Acute-onset paralysis in a patient of rheumatoid arthritis

Abstract

Renal tubular acidosis (RTA) is a disorder of renal acidification characterized by inability to acidify urine to pH <5.5 despite the presence of severe systemic metabolic acidosis and hypokalemia. Hypokalemia leads to acute-onset paralysis and may be a presenting manifestation of RTA. Its association with various autoimmune disease has been reported previously in published reports, but has not been much emphasized. We, hereby, report a case of RTA that presented during the flare of rheumatoid arthritis (RA). A 42-year-old female, a known case of RA for 5 years, presented with persistent joint pain for 1 week and acute-onset quadriparesis for 3 days. Primary investigations revealed hypokalemia with metabolic acidosis. She was managed conservatively with potassium supplements and bicarbonate supplements along with steroids and disease-modifying anti-rheumatic drugs. Such a presentation of renal tubular acidosis in a patient during the flare of rheumatoid arthritis is distinctly rare and previously unreported in published studies.

Acidose tubular renal associada ao novo coronavírus: relato de caso

“…Neste contexto, a RTA distal (clássica ou tipo 1) atua nos néfrons distais e não permitem que estes exerçam a função de secreção dos íons H+, por isso diminui o pH urinário, gerando a acidose metabólica (Singh et al, 2014-. Varshney et al, 2015.…”

A review of renal tubular acidosis

“…Secondary, or acquired dRTA, has been reported in conditions including autoimmune diseases (Sjögren syndrome, 118 systemic lupus erythematosus, 119 rheumatoid arthritis 120 ), dysproteinemic syndromes (hypergammaglobulinemia, 121 amyloidosis 122 ), vitamin D toxicosis, 123 kidney transplantation (most frequently dRTA), 124,125 sickle cell disease, 126,127 exposure to drugs and toxins (amphotericin B, 128,129 lithium carbonate, 130 amiloride, 131 vanadium, 132,133 zonisamide 134 ), obstructive uropathy, 82 and other conditions. 3,5 Mechanisms suspected in acquired dRTA secondary to disease processes include absent or defective function of H + -ATPase in the A-intercalated cells of the collecting duct (Sjögren syndrome) 135,136 ; immune complex deposition in the kidneys (systemic lupus erythematosus) 137 ; suspected deposition of autoantibodies affecting tubular pumps (rheumatoid arthritis) 138 ;…”

“…Clinical and laboratory sequelae of secondary dRTA include weakness or paralysis related to hypokalemia, 128,133,136,138 hyperkalemia in hyperkalemic dRTA, 122 polyuria, 121,231 nausea and vomiting, 136 azotemia when there is decreased glomerular filtration rate (GFR), 128 nephrocalcinosis, 232,233 and hypocitraturia. 128,133 Secondary proximal (type 2) RTA Sequelae in secondary pRTA include polyuria, 152,176 weakness related to hypokalemia, 148,152,156,192 hypophosphatemia, [152][153][154][155][156][157]163,165,192 hyponatremia, 192 hypouricemia, 192 hypomagnesemia, 234 proteinuria, 152,163 aminoaciduria, 148,[152][153][154]163,165 glucosuria, 148,152,156,157,163,192 hypercalciuria, …”

“…108 Certain forms of primary type 4 RTA, such as primary PHA type 1, are associated with significant morbidity and high infant mortality due to salt wasting. 111,229 The prognosis of secondary RTA in people is variable based on the underlying disease associated with dRTA, 128,136,138,232 pRTA, 148,157,163,165,171,184 and type 4 RTA. [194][195][196] Reporting related to prognosis pertains mainly to the underlying disease and is less specific to the secondary RTA, which can be managed or resolved with treatment of the underlying disease or removal of the causative agent.…”

Renal Tubular Acidosis in Patients with Systemic Lupus Erythematosus

“…RTA may develop due to idiopathic, familial and secondary causes. Diabetes mellitus, rheumatoid arthritis, Sjögren syndrome, lysosomal storage diseases and drugs are among the common causes of secondary RTA [6][7][8]. It is known that RTA can be seen in patients with SLE [9].…”