To the Editor We read with interest the review by Maniar and Tolan1 on rhabdomyolysis secondary to primary human immunodeficiency virus (HIV) infection in the recent issue of Infectious Diseases in Clinical Practice. Despite the thorough review, they failed to mention hypokalemia as an uncommon but recognized cause of rhabdomyolysis. A 37-year-old man was referred from the prison service with a few days' history of worsening generalized body weakness, loss of appetite, profuse diarrhea, vomiting, abdominal pain, and significant weight loss. The diarrhea had started 3 months before this admission. The diarrhea was typically voluminous and occasionally contained fresh blood. The patient was diagnosed as having HIV infection 3 years previously during routine checks for all new inmates. He was not referred to the hospital for further evaluations because he was scheduled to be repatriated back to his country. On examination, he was malnourished and cachectic. Neurological examination showed generalized hypotonia, generalized power weakness (Medical Research Council grade 2/5), and absent reflexes. There were no obvious mucocutaneous manifestations of acquired immunodeficiency syndrome (AIDS). The rest of the examinations was unremarkable. Blood investigations showed normal complete blood cell counts and normal liver function test results, except for mildly elevated serum alanine transferase of 97 μ/L. Renal function test results showed severe hypokalemia of 1.4 mmol/L (normal range [NR], 3.6-5.1 mmol/L) with sodium of 132 mmol/L (NR, 136-144 mmol/L), urea of 7.9 mmol/L (NR, 2.9-7.1 mmol/L), creatinine level of 102 mmol/L (NR, 53-115 mmol/L), and bicarbonate of 17.9 mmol/L (NR, 22-32 mmol/L). Creatine kinase (CK) was also elevated at around 2000 IU/L (NR, 40-200 IU/L) with a CK-MB of 15 IU/L. Thyroid function test result was normal. Spot urine potassium level was 3.99 mmol/L (NR, 25-150 mmol/L). Urine microscopy was normal. The electrocardiogram showed nonspecific ST- and T-wave abnormalities but surprisingly without the changes of hypokalemia. The clinical impression was rhabdomyolysis secondary to hypokalemia as a result of potassium loss from the gastrointestinal tract. The serum CK subsequently peaked at 23,000 IU/L. The patient was initially started on intravenous fluids, potassium replacement, and antibiotics (ciprofloxacin 400 mg BID). Stool microscopy showed Cryptosporidium cysts and Candida albicans. His treatment was later changed to intravenous spiramycin and fluconazole. Subcutaneous octreotide was added because there was no improvement in the stool output. CD4 counts were markedly reduced (32 cells/μL). Antiretroviral therapy with Combivir and indinavir was commenced, and this led to a marked reduction in stool output. As a result, there was an improvement in the serum potassium leading to marked improvement in power. He was able to mobilize without much assistance and was discharged back to the prison service with further follow-up. Patients with AIDS experienced many complications, and intractable diarrhea is a common gastrointestinal manifestation. This is often caused by parasitic infections but can also be caused by the HIV itself. It can be quite debilitating, and the resultant dehydration, metabolite disturbances, and malabsorption can lead to significant morbidity.2 Among the many manifestations of HIV infection, rhabdomyolysis is less common compared with the gastrointestinal manifestations. Rhabdomyolysis can occur via immune-mediated myocyte injuries or more commonly secondary to the toxic highly active antiretroviral medications.1 Other medications either legal or illicit as highlighted by Maniar and Tolan1 can also cause rhabdomyolysis. Our patient was not using any of these medications and had not been exposed to any highly active antiretroviral therapy. We cannot be certain whether the diarrhea in our patient was secondary to the Cryptosporidium or the HIV because we did not perform an endoscopy and biopsy. However, regardless of the underlying etiology, hypokalemia is a known complication of chronic diarrhea. Hypokalemia is a well-recognized cause of rhabdomyolysis.3 In our setting, such manifestation is commonly caused by periodic hypokalemic paralysis secondary to thyrotoxicosis or renal tubular acidosis.4,5 Despite the prevalence of diarrheal disorders among patients with HIV/AIDS, it is surprising that rhabdomyolysis secondary to hypokalemia had not been previously reported. Therefore, it is important for clinicians to be aware of this association. In addition, severe hypokalemia can be associated with fatal cardiac arrhythmias. In conclusion, our case highlights that the intractable diarrhea with resultant hypokalemia associated should be included as a cause of rhabdomyolysis. Shir Kiong Lu, MBChB, MRCP Aza Zetty Feroena Jamaludin, MBChB, MRCP Nallathamby Rajendran, MBBS, FRCP Vui Heng Chong, MRCP, FAMS Department of Medicine Raja Isteri Pengiran Anak Saleha Hospital Brunei Darussalam [email protected]
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Oct 31, 2024
Jun Hyuk Son + 4
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