Clinical Case Summary
A 58 year-old woman was admitted for an elective rectosigmoidectomy after two previous uncomplicated diverticulitis episodes. On the third postoperative day, her clinical status deteriorated, and an abdominal CT scan revealed an anastomotic leak, leading to a new surgery and confection of a protective ileostomy. Her condition improved progressively, and she was discharged 10 days after. However, the patient came back to the emergency one week later with abdominal pain, fatigue, and refractory nausea and vomiting, in addition to acute renal failure with severe hyponatremia and hyperkalemia. Because her daily ileostomy’s output reached about 2 liters/day, she was started on high dose opioids and loperamide to decrease the stoma’s output, as well as replacement fluid therapy, improving quickly within 24 to 48 hours. She was discharged in 5 days.
Despite the adequate control of the ileostomy’s output, her second readmission occurred 12 days later, showing the same clinical and laboratorial patterns. Considering she had a typical profile for adrenal insufficiency, fludrocortisone was associated with the antimotility agents, showing a significant improvement within hours. Nonetheless, she discontinued fludrocortisone on her own, and a third readmission occurred in 10. One more time, clinical and laboratorial characteristics were the same, with rapid improvement in the short term. An extensive investigation was conducted, revealing an aldosterone level more than 10 times higher than upper limit of normal, with normal renin levels and an adrenocorticotropic hormone in the lower limit of normal. These paradoxical findings were reinforced with a low urine and high ileostomy sodium dosages, and a diagnosis of a type 3 pseudohypoaldosteronism was made. Definitive treatment with intestinal transit’s reconstruction was performed, with complete resolution.
References
1. Carl C, Dinkelbach L, Mohr J, Perez R, Vera Lopez T, Fricke-Otto S, Niehues T. Case report: Life threatening hyponatremia in infants with urinary tract infections: two cases of type III pseudohypoaldosteronism and review of the literature. Front Pediatr. 2024 Jan 5;11:1233205. doi: 10.3389/fped.2023.1233205. PMID: 38250595; PMCID: PMC10797885.
2. Amir Babiker, Haya Aldabas, Shahad Alanazi, Bashayer Alahmadi, Waleed Tamimi, Mohsen Al Atawi, Fahad Aljuraibah, Angham Almutair. Pseudohypoaldosteronism: A challenging diagnosis with management pitfalls - Case series. Journal of Clinical and Translational Endocrinology: Case Reports, Volume 32, 2024, 100172. ISSN 2214-6245
3. Stojanović, V., Spasojević, S., Radovanović, T., & Doronjski, A. (2017). Pseudohypoaldosteronism: report of three cases. Journal of Endocrinology, Metabolism and Diabetes of South Africa, 22(2), 17–20. https://doi.org/10.1080/16089677.2017.1335532
4. Nakasone, Ruka et al. Three cases of pseudohypoaldosteronism following ileostomy in preterm infants. Pediatrics & Neonatology, Volume 62, Issue 1, 119 - 121