Question of the Week # 157

157) A 25 year old woman presents to your office with complaints of muscle cramps and weakness. She smokes 1 pack cigarettes per day and chews tobacco and flavored gum. She also has history of alcoholism and ingests about one pint of vodka every day for the past 2 years. She also uses “Ecstasy”  during weekend parties. She has a history of snoring in the night. On examination,  afebrile,  heart rate is 88/min and blood pressure is 150/98.  Laboratory investigations reveal a Sodium of 144 meq/L, potassium of 3.0meq/L, Chloride 98meq/L , Bicarbonate of 34meq/L and Creatinine of 0.8mg%. Urinary chloride is 45meq/L. Which of the following points in the patient’s history is most helpful in diagnosing her condition?

A) Alcohol use

B) Chewing tobacco and flavored gum

C) Snoring in the night

D) Smoking

E) Use of Ecstasy

6 Responses

  1. can anybody answer this q plz,i couldnt find the relation of these things with her diagnosis:[

  2. it might be alcohol bc it has diuretic effect it might hv caused her metabolic changes???

  3. Dehydration caused by drinking can affect the balance by draining potassium from the body, resulting in thirst, muscle cramps, dizziness and faintness.

  4. A

    Causes of chloride-resistant alkalosis (urine chloride >20 mEq/L) with hypertension include the following:

    Primary hyperaldosteronism – Adrenal adenoma, bilateral adrenal hyperplasia, adrenal carcinoma, glucocorticoid-remediable hyperaldosteronism


    11B-HSD2 – Genetic, licorice, chewing tobacco, carbenoxolone


    CAH – 11-Hydroxylase or 17-hydroxylase deficiency


    Current use of diuretics in hypertension


    Cushing syndrome


    Exogenous mineralocorticoids or glucocorticoids


    Liddle syndrome


    Renovascular hypertension

    Causes of chloride-resistant alkalosis (urine chloride >20 mEq/L) without hypertension include the following:

    Bartter syndrome


    Gitelman syndrome


    Severe potassium depletion


    Current use of thiazides and loop diuretics


    Hypomagnesemia

    Other causes include the following:

    Exogenous alkali administration – Sodium bicarbonate therapy in the presence of renal failure, metabolism of lactic acid or ketoacids


    Milk-alkali syndrome


    Hypercalcemia


    Intravenous penicillin


    Refeeding alkalosis


    Massive blood transfusion

  5. A alcoholism, hypomagnesemia, metabolic alkalosis

  6. The answer is B- Chewing tobacco!

    The answer to this question is Chloride resistant Hyperaldosteronism, which is Secondary Hyperaldosteronism, where the urinary chloride is unresponsive/resistant to the metabolic alkalosis taking place. The key components of chewing tobacco and some flavoured gums is Glicyrrhizin which is derived from licourice root!
    Glicyrrhizin gives you this clear picture of the side effects which is hypertension and edema (water retention) and (Resistant) elevated urine chloride although there is retention of bicarbonate. These effects are related to the inhibition of cortisol metabolism within the kidney, and the subsequent stimulation of the mineralocorticoid receptors.
    If liquid ecstasy was given- then that could have been the correct answer because that contains Glicyrrhizin and flavanoids!

    Peace,
    mufy 😉

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