Acute Type 2 Respiratory Failure From Hypokalemic Respiratory Muscle Paralysis Secondary To Distal (Type1) Renal Tubular Acidosisdue To Primary Sjogren’s Syndrome
Richmond R Gomes1*, Habiba Akhter2
1 Associate Professor, Medicine, Ad-din Women’s Medical College Hospital, Bangladesh.
2 Clinical Assistant, Medicine, Ad-din Women’s Medical College Hospital, Bangladesh.
*Corresponding Author
Dr. Richmond Ronald Gomes,
Associate Professor, Medicine, Ad-din Women’s Medical College Hospital, Bangladesh.
Tel: 8801819289499
E-mail: rrichi.dmc.k56@gmail.com
Received: October 27, 2022; Accepted: November 22, 2022; Published: November 24, 2022
Citation:Richmond R Gomes, Habiba Akhter. Acute Type 2 Respiratory Failure From Hypokalemic Respiratory Muscle Paralysis Secondary To Distal (Type1) Renal Tubular Acidosisdue To Primary Sjogren’s Syndrome. Int J Resp Dis Care Med. 2022;5(1):59-63.
Copyright: Richmond Ronald Gomes© 2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Tubulointerstitial nephritis (TIN) is the main renal involvement associated with primary Sjogren syndrome (pSS). TIN can manifest as distal renal tubular acidosis (RTA), nephrogenic diabetes insipidus, proximal tubular dysfunction, and others. Distal renal tubular acidosis (RTA) may develop in a large population of patients with Sjogren’s syndrome (SS), but most of the subjects are asymptomatic. We report a case of 37 year old woman who presented with acute quadriparesis with acute hypercapnic respiratory failure. She had history of recurrent episodes of limb weakness which was attributable to hypokalemia and initially labelled as hypokalemic periodic paralysis. Lateron she was found to have metabolic acidosis rather than alkalosis which pointed towards the diagnosisof renal tubular acidosis (RTA) in the absence of apparent gastrointestinal tract loss. Once the diagnosisof RTA was established, an attempt to search the aetiology revealed that she was having primarySjogren’s syndrome (pSS) though she did not have any symptom at the time of diagnosis. She wasfound positive for ANA, anti-SSA and anti-SSB. Schirmer test confirmed presence of dry eye. A concomitant existence ofautoimmune hypothyroidism was a noteworthy association. Continuous potassium replacementproduced rapid and complete recovery from quadriplegia and respiratoryfailure without requirement for mechanical ventilation.Presentation of this case reminds the importance of vigilancewhile managing a case of recurrent hypokalemia which might be a rare presenting feature of pSS.
2.Introduction
3.Methods
4.Discussion
5.Conclusion
6.Acknowledgement
7.References
Keywords
Distal Renal Tubular Acidosis; Primary Sjogren’s Syndrome; Quadriparesis; Hypercapnic Respiratory Failure.
Introduction
Renal tubular acidosis (RTA) is a group of disorders in which
renal excretion of acids is reduced, out of proportion to any reduction
in glomerular filtration rate. RTA is characterized by hyperchloremic
metabolic acidosis with a normal serum anion gap.
There are multiple forms of RTA, depending on which aspect of
renal acid handling has been affected (Table 1)[1]. In Type 1 or
distal RTA (dRTA), the distal nephron does not lower urine pH
normally because the collecting ducts permit excessive back diffusion
of H+ from lumen to blood. Urinary concentration and
potassium conservation also tend to be impaired, so polyuria and
polydipsia occur. With the stress of an intercurrent illness, acidosis
and hypokalemia can be life-threatening[1]. Acute hypokalemic
paralysis is an uncommon cause of acute muscleweakness,
and the reported cases of quadriplegia and acute respiratory failure
secondary to hypokalemia are rare [2-5]. We report a case of
dRTA who presented with hypokalemic muscular paralysis with
acute hypercapnic respiratory failure who did not require ventilation
because of fast respiratory function improvement by appropriate
treatment with rapid potassium infusion.
Case Report
A 37 years old pleasant, married, muslim, Bangladeshi housewife,
known case of hypothyroidism (on 100 mcgm of levothyroxine
daily) for 16 years, not known to have any other co morbiditiespresented
to us with the complaints of sudden weakness of
both upper and lower limbs for 1 day, shortness of breath for 6
hours and unable to speak for 2 hours. Weakness was sudden in
onset and increasing and became so severe that she was unable
to move without the help of others and her weakness progressed
to the point that she was completely bed ridden. All the proximal and distal muscles and both upper and lower limbs were equally
involved but there was no muscle pain. Weakness started in both
upper and lower limbs simultaneously. On query her attendant
informed that she developed her symptoms after taking heavy
meal. There is no history of trauma, pain in the neck or dysphagia,
sensory complaints like paresthesia. She also developed
breathlessness for 6 hours which was sudden and progressively
increasing but not associated with chest pain, sputum or haemoptysis.
For last two hours she was unable to speak but can understand
speech and can follow commands like closing her eyes. She
denied any history of fever, headache, visual complaints in the
form of blurring of vision, diplopia, convulsion, urinary and fecal
incontinence, recent vaccination. There was also no history of
recent previous infection like respiratory tract infection, urinary
tract infection or diarrhea. Patient’s attendant also complained of
occasional rash about which they could not elaborate. She has history
of similar type of attack about 1 year back which was managed
conservatively in a local hospital. There was no similar type
of illness in her family. She has three children and all are in good
health. She had no history of abortion, no bad obstetric history
and all of her pregnancy was uneventful.
On physical examination, she was conscious, oriented, but a bit
drowsy with GCS 14/15 and had are flexicquadriplegia. Power
was graded 0/5 in the legs and in the arms. Plantar responses were
absent bilaterally. All modalities of sensation are intact, sings of
meningeal irritation were absent. Cerebellar signs, stance and gait
could not be evaluated. She had palpable rash over both lower
limbs(figure 1), buttocks and over both palm. Her pulse was 60
beats/min, blood pressure 110/70 mmHg, respiratory rate 30
breath/min. Herchest was clear on auscultation, oxygen saturation
was 97% on 5 L of oxygen. The rest of physical exam was
unremarkable.
On initial laboratory investigations, complete blood count, random
blood sugar, SGPT, serum creatinine, CPK, chest x ray revealed
normal results except ESR was 68 mmin 1st hour . Serum
Electrolyte showed sodium 138 mmol/L, potassium 1.7 mmol/L,
chloride 111 mmol/L, bicarbonate 16.5 mmol/L. Anion gap
was normal(12.2 mmol/L).Urinary potassium was elevated with
101mmol/L. TSH, serum calcium, serum magnesium level were
normal. Electrocardiogram showed sinus bradycardia, diffuse
ST depression, T inversion, U wave in precordial limbs and prolonged
PR interval.(Figure 2)
Arterial blood gas (ABG) analysis revealed mixed respiratory
and metabolic acidosis with hypercapnic respiratory failure( pH
7.03, PO2-69 mm, PCO2- 64 mm, HCO3-16 mmol/L). She was
started treatment with intravenous sodium bi carbonate along
with intravenous and oral potassium chloride and showed dramatic
clinical improvement in 1 day. On next day, her muscle
power improved to 4/5 in both upper and lower limbs, respiratory
rate was16 breaths/min and can speak well. SaO2 was 96%
in room air. Repeat ABG in room air revealed resolved hypercapnic
respiratory failure( pH 7.40, PO2-88 mm, PCO2- 30 mm,
HCO3-14 mmol/L). Repeat serum electrolyte revealed sodium 147 mmol/L, potassium 2.9 mmol/L, chloride 109 mmol/L and
bicarbonate 18 mmol/L. Despite of correction of respiratory acidosis
her metabolic acidosis persisted. Urine routine examination
showed pH 7.2, trace proteinuria without any RBC, pus cell or any
casts. So type 1 or distal renal tubular acidosis (dRTA) was suspected
and for further evaluation of underlying cause for dRTA,
on query, she revealed that she has been suffering from occasional
rash for last 5 years which was more prominent in her legs and
buttock area and also involved her palm sparing her trunk and
face. Rashes care initially itchy and then became painful. She developed
these rashes occasionally for last 5 years and resolved
spontaneously. She denied any history of joint pain, oral ulcer,
muscle pain, hair fall, and weight loss. She also complained of
dryness of mouth for last 15 years, that was increasing and became
so severe that she cannot swallow her food without water.
She also developed dry eyes for same duration and there is no
tear during her emotional event like crying. Bedside Schirmer’s
test was done and found positive(1 mm wet on filter paper in 5
minutes- figure 3). She also complaints of bluish discoloration
of her fingers and pain on cold exposure and she has been suffering
from fatigue and weakness for last 15 years and dry cough
and worsening shortness of breath on exertion for last 2 years.
With these symptoms, she visited a number of physicians including
ophthalmologists and was managed symptomatically without
any improvement.
Further investigations revealed: ANA was strongly positive on
Hep2 cell with fine speckled pattern. Anti dS DNA, lupus anti
coagulant, anti cardiolipin antibody was negative. ENA profile
showed positive anti SSA(Ro) and anti SSB(La). RA test was positive
in high titer, Serum total protein was 77 gm/L, albumin 35
gm/L and globulin 42 gm/L, albumin globulin ratio was 1: 1.42.
Anti TPO was > 1300 U/ml(positive >60 U/ml). C4 level was
reduced to 0.1 g/L(normal 0.15-0.45 g/L). Protein Electrophoresis
showed polyclonal hypergammaglobulinemia with prominent
IgG and IgM. Pulmonary function tests showed mild restrictive
defect as evidenced by low FEV1(2.02 L) and low FVC(2.05L)
with normal FEV1/FVC (94.5%). DLCO was moderately reduced
with 55% of predicted value. KCO was normal suggestive
of parenchymal restrictive disease. Patient refused for lip biopsy.
So final diagnosis of recurrent hypokalemic paralysis due to distal
(type 1) renal tubular acidosis secondary to primary Sjogren’s
syndrome with type 3 cryoglobulinemic vasculitis with autoimmune
hypothyroidism was made. She was discharged with sodium
bicarbonate, potassium citrate, hydoxychloroquine (400 mg daily)
and artificial tear. After 1 month, on out patient door follow up
she was doing well.
Discussion
Approximately, 98% of total body potassium is located intracellularly.
Sixty percent of intracellular potassium is within skeletal
muscle, which may explain the predominance of muscular symptoms
in disorders producing hypokalemia [6, 7]. Although, the
effects of hypokalemia are multisystemic, potassium deficiency
most seriously affects the neuromuscular system, and symptoms
related to hypokalemia are typically muscular. Serum potassium
concentrations of 3.0 to 3.5 mmo U-1 may be associated with
mild muscle weakness and myalgia. Serum potassium concentrations
of 2.5 to 3.0 mmol/L are associated with the development
of clinically significant muscle weakness. The muscle weakness
generally is limited to the limbs and limb girdles. The respiratory
or cranial musculature are rarely involved and characteristically
spared in muscle weakness secondary to hypokalemia. When severe,
hypokalemia can impair respiratory function leading to hypoventilation,
and acute respiratory failure [2-5, 8, 9]. Hypokalemic
muscleweakness may simulateGuillain -Barre syndrome
[10-12]. When the serum potassium level fallsbelow 2.5 mmol/L,
rhabdomyolysis may occur [7, 13, 14]. The lowest serum potassium
level reported was 1.1 mmol./L this was associated with areflexic
quadriplegia, coma, and acute respiratory failure managed
with IPPV8.
Hypokalemia is a common clinical problem, and is the most frequent
electrolyte disorder encountered in clinical practice. The
major causes of hypokalemia are: Inadequate potassium intake,
excessive skin, renal (diuretics, adrenal insufficiency, salt losing
nephropathy), orgastrointestinal losses (diarrhoea, vomiting), and
increased entry into cells by a variety of mechanisms including increased
availability of insulin, elevated beta adrenergic activity and
elevation in extracellular pH (metabolic orrespiratory alkalosis).
RTA is characterized by hyperchloremic metabolic acidosis with
a normal serum anion gap. Thereare multiple forms of RTA, depending
on which aspect of renal acid handling has been affected
(Table 1).
The presence of severe hypokalemia (K+ 1.7mmol/L) with normal anion gap metabolic acidosis and urinary pH >5.5 suggested
the diagnosis of Type 1 dRTA. Although quadriplegia is a wellknown
complication of severe hypokalemia, acute respiratory
failure due to dRTA is rarely reported [15]. A thorough search of
the available literature (Medline) revealed only six cases of dRTA
leading to hypokalemic respiratory failure requiring mechanical
ventilation [16-21].
Ascending paralysis of the extremities suggested Guillain-Barré
syndrome, however the presence of hypokalemia, metabolic acidosis
and an alkaline urine confirmed the diagnosis, and lumbar
puncture was not performed. Moreover, there was a significant
improvement in muscle power after K+ supplementation.
The pathogenesis of classic hypokalemicd RTA is not yet clear.
The hallmark is the inability to acidify the urine to pH <5.5; there
is no impairment in bicarbonate reabsorption in proximal tubules
[1]. In the majority of patients, there is a defect in H+ secretion by
the H+-K+-ATPase pump in tubular cells which causes hypokalemia,
decrease in NH4+ excretion, hyperchloaemic metabolic
acidosis and volume depletion. Occasionally, strikingly severe hypokalemia,
metabolic acidosis and hypocalcaemia may require immediate
therapy. This constellation of findings in an emergency
setting has been labelled as a “crisis of dRTA” [22]. Clinical presentation
in our patient was also quite catastrophic, with quadriparesis,
acute respiratory failure which could have proved fatal
without prompt and effective management.
Chronic positive acid balance causes Ca2+, Mg2+ and PO43-
wasting and there is an increased incidence of nephrocalcinosis.
A prominent feature of dRTA is abnormal Ca2+ metabolism
leading to musculoskeletal complaints. Hypercalciuria, alkaline
urine and low levels of urinary citrate result in calcium phosphate
stones [22].
The majority of patients with dRTA have it in association with a
systemic illness such as Sjögren’s syndrome, hypergammaglobulinaemia,
chronic active hepatitis (CAH) or lupus. The frequency
of dRTA in Sjögren’s syndrome has been reported to be 25 to
40% [22]. Ohtani et al and Poux et al have described hypokalemic
quadriplegia and respiratory arrest due to dRTA in patients with
primary Sjögren’s syndrome [18, 19]. Koul and Saleem reported
a case of CAH with dRTA which presented with hypokalemic
muscular paralysis requiring respiratory assistance [21].
The diagnostic criteria of Sjogren's syndrome were satisfied by
the findings of xerostomia, high titer of anti SSA and anti SSB
antibodies. The frequency of dRTA in Sjogren’s syndrome has
been reported to be about 25-40%. [23, 24]. There are many case
reports of Sjogren’s syndrome associated with hypokalemic quadriplegia
[25-31]. Tsuboi et al described that the periodic paralysis
was observed in almost 40% of Sjogrensyndrome cases associated
with dRTA [31]. However only three cases were reported that
respiratory arrest depends on severe hypokalemia associated with
renal tubular acidosis due to various causes [32-34] and there is
only one case report describing respiratory failure due to Sjogren’s
syndrome [34]. There is no significant difference at the level of
serum potassium between respiratory arrest group and quadriplegia
alone group(1.0-2.8 mmol/L). These results suggests that
the progress for respiratory arrest may be may be influenced by
interindividual differences in the sensitivity towards hypokalemia
(and presumably also transmembrane K gradient) of respiratory
muscles. Even patients with hypokalemia<1.7 mEq/l were liable
to develop respiratory arrest. The above cases, including our o
own patient, were all female, and showed good prognosis with
immediate respiratory support and potassium supplementation.
However, Nimmannit et al. described fatal cases of hypokalemic
respiratory failure and ventricular fibrillation due to endemic RTA
in Thailand. This condition occurred in otherwise healthy young
males and sometimes resulted in nocturnal death which is different
from the present case.
Treatment of dRTA involves correction of metabolic acidosis
by administration of alkali in an amount sufficient to neutralize
the production of diet-derived acids. This is usually equal to
1-3 mmol/kg/.day of sodium bicarbonate in adults. In children,
a large amount of bicarbonate must be administered to correct
acidosis and maintain normal growth. Sustained correction of
metabolic acidosis usually suppresses renal Na+ and K+ wasting
with attendant correction of extracellular fluid volume and
hypokalemia. Therefore in most patients with dRTA, K+ supplementation
is not necessary. However, if the patient presents
with hypokalemic respiratory paralysis, the K+ deficit should be
replaced without delay before initiating bicarbonate therapy [22],
because if bicarbonate is given alone it may further worsen the
already existing hypokalemia. The rate of infusion of KCl should
be up to a maximum of 0.25 mmol/kg/.hr. These patients are
often volume depleted and treatment should include correction
of the fluid deficit if necessary guided by central venous pressure
monitoring.
It is well known that hypokalemia can cause muscle weakness and
respiratory failure, but is probably under-appreciated. A prompt
diagnosis and treatment of hypokalemia is warranted to prevent
respiratory failure and the requirement for mechanical ventilation,
and to prevent other complications, mainly cardiac.
This case report highlights the fact that the dRTA with severe
hypokalemia should be kept in mindin any patient presenting with
respiratory failure. Secondly, all patients with dRTA must be investigated
for any associated systemic illnesses and put on lifelong
alkalinizing agents. In pSS, RTA is commonly asymptomatic.
However, if such a state persists, patient may develop quadriplegia.
Furthermore, if adequate treatment is not received, muscle
paralysis may progress to respiratory arrest. Although respiratory
arrest associated with Sjogren’s syndrome is very rare, this complication
is very severe and can be fatal. It is important to pay
attention to the occurrence of severe hypokalemia with metabolic
acidosis and provide adequate treatment for this combination in
patient with pSS.
Figure 2. Electrocardiogram showing sinus bradycardia, diffuse ST depression, T inversion(black arrow), U wave(red arrow) in precordial limbs and prolonged PR interval.
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