A sixty-three-year-old woman with a history of kyphoscoliosis, restrictive respiratory failure and hypersensitivity was referred to our hospital.
The patient had peritonitis secondary to perforated diverticulum treated with Hart-mann technique.
Postoperatively she developed an enterocutaneous fistula, treated with oral enteral nutrition.
His refusal to undergo surgery was discharged with this treatment when he had a output of 200 ml/day, scheduled for outpatient periodic reviews, which he did not come.
Three months later, the patient came to the emergency department complaining of asthenia, anorexia, nausea, dizziness, abdominal pain, stool output, occasional decrease and a significant increase in the rate of voiding dysfunction.
The patient was afflicted with an AT of 85/50 mmHg and presented diffuse pain due to abdominal palpation.
During his stay in the emergency room he presented decreased level of consciousness that improved after intravenous fluid administration.
Analytically, he presented: hemoglobin 12.3 g/dl; leukocytes 10.400/mm3; blood glucose 102 mg/dl; urea 426 mg/dl; creatinine 2.9 mg/dl mEq/dl; total proteins 9.3 g/dl; urinary Ca 10.5 mg
She was diagnosed with shock, acute renal failure, metabolic acidosis, severe hyponatremia and hyperkalemia.
The suspicion of acute adrenal insufficiency was started with adrenal insufficiency and she was treated with intravenous fluid replacement, with good clinical and analytical response.
The following laboratory tests showed a decrease in hemoglobin concentration to 7.6 g/dl and received transfusion of two solids concentrates.
She was admitted to internal medicine and subsequently underwent surgery with the diagnosis of intestinal obstruction.
On the sixth day of admission parenteral nutrition was started.
The patient was fully conscious, hemodynamically stable, without edema, and renal function, hyponatremia and hyperkalemia had normalized.
The patient weighed 68 kg and measured 145 cm (BMI 32 kg/m2).
The composition of the TPN was: total volume 2,500 ml, 1,500 kcal, N 11 g, glucose 200 g, lipids 40 g, Na 120 mEq, K 60 mEq, Mg 15 mEq, P 15 mEq, Zn
The next day the patient complained of paresthesia in the hands and perioral region.
Thiamine i.m. was administered empirically.
A few hours later she began to present a decreased level of consciousness and bipsychiatric motility, with preservation of the extremities.
The clinical picture progressed during the next day, presenting deterioration of the level of consciousness of fluctuating type, with aphasia and paraparesis in MSI and becoming stupor.
Her blood pressure was 130/70 mmHg.
PNT was suspended, maintained with serum therapy and empirical support with vitamins.
Cranial CT was normal.
She was admitted to the ICU due to suspected metabolic encephalopathy. An EEG showed epiconvulsive status epilepticus, and treatment with IV phenytoin was initiated.
Analytically, he presented Hb 10.7 g/l; 12800 leukocytes with 71.5% granulocytes; blood glucose 91 mg/dl; creatinine 0.5 mg/dl; Na 143 mEq/l; K 2.6 mEq/l; Pdl
The ECG showed no arrhythmias.
Arterial gas was similar to the previous one.
Severe hypophosphatemia with hypomagnesemia and hypokalemia were diagnosed.
Salts of phosphate i.v., magnesium and potassium were administered with good clinical response, progressively improving the neurological status until normalization.
Parenteral nutrition was restarted and the patient progressively increased caloric intake with a higher intake of phosphorus, magnesium and potassium.
During her admission she also presented several intoxications due to phenytoin with neurological symptoms, and sepsis due to central catheter-related Candida spp., of which she had no sequelae.
PNT and IV fluids were progressively suspended.
Since the diagnosis of adrenal insufficiency was not confirmed and there was an important sign of malformation at admission that could explain the analytical alterations, a progressive decrease of corticoids was performed until they were suspended, without symptoms or adrenal symptoms.
Cortisol after ACTH stimulation (250 mg) was 43.9 μg/dl at 30 minutes, reflecting a normal adrenal reserve.
The patient refused intestinal transit reconstruction surgery.
The enterocutaneous fistula persisted with an output of approximately 300 cc/day.
The patient was discharged with good clinical and laboratory status.
Table I shows the evolution of phosphorus, magnesium and potassium levels during hospitalization.
