Non-Sustained Monomorphic Ventricular Tachycardia associated with Hypokalemia Due to Use of Fludrocortisone: Case Report and Review of the Literature
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Jul 4, 2023
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Abstract
Clinical Case: A 35-year-old patient with a history of infectious adrenalitis in outpatient management with fludrocortisone, who consulted the emergency department due to a clinical picture of 8 days given by left tinnitus associated with syncopal symptoms with relaxation of the sphincters, in whom severe hypokalemia is documented because his laboratory tests showed serum potassium of admission at 2.0 meq/L (normal 3.5-5.1 meq/L) with electrocardiographic changes such as ventricular extrasystoles and bursts of ventricular tachycardia requiring a stay in the recovery room and interdisciplinary management. His ventricular tachycardia was completely relieved after correction of hypokalemia. Conclusion: Early suspicion of hypokalemia associated with the use of potent mineralocorticoids in cases of infectious adrenalitis improves survival and prognosis in patients with this entity. Although not much literature has been found, references to an incidence of up to 30% have been found.
Keywords
Infectious adrenalitis; mineralocorticoids; suprarrenal insufficiency; hypokalemia; ventricular extrasystoles; ventricular tachycardia.Adrenalitis infecciosa; mineralocorticoides; insuficiencia suprarrenal; hipopotasemia; extrasístoles ventriculares; taquicardia ventricular
References
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15. Epstein M, Lifschitz MD. The unappreciated role of extrarenal and gut sensors in modulating renal potassium handling: implications for diagnosis of dyskalemias and interpreting clinical trials. KI Reports. 2016;1:43-56.
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18. Viera AJ, Wouk N. Potassium disorders: hypokalemia and hyperkalemia. Am Fam Physician. 2015 Sep 15;92(6):487-95.
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21. Liu P, Han D, Sun X, Tan H, Wang Z, Liu C, et al. Prevalence and risk factors of acquired long QT syndrome in hospitalized patients with chronic kidney disease. J Investig Med. 2019;67:289-94. https://doi.org/10.1136/jim-2018-000798
22. TeBay C, Hill AP, Windley MJ. Metabolic and electrolyte abnormalities as risk factors in drug-induced long QT syndrome. Biophys Rev. 2022 Jan 27;14(1):1-15. https://doi.org/10.1007/s12551-022-00929-7.
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24. Lim S. Approach to hypokalemia. Acta Med Indones. 2007 Jan-Mar;39(1):56-64.
25. Gomes LG, Madureira G, Mendonca BB, Bachega TA. Mineralocorticoid replacement during infancy for salt wasting congenita l adrenal hyperplasia due to 21- hydroxylase deficiency. Clinics (Sao Paulo). 2013;68(2):147-52.
26. Igarashi Y. [Synthetic mineralocorticoid, clinical application of fludrocortisone acetate (Florinef)]. Nihon Rinsho. 1994 Mar;52(3):779-86. Japanese.
27. Tejada Cifuentes F. Alteraciones del equilibrio del potasio: hipopotasemia. Rev Clín Med Fam [internet]. 2008 [citado 2023 abr 6];2(3):129-33. Available from: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1699-695X2008000100008&lng=es&tlng=es
28. Rogoff B, Pride YB. EKG rhythm. En: StatPearls [internet]. Treasure Island (FL): StatPearls Publishing; 2022. Disponible en: https://www.ncbi.nlm.nih.gov/books/NBK555952/
29. Helfant RH. Hypokalemia and arrhythmias. Am J Med. 1986 Apr 25;80(4A):13-22. https://doi.org/10.1016/0002-9343(86)90336-0
30. Colombo MG, Kirchberger I, Amann U, Dinser L, Meisinger C. Association of serum potassium concentration with mortality and ventricular arrhythmias in patients with acute myocardial infarction: a systematic review and meta-analysis. Eur J Prev Cardiol. 2018 Apr;25(6):576-95. https://doi.org/10.1177/2047487318759694
31. Acevedo Peña JR, Guerrero López F, Barreto Cuervo J, Cárdenas Muñoz Y, Correa Estupiñán E, Caballero I, et al. Recomendaciones para el uso seguro de potasio en adultos, prevención y tratamiento de la hipokaliemia. Rev Medica Sanitas [internet]. 2012;15(2):28-36. Disponible en: https://revistas.unisanitas.edu.co/index.php/RMS/article/download/413/329/721
32. DeCarolis DD, Kim GM, Rector TS, Ishani A. Comparative dose response using the intravenous versus enteral route of administration for potassium replenishment. Intensive Crit Care Nurs. 2016 Oct;36:17-23. https://doi.org/10.1016/j.iccn.2015.08.005
33. Hirsch TM, Braun D. Hypokalemia. JAAPA. 2021 Jan 1;34(1):50-51. https://doi.org/10.1097/01.JAA.0000723960.54308.e9
34. Sur M, Mohiuddin SS. Potassium. 2021 Dec 21. En: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Disponible en: https://www.ncbi.nlm.nih.gov/books/NBK539791/
2. Brown G. Fludrocortisone for heparin-induced hyperkalemia. Can J Hosp Pharm. 2011 Nov;64(6):463-4.
3. Blanco Santos A. Homeostasis del potasio. Nefrología [internet]. 2019;1(1):1-49. Disponible en: https://www.revistanefrologia.com/index.php?p=revista&tipo=pdf-simple&pii=X2659800019000460
4. Tinawi M. Hypokalemia: a practical approach to diagnosis and treatment. Arch Clin Biomed Res. 2020;4:48-66. https://doi.org/10.26502/acbr.50170088
5. Palmer BF, Clegg DJ. Physiology and pathophysiology of potassium homeostasis. Adv Physiol Educ. 2016 Dec;40(4):480-490. https://doi.org/10.1152/advan.00121.2016
6. Hall JE. Guyton y Hall: tratado de fisiología médica. 13.ª ed. Barcelona: Elsevier; 2016.
7. Corzo J. Transporte a través de membranas [internet]. 2005 may 20. Disponible en: https://bioquibi.webs.ull.es/temascompletos/transporte/Introtransporte.htm
8. Universidad de los Andes. Absorción de agua y electrolitos [internet]. 2002. Dispoible en: http://www.saber.ula.ve/bitstream/handle/123456789/32972/clase_11.pdf?sequence=4&isAllowed=y 36
9. Koppen BM, Staton BA. Regulation of potassium balance. Renal Physiol. 2018;7:115-30.
10. Sequera Ortiz P, Alcázar Arroyo R, Albalate Ramón M. Trastornos del potasio: hipopotasemia. Hiperpotasemia. Nefrología al Día [internet]. Disponible en: https://www.nefrologiaaldia.org/383
11. Wang X, Han D, Li G. Electrocardiographic manifestations in severe hypokalemia. J Int Med Res. 2020 Jan;48(1):300060518811058. https://doi.org/10.1177/0300060518811058.
12. Kim GH, Han JS. Therapeutic approach to hypokalemia. Nephron. 2002;92 Suppl 1:28-32. https://doi.org/10.1159/000065374
13. Castro D, Sharma S. Hypokalemia. En: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Disponible en: https://www.ncbi.nlm.nih.gov/books/NBK482465/
14. Palmer BF. Regulation of potassium homeostasis. Clin J Am Soc Nephrol. 2015;10:1050-60.
15. Epstein M, Lifschitz MD. The unappreciated role of extrarenal and gut sensors in modulating renal potassium handling: implications for diagnosis of dyskalemias and interpreting clinical trials. KI Reports. 2016;1:43-56.
16. Palmer BF, Clegg DJ. Physiology and pathophysiology of potassium homeostasis. Adv Physiol Educ. 2016;40:480-90.
17. Gumz ML, Rabinowitz L, Wingo CS. An integrated view of potassium homeostasis. N Engl J Med. 2015;373:60-72.
18. Viera AJ, Wouk N. Potassium disorders: hypokalemia and hyperkalemia. Am Fam Physician. 2015 Sep 15;92(6):487-95.
19. Elliott TL, Braun M. Electrolytes: potassium disorders. FP Essent. 2017 Aug;459:21- 28.
20. Tse G, Li KHC, Cheung CKY, Letsas KP, Bhardwaj A, Sawant AC, Liu T, Yan GX, Zhang H, Jeevaratnam K, Sayed N, Cheng SH, Wong WT. Arrhythmogenic Mechanisms in Hypokalaemia: Insights From Pre-clinical Models. Front Cardiovasc Med. 2021 Feb 3;8:620539. https://doi.org/10.3389/fcvm.2021.620539
21. Liu P, Han D, Sun X, Tan H, Wang Z, Liu C, et al. Prevalence and risk factors of acquired long QT syndrome in hospitalized patients with chronic kidney disease. J Investig Med. 2019;67:289-94. https://doi.org/10.1136/jim-2018-000798
22. TeBay C, Hill AP, Windley MJ. Metabolic and electrolyte abnormalities as risk factors in drug-induced long QT syndrome. Biophys Rev. 2022 Jan 27;14(1):1-15. https://doi.org/10.1007/s12551-022-00929-7.
23. Jha S. A case report on QTc Prolongation: understanding the medication risks and electrolyte imbalance. Cureus. 2022 Jan 19;14(1):e21421. https://doi.org/10.7759/cureus.21421
24. Lim S. Approach to hypokalemia. Acta Med Indones. 2007 Jan-Mar;39(1):56-64.
25. Gomes LG, Madureira G, Mendonca BB, Bachega TA. Mineralocorticoid replacement during infancy for salt wasting congenita l adrenal hyperplasia due to 21- hydroxylase deficiency. Clinics (Sao Paulo). 2013;68(2):147-52.
26. Igarashi Y. [Synthetic mineralocorticoid, clinical application of fludrocortisone acetate (Florinef)]. Nihon Rinsho. 1994 Mar;52(3):779-86. Japanese.
27. Tejada Cifuentes F. Alteraciones del equilibrio del potasio: hipopotasemia. Rev Clín Med Fam [internet]. 2008 [citado 2023 abr 6];2(3):129-33. Available from: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1699-695X2008000100008&lng=es&tlng=es
28. Rogoff B, Pride YB. EKG rhythm. En: StatPearls [internet]. Treasure Island (FL): StatPearls Publishing; 2022. Disponible en: https://www.ncbi.nlm.nih.gov/books/NBK555952/
29. Helfant RH. Hypokalemia and arrhythmias. Am J Med. 1986 Apr 25;80(4A):13-22. https://doi.org/10.1016/0002-9343(86)90336-0
30. Colombo MG, Kirchberger I, Amann U, Dinser L, Meisinger C. Association of serum potassium concentration with mortality and ventricular arrhythmias in patients with acute myocardial infarction: a systematic review and meta-analysis. Eur J Prev Cardiol. 2018 Apr;25(6):576-95. https://doi.org/10.1177/2047487318759694
31. Acevedo Peña JR, Guerrero López F, Barreto Cuervo J, Cárdenas Muñoz Y, Correa Estupiñán E, Caballero I, et al. Recomendaciones para el uso seguro de potasio en adultos, prevención y tratamiento de la hipokaliemia. Rev Medica Sanitas [internet]. 2012;15(2):28-36. Disponible en: https://revistas.unisanitas.edu.co/index.php/RMS/article/download/413/329/721
32. DeCarolis DD, Kim GM, Rector TS, Ishani A. Comparative dose response using the intravenous versus enteral route of administration for potassium replenishment. Intensive Crit Care Nurs. 2016 Oct;36:17-23. https://doi.org/10.1016/j.iccn.2015.08.005
33. Hirsch TM, Braun D. Hypokalemia. JAAPA. 2021 Jan 1;34(1):50-51. https://doi.org/10.1097/01.JAA.0000723960.54308.e9
34. Sur M, Mohiuddin SS. Potassium. 2021 Dec 21. En: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Disponible en: https://www.ncbi.nlm.nih.gov/books/NBK539791/
How to Cite
Zambrano Jiménez , R. A., & Niño Mahecha, F. E. (2023). Non-Sustained Monomorphic Ventricular Tachycardia associated with Hypokalemia Due to Use of Fludrocortisone:: Case Report and Review of the Literature. Universitas Medica, 64(2). https://doi.org/10.11144/Javeriana.umed64-2.tvmn
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