Jakub Ruszkowski
@jruszkowski.bsky.social
MD, PhD. Internal medicine specialist, nephrology trainee. Passionate about pathophysiology, immunology, statistics, and evidence synthesis.
🧵11/11
Source: Joshi A, et al. Sjögren's syndrome and hepatitis C virus infection presenting as hypokalemic quadriparesis: A case report. Journal of International Medical Research 2025;53(12):1-8. DOI: 10.1177/03000605251404767
Source: Joshi A, et al. Sjögren's syndrome and hepatitis C virus infection presenting as hypokalemic quadriparesis: A case report. Journal of International Medical Research 2025;53(12):1-8. DOI: 10.1177/03000605251404767
December 21, 2025 at 2:10 PM
🧵11/11
Source: Joshi A, et al. Sjögren's syndrome and hepatitis C virus infection presenting as hypokalemic quadriparesis: A case report. Journal of International Medical Research 2025;53(12):1-8. DOI: 10.1177/03000605251404767
Source: Joshi A, et al. Sjögren's syndrome and hepatitis C virus infection presenting as hypokalemic quadriparesis: A case report. Journal of International Medical Research 2025;53(12):1-8. DOI: 10.1177/03000605251404767
🧵10/11
KEY LESSONS 🎯:
1. Consider autoimmune diseases (especially Sjögren's) in refractory hypokalemia + distal RTA
2. Sicca symptoms may be subtle - ask specifically about them!
3. HCV can mimic Sjögren's - check viral load
4. Early diagnosis + electrolyte correction = rapid recovery
KEY LESSONS 🎯:
1. Consider autoimmune diseases (especially Sjögren's) in refractory hypokalemia + distal RTA
2. Sicca symptoms may be subtle - ask specifically about them!
3. HCV can mimic Sjögren's - check viral load
4. Early diagnosis + electrolyte correction = rapid recovery
December 21, 2025 at 2:10 PM
🧵10/11
KEY LESSONS 🎯:
1. Consider autoimmune diseases (especially Sjögren's) in refractory hypokalemia + distal RTA
2. Sicca symptoms may be subtle - ask specifically about them!
3. HCV can mimic Sjögren's - check viral load
4. Early diagnosis + electrolyte correction = rapid recovery
KEY LESSONS 🎯:
1. Consider autoimmune diseases (especially Sjögren's) in refractory hypokalemia + distal RTA
2. Sicca symptoms may be subtle - ask specifically about them!
3. HCV can mimic Sjögren's - check viral load
4. Early diagnosis + electrolyte correction = rapid recovery
🧵9/11
TREATMENT:
✅ Sodium bicarbonate 1g BID
✅ Spironolacton 50mg daily
✅ Potassium chloride (oral)
OUTCOME:
Day 5: Patient could WALK! 🎉
At discharge: Normal muscle strength in all limbs, normalized lab parameters. Complete recovery achieved!
TREATMENT:
✅ Sodium bicarbonate 1g BID
✅ Spironolacton 50mg daily
✅ Potassium chloride (oral)
OUTCOME:
Day 5: Patient could WALK! 🎉
At discharge: Normal muscle strength in all limbs, normalized lab parameters. Complete recovery achieved!
December 21, 2025 at 2:10 PM
🧵9/11
TREATMENT:
✅ Sodium bicarbonate 1g BID
✅ Spironolacton 50mg daily
✅ Potassium chloride (oral)
OUTCOME:
Day 5: Patient could WALK! 🎉
At discharge: Normal muscle strength in all limbs, normalized lab parameters. Complete recovery achieved!
TREATMENT:
✅ Sodium bicarbonate 1g BID
✅ Spironolacton 50mg daily
✅ Potassium chloride (oral)
OUTCOME:
Day 5: Patient could WALK! 🎉
At discharge: Normal muscle strength in all limbs, normalized lab parameters. Complete recovery achieved!
🧵8/11
PATHOPHYSIOLOGY of distal RTA in Sjögren's:
Autoimmune attack → absence of H+-ATPase pumps in intercalated cells → can't excrete H+ into urine → H+ retention → metabolic acidosis with normal anion gap.
Increased urinary K+ loss → severe hypokalemia → quadriparesis 💪
PATHOPHYSIOLOGY of distal RTA in Sjögren's:
Autoimmune attack → absence of H+-ATPase pumps in intercalated cells → can't excrete H+ into urine → H+ retention → metabolic acidosis with normal anion gap.
Increased urinary K+ loss → severe hypokalemia → quadriparesis 💪
December 21, 2025 at 2:10 PM
🧵8/11
PATHOPHYSIOLOGY of distal RTA in Sjögren's:
Autoimmune attack → absence of H+-ATPase pumps in intercalated cells → can't excrete H+ into urine → H+ retention → metabolic acidosis with normal anion gap.
Increased urinary K+ loss → severe hypokalemia → quadriparesis 💪
PATHOPHYSIOLOGY of distal RTA in Sjögren's:
Autoimmune attack → absence of H+-ATPase pumps in intercalated cells → can't excrete H+ into urine → H+ retention → metabolic acidosis with normal anion gap.
Increased urinary K+ loss → severe hypokalemia → quadriparesis 💪
🧵7/11
But wait - there's a twist! 😮
HCV antibody: POSITIVE
This created a diagnostic dilemma because chronic HCV infection can mimic primary Sjögren's syndrome with similar clinical & lab features.
Solution: HCV RNA PCR was ordered. It was NEGATIVE ✅ This excluded active viral replication.
But wait - there's a twist! 😮
HCV antibody: POSITIVE
This created a diagnostic dilemma because chronic HCV infection can mimic primary Sjögren's syndrome with similar clinical & lab features.
Solution: HCV RNA PCR was ordered. It was NEGATIVE ✅ This excluded active viral replication.
December 21, 2025 at 2:10 PM
🧵7/11
But wait - there's a twist! 😮
HCV antibody: POSITIVE
This created a diagnostic dilemma because chronic HCV infection can mimic primary Sjögren's syndrome with similar clinical & lab features.
Solution: HCV RNA PCR was ordered. It was NEGATIVE ✅ This excluded active viral replication.
But wait - there's a twist! 😮
HCV antibody: POSITIVE
This created a diagnostic dilemma because chronic HCV infection can mimic primary Sjögren's syndrome with similar clinical & lab features.
Solution: HCV RNA PCR was ordered. It was NEGATIVE ✅ This excluded active viral replication.
🧵6/11
What causes distal RTA in a young woman? 🔍
Autoimmune workup showed:
ANA 97.2 AU/mL ↑
SSA/Ro-52 antibodies +++
Directed history: She'd had DRY EYES for months 👁️
Schirmer's test: positive (severe bilateral dry eyes)
DIAGNOSIS: Primary Sjögren's syndrome with distal RTA!
What causes distal RTA in a young woman? 🔍
Autoimmune workup showed:
ANA 97.2 AU/mL ↑
SSA/Ro-52 antibodies +++
Directed history: She'd had DRY EYES for months 👁️
Schirmer's test: positive (severe bilateral dry eyes)
DIAGNOSIS: Primary Sjögren's syndrome with distal RTA!
a cat is being treated with a bottle of eye drops
ALT: a cat is being treated with a bottle of eye drops
media.tenor.com
December 21, 2025 at 2:10 PM
🧵6/11
What causes distal RTA in a young woman? 🔍
Autoimmune workup showed:
ANA 97.2 AU/mL ↑
SSA/Ro-52 antibodies +++
Directed history: She'd had DRY EYES for months 👁️
Schirmer's test: positive (severe bilateral dry eyes)
DIAGNOSIS: Primary Sjögren's syndrome with distal RTA!
What causes distal RTA in a young woman? 🔍
Autoimmune workup showed:
ANA 97.2 AU/mL ↑
SSA/Ro-52 antibodies +++
Directed history: She'd had DRY EYES for months 👁️
Schirmer's test: positive (severe bilateral dry eyes)
DIAGNOSIS: Primary Sjögren's syndrome with distal RTA!
🧵5/11
Muscle enzymes were dramatically elevated:
CK 36,614 IU/L ↑↑↑
AST 348 U/L ↑↑
LDH 404 U/L ↑↑
Initially suggested inflammatory myopathy, BUT:
❌ Acute onset (not gradual)
❌ No rash
❌ Enzymes normalized WITHOUT immunosuppression
Diagnosis: hypokalemia-induced rhabdomyolysis!
Muscle enzymes were dramatically elevated:
CK 36,614 IU/L ↑↑↑
AST 348 U/L ↑↑
LDH 404 U/L ↑↑
Initially suggested inflammatory myopathy, BUT:
❌ Acute onset (not gradual)
❌ No rash
❌ Enzymes normalized WITHOUT immunosuppression
Diagnosis: hypokalemia-induced rhabdomyolysis!
December 21, 2025 at 2:10 PM
🧵5/11
Muscle enzymes were dramatically elevated:
CK 36,614 IU/L ↑↑↑
AST 348 U/L ↑↑
LDH 404 U/L ↑↑
Initially suggested inflammatory myopathy, BUT:
❌ Acute onset (not gradual)
❌ No rash
❌ Enzymes normalized WITHOUT immunosuppression
Diagnosis: hypokalemia-induced rhabdomyolysis!
Muscle enzymes were dramatically elevated:
CK 36,614 IU/L ↑↑↑
AST 348 U/L ↑↑
LDH 404 U/L ↑↑
Initially suggested inflammatory myopathy, BUT:
❌ Acute onset (not gradual)
❌ No rash
❌ Enzymes normalized WITHOUT immunosuppression
Diagnosis: hypokalemia-induced rhabdomyolysis!
Normal anion gap metabolic acidosis + positive urine anion gap = RENAL TUBULAR ACIDOSIS
But which type? Proximal vs distal?🤔
Key findings that pointed to DISTAL RTA:
✅ Severe hypo-K
✅ Urine pH >5.5 despite systemic acidosis
✅ NO Fanconi syndrome features
www.kireportscommunity.org/post/renal-t...
But which type? Proximal vs distal?🤔
Key findings that pointed to DISTAL RTA:
✅ Severe hypo-K
✅ Urine pH >5.5 despite systemic acidosis
✅ NO Fanconi syndrome features
www.kireportscommunity.org/post/renal-t...
December 21, 2025 at 2:10 PM
Normal anion gap metabolic acidosis + positive urine anion gap = RENAL TUBULAR ACIDOSIS
But which type? Proximal vs distal?🤔
Key findings that pointed to DISTAL RTA:
✅ Severe hypo-K
✅ Urine pH >5.5 despite systemic acidosis
✅ NO Fanconi syndrome features
www.kireportscommunity.org/post/renal-t...
But which type? Proximal vs distal?🤔
Key findings that pointed to DISTAL RTA:
✅ Severe hypo-K
✅ Urine pH >5.5 despite systemic acidosis
✅ NO Fanconi syndrome features
www.kireportscommunity.org/post/renal-t...
🧵3/11
Despite adequate K+ and fluid replacement AND no more vomiting after antiemetics, potassium levels REMAINED critically low! 🚨
This refractory hypokalemia suggested something more than just GI losses.
ABG was ordered and revealed:
pH 7.296 ↓
HCO3- 14.4 mmol/L ↓
Normal anion gap: 11
Despite adequate K+ and fluid replacement AND no more vomiting after antiemetics, potassium levels REMAINED critically low! 🚨
This refractory hypokalemia suggested something more than just GI losses.
ABG was ordered and revealed:
pH 7.296 ↓
HCO3- 14.4 mmol/L ↓
Normal anion gap: 11
December 21, 2025 at 2:10 PM
🧵3/11
Despite adequate K+ and fluid replacement AND no more vomiting after antiemetics, potassium levels REMAINED critically low! 🚨
This refractory hypokalemia suggested something more than just GI losses.
ABG was ordered and revealed:
pH 7.296 ↓
HCO3- 14.4 mmol/L ↓
Normal anion gap: 11
Despite adequate K+ and fluid replacement AND no more vomiting after antiemetics, potassium levels REMAINED critically low! 🚨
This refractory hypokalemia suggested something more than just GI losses.
ABG was ordered and revealed:
pH 7.296 ↓
HCO3- 14.4 mmol/L ↓
Normal anion gap: 11
🧵2/11
Initial labs showed SEVERE electrolyte disturbances:
K+ 1.7 mmol/L ↓↓ (critical!)
Na+ 130.1 mmol/L ↓
Mg2+ 1.05 mg/dL ↓
Working diagnosis: quadriparesis secondary to hypokalemia.
Treatment started: IV fluids, potassium supplementation, antiemetics.
But there was a problem...
Initial labs showed SEVERE electrolyte disturbances:
K+ 1.7 mmol/L ↓↓ (critical!)
Na+ 130.1 mmol/L ↓
Mg2+ 1.05 mg/dL ↓
Working diagnosis: quadriparesis secondary to hypokalemia.
Treatment started: IV fluids, potassium supplementation, antiemetics.
But there was a problem...
December 21, 2025 at 2:10 PM
🧵2/11
Initial labs showed SEVERE electrolyte disturbances:
K+ 1.7 mmol/L ↓↓ (critical!)
Na+ 130.1 mmol/L ↓
Mg2+ 1.05 mg/dL ↓
Working diagnosis: quadriparesis secondary to hypokalemia.
Treatment started: IV fluids, potassium supplementation, antiemetics.
But there was a problem...
Initial labs showed SEVERE electrolyte disturbances:
K+ 1.7 mmol/L ↓↓ (critical!)
Na+ 130.1 mmol/L ↓
Mg2+ 1.05 mg/dL ↓
Working diagnosis: quadriparesis secondary to hypokalemia.
Treatment started: IV fluids, potassium supplementation, antiemetics.
But there was a problem...
Reposted by Jakub Ruszkowski
