Three Cases of Hypophosphatemia Following Prolonged Seawater Immersion

Abstract

Severe hypophosphatemia is a potentially life-threatening electrolyte disorder. There is limited information about serious electrolyte disorders in survivors of prolonged seawater immersion. We report three scuba divers who went missing in the ocean off southern Taiwan and were rescued 40 h later, about 100 km from where their dive began. They initially presented with hypothermia, severe dehydration, acute renal injury, rhabdomyolysis, severe hypophosphatemia, metabolic acidosis, and low T3 syndrome. The possible etiologies of the hypophosphatemia include decreased phosphate intake, cellular redistribution of phosphate and increased renal excretion. Their decreased phosphate intake was a consequence of prolonged starvation. Medical treatment, which included rewarming, administration of carbohydrates, and correction of the metabolic acidosis, contributed to cellular redistribution of phosphate. The increased phosphaturia that we observed may have resulted from impaired tubular resorption of phosphate during recovery from acute renal tubular injury, aggressive extracellular fluid volume expansion, a surge of adrenal hormone, and metabolic acidosis. Aggressive managements can prevent seriously irreversible complications. Correction of life-threatening electrolyte imbalances and severe metabolic derangements can be life-saving and improve the prognosis for these patients.