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Old 09-21-2012
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Arrow Gyrus Daily Questions; Internal Medicine #15

A 44-year-old woman presents for evaluation of dry eyes and mouth. She first noticed these symptoms >5 years ago and the symptoms have worsened over time. She describes her eyes as gritty-feeling, as if there were sand in her eyes. Sometimes her eyes burn, and she states that it is difficult to be outside in bright sunlight. In addition, her mouth is quite dry. In her job, she is frequently asked to give business presentations and finds it increasingly difficult to complete a 30- to 60-minute presentation. She usually has water with her at all times. Although she reports good dental hygiene without any recent changes, her dentist has had to place fillings twice in the past 3 years for dental caries. Her only other past medical history is treated tuberculosis that she contracted while in the Peace Corp in Southeast Asia when in her twenties. She takes no medication regularly and does not smoke. Ocular examination reveals punctuate corneal ulcerations on Rose Bengal stain, and the Schirmer test shows <5 mm of wetness after 5 min. Her oral mucosa is dry with thick mucous secretions, and the parotid glands are enlarged bilaterally. Laboratory examination reveals positive antibodies to Ro and La (SS-A and SS-B). In addition, her chemistries reveal a sodium of 142 mEq/L, potassium 2.6 mEq/L, chloride 115 mEq/L, and bicarbonate of 15 mEq/L. What is the most likely cause of the hypokalemia and acidemia in this patient?

A. Diarrhea
B. Distal (type I) renal tubular acidosis
C. Hypoaldosteronism
D. Purging with underlying anorexia nervosa
E. Renal compensation for chronic respiratory alkalosis
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I would go with
Type 1 renal tubular acidosis
But just a guess. Looking forward to explanation.


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Distal RTA, also LES likes to rape the distal tubule
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Distal (type I) renal tubular acidosis

It is associated with autoimmune diseases classically Sjögren's syndrome
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I think B.....

Some causes of distal RTA are-
1.Amphotericin B
2.Sjogren syndrome
3.cirrhosis
4.nephrocalcinosis
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The answer is B. Distal (type I) renal tubular acidosis

The patient in this vignette is presenting with severe dry eyes and mouth in the presence of autoantibodies to Ro and La (SS-A and SS-B, extractable nuclear and cytoplasmic antigens) consistent with the diagnosis of Sjögren’s syndrome.

Onethird of patients with Sjögren’s syndrome have extraglandular involvement of the disease, most commonly in the lungs and kidneys. In this patient with acidemia and hypokalemia, the possibility of renal disease due to Sjögren’s syndrome should be considered.

Interstitial nephritis is a common manifestation of Sjögren’s syndrome in the kidneys. Distal (type I) renal tubular acidosis is also frequent, occurring in 25% of individuals with Sjögren’s syndrome. Diagnosis could be confirmed by obtaining urine electrolytes to demonstrate a positive urine anion gap. Renal biopsy is not necessary.

Hypoaldosteronism is associated with a type IV renal tubular acidosis that results in hyperkalemia and a non-anion gap acidosis.

Renal compensation for respiratory alkalosis should not result in hypokalemia. Purging in anorexia nervosa could result in hypokalemia and increased risk of dental caries, but it would be associated with metabolic alkalosis rather than acidosis.
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