Manzar Zakria, Mansoor Nadeem, Naseer Rashid Dar.
Renal Tubular Acidosis presenting as Quadriparesis.
Pak Armed Forces Med J Jan ;53(2):249-50.

A thirty-five years old lady was admitted to another hospital because of rapid weakness in all four limbs developing over a period of two days. She developed respiratory embarrassment and was transferred to our hospital for ventilator support. Patient had been visiting various physicians because of generalized ill health and episodic weakness in the last five years. She had been hospitalized several times because of transient weakness of extremities from which she recovered spontaneously. These episodes were ascribed to conversion disorder. There was no history of arthralgia, Raynaud`s phenomenon or the Sicca syndrome. There was no family history of familial periodic paralysis. One day before admission she developed progressive weakness of upper extremities followed by lower ones. On physical examination, she was well oriented. Muscle strength was 0-1/5 in the legs and arms, proximally as well as distally. Muscle stretch reflexes were absent. The sensory system examination revealed no abnormality and cranial nerves were intact. The rectal-sphincter tone was preserved. Analysis of a cerebrospinal fluid specimen revealed no abnormality. Forced vital capacity was 6 ml per kilogram (normal value for age, >40 ml/kilogram). Oxygen saturation was maintained at 88 percent with nasal administration of oxygen at 5 Liters/min. Chest radiograph showed no abnormalities. ECG showed high U wave & low S-T segment. The initial differential diagnosis included Guillain-Barre syndrome familial periodic paralysis, Botulism and electrolyte imbalance. The patient was to be placed on ventilator when the results of arterial blood gases revealed pH 7.29, PCO2 55mmHg, bicarbonate 15 m.mol/L and base excess -8 m.mol/L and normal serun anion gap. Other laboratory values were: Sodium 144 m.mol/L, potassium 2.6 mmol/L, chloride 111 mmol/L, creatinine 106 umol/L, blood glucose 8.2 mmol/L, calcium 1.81 m.mol/L, phosphate 0.84 m.mol/ L. Urinary pH was 6.5 and urine microscopy showed no abnormal findings. Continued …

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