Acute Ascending Muscle Weakness Secondary to Medication-Induced Hyperkalemia

Secondary hyperkalemic paralysis is an uncommon but potentially life-threatening consequence of drug-induced disease. We report a case of a 53-year-old female with history of chronic kidney disease presenting to the emergency department with a one-day history of upper and lower extremity weakness and paresthesias. Serum potassium concentration on admission was greater than 8？mEq/L, and serum creatinine was elevated above baseline. Electrocardiogram showed first-degree atrioventricular block with peaked T waves. The patient reported compliance with daily lisinopril 10？mg, spironolactone 25？mg, and 40？mEq twice daily of potassium chloride. Symptoms and electrocardiogram returned to baseline within 24 hours of presentation and serum potassium returned to 4.2？mEq/L at approximately 36 hours without the need for dialysis. This case emphasizes the importance of including such a condition in the differential diagnosis of patients with ascending paralysis and the importance of close monitoring of patients placed on potassium-elevating agents. 1. Introduction Secondary hyperkalemic paralysis is an uncommon but potentially life-threatening consequence of drug-induced disease in patients with renal insufficiency. However, prompt differential diagnosis and treatment typically result in complete symptom reversal prior to the development of life-threatening consequences. We report a case of ascending muscle paralysis in a patient with chronic kidney disease prescribed multiple potassium-elevating agents. 2. Case Presentation A 53-year-old African American female presented to the emergency department with a one-day history of upper and lower extremity weakness and paresthesias. She reported waking up with lower extremity weakness and became progressively weak and unable to ambulate throughout the course of the morning. After sustaining a fall, she was able to crawl to the nearest phone to call a friend to transport her to the emergency department. The patient’s past medical history consisted of hypertension, diabetes mellitus, pulmonary hypertension, nonischemic cardiomyopathy, and systolic heart failure. Home medications included simvastatin 40？mg daily, digoxin 0.125？mg daily, furosemide 40？mg daily, carvedilol 25？mg twice daily, lisinopril 10？mg daily, spironolactone 25？mg twice daily, insulin 70/30 (40 units every AM, 25 units every PM), ferrous sulfate 325？mg daily, and potassium chloride 20？mEq twice daily. The patient reported taking two potassium chloride tablets twice daily for approximately the past week. Vital signs on admission were as follows: temperature