Abstract
BackgroundHyperkalemia is a serious medical condition that requires immediate intervention. However, pseudohyperkalemia and reverse pseudohyperkalemia are misleading clinical manifestations that can result in incorrect diagnosis and consequent harmful intervention.Case presentationAn 11-year-old girl manifested an incidental finding of hyperleukocytosis (WBC > 400 × 109/L), with 90% blast cells during routine pre-operative investigations for adenotonsillectomy. Initial investigations demonstrated elevated serum potassium levels (7.5 mmol/L), despite concomitantly normal levels in venous blood gas samples (3.9–4.4 mmol/L) and being clinically stable with normal 12-lead ECG. Surprisingly, plasma potassium level was exacerbated, in comparison to the serum level by > 1 mmol/L. This finding is consistent with reverse pseudohyperkalemia that is associated with hyperleukocytosis in acute leukemia that does not require any active intervention.ConclusionThis case report emphasizes the significance of interpreting potassium levels accurately, preferably utilizing whole-blood potassium level over serum and plasma level in newly diagnosed leukemia cases with hyperleukocytosis. Additionally, having a high index for the possibility of reverse pseudohyperkalemia, secondary to leakage from fragile leukocytes, avoids unnecessary treatment that might cause harm to the patient.
Highlights
Hyperkalemia is a potentially life-threatening condition that requires immediate medical intervention
Identifying PHK and reverse pseudohyperkalemia (rPHK) in patients with leukemia and hyperleukocytosis carries a significant clinical implication in patient monitoring and management, by avoiding unnecessary interventions that might cause harm to such patients. This case report discusses a child with acute leukemia that presented with hyperleukocytosis and hyperkalemia
Early recognition and diagnoses of rPHK are vital in all patients with significant leukocytosis that present with hyperkalemia, in the absence of other clinical or EKG-based evidence of hyperkalemia, in order to avoid any harmful outcomes following any invasive intervention
Summary
Recognition and diagnoses of rPHK are vital in all patients with significant leukocytosis (from hematologic neoplasms) that present with hyperkalemia, in the absence of other clinical or EKG-based evidence of hyperkalemia, in order to avoid any harmful outcomes following any invasive intervention. We conclude that the potential for PHK and rPHK exists in serum and plasma samples, within the setting of leukocytosis in a patient with hematological malignancy. In such cases, whole-blood analysis is more accurate. Cancer centers should establish a mechanism through which their information system flags results of high potassium levels, in patients with leukocyte counts > 100,000/mm that raise the possibility of PHK and minimize medical errors and improper management, in order to ensure a better quality of care and enhance patient safety.
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