/O difficulty in lifting head from pillow +from pillow +
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Progressive nature (initially Progressive nature (initially pronounced in lower limb than upper limb)pronounced in lower limb than upper limb)
H/O severe pain in the muscles +H/O severe pain in the muscles +
No H/O Bladder / Bowel involvementNo H/O Bladder / Bowel involvement
No H/O Headache No H/O Headache
H/O vomiting + for 2 days H/O vomiting + for 2 days
No H/O Fever / Passage of loose stools No H/O Fever / Passage of loose stools
No H/O Cranial nerve defects / Sensory No H/O Cranial nerve defects / Sensory deficitsdeficits
No H/O Head trauma / Neck painNo H/O Head trauma / Neck pain
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No H/O similar illness in the past.No H/O similar illness in the past.
No H/O admissions in the pastNo H/O admissions in the past
No H/O DM / PT / BA / Seizure No H/O DM / PT / BA / Seizure disorder.disorder.
No H/O any drug intake in the No H/O any drug intake in the past.past.
Family historyFamily history
No H/O similar illness in the No H/O similar illness in the familyfamily
Past HistoryPast History
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Personal historyPersonal history
Born out of non consanguineous Born out of non consanguineous marriagemarriage
FTND : Antenatal & postnatal history FTND : Antenatal & postnatal history uneventfuluneventful
He is married : two children +He is married : two children +Non smokerNon smokerConsumes alcohol for the past 15 Consumes alcohol for the past 15
years on & offyears on & off
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General ExaminationGeneral Examination
ConsciousConsciousOrientedOrientedAfebrileAfebrileHydration fairHydration fairNo Pallor / Icterus / Cyanosis /Clubbing / No Pallor / Icterus / Cyanosis /Clubbing /
Dyspnoea Dyspnoea No GLA/thyroid swellingNo GLA/thyroid swellingHt : 158 cm Wt : 58 kgHt : 158 cm Wt : 58 kg
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PR : 76 / min : Regular : N volume : PR : 76 / min : Regular : N volume : N character : Peripheral pulses N character : Peripheral pulses equally felt equally felt
BP : 124/70 mm hgBP : 124/70 mm hg (Trosseau’s (Trosseau’s sign + )sign + )
RR : 14 / minRR : 14 / min
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Systemic ExaminationSystemic Examination
CENTRAL NERVOUS SYSTEMCENTRAL NERVOUS SYSTEM : :
HIGHER FUNCTIONS: NormalHIGHER FUNCTIONS: Normal CRANIAL NERVES: No deficitsCRANIAL NERVES: No deficits
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MOTOR SYSTEM:MOTOR SYSTEM:
RIGHTRIGHT LEFTLEFT
BULKBULK NormalNormal NormalNormal
TONETONE HypotonicHypotonic
(pain +)(pain +) HypotonicHypotonic
(pain +)(pain +)
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POWER POWER (UL)(UL)
1/51/5 1/51/5
POWER POWER (LL)(LL)
1/51/5 1/51/5
REFLEXESREFLEXES
AnkleAnkle AbsentAbsent Absent Absent
KneeKnee SluggishSluggish
SluggishSluggish
BicepsBiceps AbsentAbsent
AbsentAbsent
TricepsTriceps AbsentAbsent
AbsentAbsent
PlantarPlantar FlexorFlexor FlexorFlexor
AbdominalAbdominal PresentPresent PresentPresent
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SENSORY SYSTEM EXM : NormalSENSORY SYSTEM EXM : NormalCEREBELLUM : Not examinedCEREBELLUM : Not examinedSIGNS OF MENINGEAL IRRITATION : SIGNS OF MENINGEAL IRRITATION :
Absent AbsentSPINE & CRANIUM : NormalSPINE & CRANIUM : Normal
OTHER SYSTEMS : WNLOTHER SYSTEMS : WNL
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Problems
QuadriplegiaQuadriplegia Muscle crampsMuscle cramps Trousseau’ s sign + veTrousseau’ s sign + ve
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DiagnosisDiagnosis
Case of….Probably a Mixed electrolyte Case of….Probably a Mixed electrolyte imbalance…imbalance…
HYPOKALEMIA with HYPOCALCEMIAHYPOKALEMIA with HYPOCALCEMIA
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InvestigationInvestigation
CBC : (21/6/10)CBC : (21/6/10)
Hb 12.4 mg/dlHb 12.4 mg/dl
TC 7500 cells/mm^3TC 7500 cells/mm^3
DC P65 L32 E3DC P65 L32 E3
ESR 2/5ESR 2/5
Plt 1.2 lacs/mm^3Plt 1.2 lacs/mm^3
PCV 38%PCV 38%
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RBS - 60 mg/dlRBS - 60 mg/dlBlood urea - 26 mg/dlBlood urea - 26 mg/dlSr creatinine - 0.9 mg/dlSr creatinine - 0.9 mg/dlSr. ElectrolytesSr. Electrolytes
Na - 126Na - 126
Cl - 103Cl - 103
K - 2K - 2
HCO3 -24HCO3 -24
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Urine :Urine :
alb & sugar – nilalb & sugar – nil
deposits 1-2 pus cells/hpfdeposits 1-2 pus cells/hpf• CXR PA – NADCXR PA – NAD• ECGECG(21/6/2010) – (21/6/2010) – SR / ST SR / ST
sagging /T wave inversion sagging /T wave inversion /prominent U waves in chest /prominent U waves in chest leadsleads
• HIV - NegativeHIV - Negative• Sr calcium Sr calcium (22/6/2010)(22/6/2010) – 4 – 4• LFT : NLFT : N
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Treatment givenTreatment given
Correction of K +Correction of K +Correction of Ca ++Correction of Ca ++
… … Proceeded to detect the causeProceeded to detect the cause
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ABG ABG
ABGABG 24/6/201024/6/2010 29/6/201029/6/2010
PCO2PCO2 42.15mm hg42.15mm hg 41.82mm hg41.82mm hg
PHPH 7.477.47 7.497.49
K+K+ 1.81mmol/l1.81mmol/l 2.97mmol/l2.97mmol/l
HCO3HCO3 27.18mmol/l27.18mmol/l 26.76mmol/l26.76mmol/l
Metabolic alkalosisMetabolic alkalosis
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41 year old male , with no significant 41 year old male , with no significant past history , normotensive admitted past history , normotensive admitted with… with…
HypokalemiaHypokalemiaHypocalcemiaHypocalcemiaMetabolic alkalosis….Metabolic alkalosis….
? Gitelman’s syndrome? Gitelman’s syndrome
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Repeated electrolytesRepeated electrolytes
23/623/6 25/625/6 27/627/6 30/630/6
Sr K +Sr K + 2.92.9 3.13.1 2.82.8 3.23.2
Sr Ca +Sr Ca +++
44 6.16.1 6.56.5 88
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24 hr urine for24 hr urine for……
K+ - 38.3 meq (25 – 125)K+ - 38.3 meq (25 – 125)Cl- - 268.7 meq (110 – 250)Cl- - 268.7 meq (110 – 250)Ca++ - 542.5 meq (100 – 320)Ca++ - 542.5 meq (100 – 320)
Sr. MagnesiumSr. Magnesium – – 2.5 2.5 mg/dl mg/dl (1.7 – 2.55)(1.7 – 2.55)
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Nephrology Nephrology opinion(2/7/10)opinion(2/7/10)
Impression : Impression : Bartter’s syndromeBartter’s syndromeAdvice : X Ray KUBAdvice : X Ray KUB
USG AbdomenUSG Abdomen
To transfer the patient to nephrology To transfer the patient to nephrology ward…ward…
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X Ray KUB – no features of X Ray KUB – no features of nephrocalcinosisnephrocalcinosis
USG Abdomen – Normal studyUSG Abdomen – Normal studyRepeat ECG (5/7/2010) - WNLRepeat ECG (5/7/2010) - WNL
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Case of …Case of …
• Normal blood pressureNormal blood pressure• HypokalemiaHypokalemiaMetabolic AlkalosisMetabolic AlkalosisU K > 30 meq / dayU K > 30 meq / dayU Cl ^edU Cl ^edU Ca ^edU Ca ^edNormal Mg++ levelsNormal Mg++ levels … … with Hypocalcemiawith Hypocalcemia
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HYPOKALEMIAurine potassium >30 mEq/day
Metabolic alkalosis
Urine chloride<20 mEq/liter Urine chloride>20 mEq/liter
•Nasogastric suction•vomiting
Blood pressure
NORMOTENSIVE/ HYPOTENSIVEHYPERTENSIVE
•BARTTER’S SYNDROME•GITELMAN’S SYNDROME•AGGRESSIVE DIURETIC USE
Normal / low aldosterone•CUSHINGS•CAH•LIDDLE’S SYNDROME•APPARENT Mineralocorticoid excess
•HYPERALDOSTERONISM(1’and 2’)
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Final DiagnosisFinal Diagnosis
Bartter’s syndrome Bartter’s syndrome Probably Probably type Vtype V (d/t co (d/t co existing Hypocalcemia)existing Hypocalcemia)
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BARTTER’S SYNDROMEBARTTER’S SYNDROME
Autosomal recessiveAutosomal recessiveFn of thick ascending LOH affectedFn of thick ascending LOH affected Inactivating mutations of one of 4 Inactivating mutations of one of 4
genes encoding membrane proteins genes encoding membrane proteins (Types I to IV)(Types I to IV)
Gain of function mutation in Gain of function mutation in extracellular Ca ion sensing receptor extracellular Ca ion sensing receptor (CaSR)… variant of Bartter +ing with (CaSR)… variant of Bartter +ing with Hypocalcemia (AD inheritance)Hypocalcemia (AD inheritance)
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Bartter’s syndrome typesBartter’s syndrome types
Type IType I : mutation in the gene for Na : mutation in the gene for Na K 2Cl cotrasporter (NKCC2) + on the K 2Cl cotrasporter (NKCC2) + on the apical membrane of LOHapical membrane of LOH
Type IIType II : mutation in the gene for : mutation in the gene for ATP regulated K channel (ROMK)ATP regulated K channel (ROMK)
Type IIIType III : mutation in the basolateral : mutation in the basolateral voltage gated Cl channel (ClC – Kb)voltage gated Cl channel (ClC – Kb)
Type IVType IV : mutation in the BSND : mutation in the BSND protein (barttin) that activates beta protein (barttin) that activates beta subunit for ClC Kb and ClC Ka subunit for ClC Kb and ClC Ka
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Type VType V : Gain of function mutation in : Gain of function mutation in the CaSR gene … + with the CaSR gene … + with HypocalcemiaHypocalcemia
……. First four types are autosomal . First four types are autosomal recessive : type V is autosomal recessive : type V is autosomal dominantdominant
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Clinical featuresClinical features
Present in antenatal period Present in antenatal period or in neonates( III can + in early or in neonates( III can + in early
childhood)childhood)Antenatal …Antenatal … Polyhydramnios & Preterm labourPolyhydramnios & Preterm labourPostnatal …Postnatal … Polyuria , Polydipsia , FTT ,Growth Polyuria , Polydipsia , FTT ,Growth
retardation , Dehydration , retardation , Dehydration , Nephrocalcinosis (universal in I & II ; Nephrocalcinosis (universal in I & II ; only in 20% of III) , Muscle only in 20% of III) , Muscle weakness , Fatigueweakness , Fatigue
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Systemic features include fever, Systemic features include fever, vomiting, diarrhea +… vomiting, diarrhea +…
Probably all are d/t PG mediation Probably all are d/t PG mediation fever can be d/t dehydration fever can be d/t dehydration vomiting d/t hypokalemic paralytic ileus.vomiting d/t hypokalemic paralytic ileus.TYPE IV : Sensorineural deafness TYPE IV : Sensorineural deafness
specific detected as early as 1 month of specific detected as early as 1 month of age : also CRF progression in childhood age : also CRF progression in childhood is commonis common
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Biochemical abnormalitiesBiochemical abnormalities
Hypokalemic metabolic alkalosisHypokalemic metabolic alkalosisHyperrenninemic hyperaldosteronismHyperrenninemic hyperaldosteronismNormal blood pressureNormal blood pressure Inappropriate urine excretion of K +Inappropriate urine excretion of K + Inappropriate urine excretion of Cl –Inappropriate urine excretion of Cl –HypercalciuriaHypercalciuriaNormo magnesemiaNormo magnesemiaUrinary PG ^ed in majorityUrinary PG ^ed in majorityBlunted response to loop diureticsBlunted response to loop diuretics
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NephrocalcinosisNephrocalcinosis ++ ++ +-+- ++ ++ --
PolyhydramniosPolyhydramnios ++ ++ ++ ++ -- --
FTTFTT ++ ++ ++ ++ -- --
Growth RetardationGrowth Retardation ++ ++ ++ ++ -- --
PolyuriaPolyuria ++ ++ ++ ++ ++ --
PolydipsiaPolydipsia ++ ++ ++ ++ ++ --
Muscle cramps/painMuscle cramps/pain -- -- -- -- ++ +-+-
ChondrocalcinosisChondrocalcinosis -- -- -- -- -- +-+-
SN hearing lossSN hearing loss -- -- -- ++ -- --
HypocalcemiaHypocalcemia -- -- -- -- ++ --
FEATURESFEATURESB B II
B B IIII
B B IIIIII
B B IVIV
B B VV
GMGM
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Differential diagnosisDifferential diagnosis1.Gitelman’s syndrome1.Gitelman’s syndrome ( Differentiated by Hypocalciuria + : ( Differentiated by Hypocalciuria + :
Hypomagnesaemia +)Hypomagnesaemia +)
2.Vomiting 2.Vomiting (Differentiated by Urinary Cl < 20 (Differentiated by Urinary Cl < 20
meq/L)meq/L)
3.Abuse of loop diuretics3.Abuse of loop diuretics (H/O drug intake + or assaying the (H/O drug intake + or assaying the
expected drugs in urine) expected drugs in urine)
……. All are observed in older patients . All are observed in older patients
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TreatmentTreatment
Restore plasma K to about 3.5 Restore plasma K to about 3.5 mmol/l mmol/l
K+ supplementation / Spironolactone K+ supplementation / Spironolactone / Amiloride/ Amiloride
PG inhibitor like indomethacin 2 PG inhibitor like indomethacin 2 mg/day in divided doses …in infants mg/day in divided doses …in infants have reduced incidence of growth have reduced incidence of growth retardationretardation
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Few case reports of Few case reports of adult onset Bartter's adult onset Bartter's
syndromesyndrome
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American journal of medicine : vol American journal of medicine : vol 61: issue 1 :198561: issue 1 :1985
A patient with Bartter's syndrome in A patient with Bartter's syndrome in whom the disease was recognized at whom the disease was recognized at 52 years52 years of age has been described of age has been described in…. in….
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• Adult onset Bartter diagnosed at Adult onset Bartter diagnosed at the age ofthe age of 40 yrs40 yrs
Korean journal of medicine : vol 10 : Korean journal of medicine : vol 10 : number 4 :1995number 4 :1995
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Male who had not been Male who had not been diagnosed as Bartter syndrome diagnosed as Bartter syndrome type IV until type IV until 28 yr28 yr because of a because of a mild clinical manifestation. The mild clinical manifestation. The patient also had congenital patient also had congenital deafnessdeafness. . The Journal of Clinical Endocrinology &
Metabolism : Vol. 88 : Number 2 : 2003
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Deaf daughter of consanguineous Deaf daughter of consanguineous parents, who was referred for the parents, who was referred for the first time at the first time at the age of 20age of 20, because , because of refractory hypocalcaemia of refractory hypocalcaemia
Antenatal polyhydramnios +Antenatal polyhydramnios +Polydipsia and polyuria. The patient's Polydipsia and polyuria. The patient's
height and weight reached, height and weight reached, respectively, 165 cm and 70 kgrespectively, 165 cm and 70 kg
Oxford journal of medicine : vol 22 : Oxford journal of medicine : vol 22 :
number 1 : 2006number 1 : 2006
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ReferencesReferences
Harrison’s text book of internal Harrison’s text book of internal medicinemedicine
Oxford text book of nephrologyOxford text book of nephrologyBrenner & Rector’s text book of Brenner & Rector’s text book of
nephrologynephrology
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APPROACH TO APPROACH TO HYPOKALEMIAHYPOKALEMIA
HYPOKALEMIAHYPOKALEMIAHYPOKALEMIAHYPOKALEMIA
urine potassium < 25 mEq/dayurine potassium < 25 mEq/day urine potassium >30 mEq/dayurine potassium >30 mEq/day
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urine potassium < 25 mEq/day
Metabolic acidosis
Acid base status
Normal acid base
• Profound sweating• Prolonged decreased Intake• Vomiting, NG suction ,
remote diuretic use
Lower GI loss
Urinary conservation +Urinary conservation +
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urine potassium >30 mEq/day
Metabolic alkalosis Normal acid base Metabolic acidosis
Acid base status
•Post ATN/ post obstructive diuresis•Osmotic diuresis•Gentle diuretic use•Decreased magnesium ions•High dose penicillin•Polydipsia/ diabetes insipidus
•Type 1 RTA•Type 2 RTA•DKA•Amphotericin B•acetazolamide
Urinary conservationUrinary conservation - -