Severe metabolic alkalosis with fludrocortisone therapy—a case report

Abstract

Background: We present an atypical case of severe metabolic alkalosis, not reported in the literature to date.

Case Presentation: Owing to concerns of apneas and desaturation, a 75-year-old man presented to the emergency department with significantly deranged physiology: bicarbonate level of 63.6 mmol/L, a base excess of 40.6, and a potassium concentration of 1.9 mmol/L.Primary diagnoses included metabolic alkalosis secondary to fludrocortisone therapy with respiratory compensation, hypokalemia, and hypochloremia. He initially received potassium replacement with cardiac monitoring, followed by permissive hypercapnia in the intensive care unit. He received acetazolamide to further improve his acid-base status. The patient had a good outcome with gradual return of his pH and bicarbonate levels to baseline. He was then discharged.

Conclusion: Iatrogenic mineralocorticoid excess should be considered when the patient presents with significantly raised bicarbonate levels. When starting fludrocortisone, renal function needs to be diligently monitored due to risk of hypokalemia metabolic alkalosis.

Conflict of interest statement

The authors declare no conflict of interest.

Author contributions

Williams GSM was the intensive care registrar on call when the patient presented to the hospital. She initiated intensive care management and drafted the article. Hinxman H was the intensive care consultant-on-call when the patient presented to the hospital. She formulated the management plan for the patient and reviewed and edited the article.

Funding

None.

Ethical approval of studies and informed consent

The study followed the principles of the Declaration of Helsinki as revised in 2013. The Health Research Authority decision tool^[22] was used to determine if Ethics Committee review was required for this case report; the outcome was that no review was required. Written informed consent was obtained from the patient’s wife as the patient lacked the capacity to consent.

Acknowledgments

We thank the patient and his family for allowing the publication of this case report.

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