Clinical Communications: AdultsTetraparesis and Failure of Pacemaker Capture Induced by Severe Hyperkalemia: Case Report and Systematic Review of Available Literature
Introduction
Severe hyperkalemia is a well-known life-threatening event that can lead to fatal cardiac dysrhythmias or neurologic derangements, such as muscle weakness and paralysis. Paralysis related to high serum potassium levels may be a recurrent and predictable syndrome due to a genetic disease (familial periodic paralysis) or an isolated, acute, and often undiagnosed event; the latter condition is known as secondary hyperkalemic paralysis (SHP). In clinical practice, neurologic symptoms are rarely seen, perhaps because cardiac manifestations begin earlier and are more frequently thought of and managed. We report a case where a patient presented with the chief complaint of hyperkalemia-induced paralysis and subtle, though very serious, cardiac abnormalities. In addition, we present a systematic review of available literature, discussing this condition together with the cardiac and neurologic effects of hyperkalemia, as well as its pathogenesis and therapeutic options.
Section snippets
Case Report
A 75-year-old woman was sent to the emergency department by her general practitioner, who diagnosed “Transient ischemic attack. Drop attack. Patient unable to keep a standing position.” Her history revealed an acute myocardial infarction several years earlier, hypertension, sick sinus syndrome managed with a dual-chamber pacemaker (PMK), and mild chronic kidney disease. Her medications included acetylsalicylic acid (300 mg/d), benazepril (10 mg/d), amiloride/hydrochlorothiazide (5/50 mg/d),
Literature Review
We performed a systematic review of available medical literature on SHP using PubMed, Scopus, and EBSCO databases. After excluding all cases of familial periodic paralysis, we found 101 articles reporting cases of SHP. Two articles were not reviewed because they were written in Japanese and Polish 1, 2. Finally, we included 99 articles in our revision (the list is available as an online Supplementary Appendix). For one article (Teixeira, 2009; see Supplementary Appendix), the full text was not
Discussion
Although in the context of medical emergencies severe hyperkalemia is a rather common clinical condition, neurologic findings seem to occur much more rarely than cardiac symptoms, even if derived from similar pathophysiologic mechanisms. Based on Nernst equation, the ratio of extracellular to intracellular potassium concentration (Ke/Ki) determines the value of the resting membrane potential; when Ke increases, the difference in membrane potential decreases and, accordingly, the activation of
Why Should an Emergency Physician Be Aware of This?
SHP is a rare but potentially fatal clinical condition, the precise pathogenesis of which is unknown. High serum potassium levels may affect either muscle cell membrane or peripheral nerves. Even if mild chronic hyperkalemia can be an exception, high serum potassium levels should always be considered as a potentially life-threatening condition. The effects can be catastrophic, especially when the increase in serum potassium is acute, as a rapid increase may precipitate fatal dysrhythmias and
Acknowledgments
The authors thank Mrs. Daniela Fedele, Library of Medicine, University of Trieste, for her excellent support.
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