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Symptoms and Signs – Differential Diagnosis of Hyperkinetic Movement Disorders
• Thyrotoxicosis
• Tardive dyskinesia (e.g., phenothiazines)
• Systemic lupus erythematosus (SLE), polycythemia
• Liver failure
• Hemiballismus (lacunar cerebrovascular accident [CVA] near subthalamic nuclei in basal ganglia, metastatic lesions, toxoplasmosis [in AIDS])
• Dystonia (idiopathic, familial, drug induced [prochlorperazine, metoclopramide]), Wilson’s disease
• Chorea, choreoathetosis: drug induced, Huntington’s chorea, Sydenham’s chorea
• Thyrotoxicosis
• Tardive dyskinesia (e.g., phenothiazines)
• Systemic lupus erythematosus (SLE), polycythemia
• Liver failure
• Hemiballismus (lacunar cerebrovascular accident [CVA] near subthalamic nuclei in basal ganglia, metastatic lesions, toxoplasmosis [in AIDS])
• Dystonia (idiopathic, familial, drug induced [prochlorperazine, metoclopramide]), Wilson’s disease
• Chorea, choreoathetosis: drug induced, Huntington’s chorea, Sydenham’s chorea
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Symptoms and Signs – Differential Diagnosis of Hyperkalemia
PSEUDOHYPERKALEMIA
• Hemolyzed specimen
• Severe thrombocytosis (platelet count >106 mL)
• Severe leukocytosis (white blood cell count >105 mL)
• Fist clenching during phlebotomy
EXCESSIVE POTASSIUM INTAKE (OFTEN IN SETTING OF
IMPAIRED EXCRETION)
• Potassium replacement therapy
• High-potassium diet
• Salt substitutes with potassium
• Potassium salts of antibiotics
DECREASED RENAL EXCRETION
• Potassium-sparing diuretics (e.g., spironolactone, triamterene,
amiloride)
• Renal insufficiency
• Mineralocorticoid deficiency
• Hyporeninemic hypoaldosteronism (diabetes mellitus [DM])
• Tubular unresponsiveness to aldosterone (e.g., systemic lupus
erythematosus [SLE], multiple myeloma, sickle cell disease)
• Type 4 renal tubular acidosis (RTA)
• Angiotensin-converting enzyme (ACE) inhibitors
• Heparin administration
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Trimethoprim-sulfamethoxazole
• β-Blockers
• Pentamidine
REDISTRIBUTION (EXCESSIVE CELLULAR RELEASE)
• Acidemia (each 0.1 decrease in pH increases the serum potassium
by 0.4 to 0.6 mEq/L). Lactic acidosis and ketoacidosis cause
minimal redistribution.
• Insulin deficiency
• Drugs (e.g., succinylcholine, markedly increased digitalis level,
arginine, β-adrenergic blockers)
• Hypertonicity
• Hemolysis
• Tissue necrosis, rhabdomyolysis, burns
PSEUDOHYPERKALEMIA
• Hemolyzed specimen
• Severe thrombocytosis (platelet count >106 mL)
• Severe leukocytosis (white blood cell count >105 mL)
• Fist clenching during phlebotomy
EXCESSIVE POTASSIUM INTAKE (OFTEN IN SETTING OF
IMPAIRED EXCRETION)
• Potassium replacement therapy
• High-potassium diet
• Salt substitutes with potassium
• Potassium salts of antibiotics
DECREASED RENAL EXCRETION
• Potassium-sparing diuretics (e.g., spironolactone, triamterene,
amiloride)
• Renal insufficiency
• Mineralocorticoid deficiency
• Hyporeninemic hypoaldosteronism (diabetes mellitus [DM])
• Tubular unresponsiveness to aldosterone (e.g., systemic lupus
erythematosus [SLE], multiple myeloma, sickle cell disease)
• Type 4 renal tubular acidosis (RTA)
• Angiotensin-converting enzyme (ACE) inhibitors
• Heparin administration
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Trimethoprim-sulfamethoxazole
• β-Blockers
• Pentamidine
REDISTRIBUTION (EXCESSIVE CELLULAR RELEASE)
• Acidemia (each 0.1 decrease in pH increases the serum potassium
by 0.4 to 0.6 mEq/L). Lactic acidosis and ketoacidosis cause
minimal redistribution.
• Insulin deficiency
• Drugs (e.g., succinylcholine, markedly increased digitalis level,
arginine, β-adrenergic blockers)
• Hypertonicity
• Hemolysis
• Tissue necrosis, rhabdomyolysis, burns
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Symptoms and Signs – Differential Diagnosis of Hyperkinetic Movement Disorders
• Chorea, choreoathetosis: drug induced, Huntington’s chorea, Sydenham’s chorea
• Dystonia (idiopathic, familial, drug induced [prochlorperazine, metoclopramide]), Wilson’s disease
• Hemiballismus (lacunar cerebrovascular accident [CVA] near subthalamic nuclei in basal ganglia, metastatic lesions, toxoplasmosis [in AIDS])
• Liver failure
• Systemic lupus erythematosus (SLE), polycythemia
• Tardive dyskinesia (e.g., phenothiazines)
• Thyrotoxicosis
• Chorea, choreoathetosis: drug induced, Huntington’s chorea, Sydenham’s chorea
• Dystonia (idiopathic, familial, drug induced [prochlorperazine, metoclopramide]), Wilson’s disease
• Hemiballismus (lacunar cerebrovascular accident [CVA] near subthalamic nuclei in basal ganglia, metastatic lesions, toxoplasmosis [in AIDS])
• Liver failure
• Systemic lupus erythematosus (SLE), polycythemia
• Tardive dyskinesia (e.g., phenothiazines)
• Thyrotoxicosis
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Symptoms and Signs – Differential Diagnosis of Primary Hyperlipoproteinemia
• Alcohol
• Diabetes mellitus (DM)
• Diet high in saturated fats
• Glucocorticoid use/excess
• Glycogen storage diseases
• Hepatic dysfunction
• Lipodystrophies
• Oral contraceptives
• Renal disease
• Alcohol
• Diabetes mellitus (DM)
• Diet high in saturated fats
• Glucocorticoid use/excess
• Glycogen storage diseases
• Hepatic dysfunction
• Lipodystrophies
• Oral contraceptives
• Renal disease
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Symptoms and Signs – Differential Diagnosis of Hypernatremia
ISOVOLEMIC HYPERNATREMIA
Decreased total body water, normal total body sodium and extracellular fluid
• Diabetes insipidus (neurogenic and nephrogenic)
• Skin loss (hyperemia), iatrogenic, reset osmostat
HYPERVOLEMIC HYPERNATREMIA
Increased total body water, markedly increased total body sodium and extracellular fluid
• Iatrogenic (administration of hypernatremic solutions)
• Mineralocorticoid excess (Conn’s syndrome, Cushing’s syndrome)
• Salt ingestion
HYPOVOLEMIC HYPERNATREMIA
Loss of H2O and Na+ (H2O Loss > Na+)
• Renal losses (e.g., diuretics, glycosuria)
• GI, respiratory, skin losses
• Adrenal deficiencies
ISOVOLEMIC HYPERNATREMIA
Decreased total body water, normal total body sodium and extracellular fluid
• Diabetes insipidus (neurogenic and nephrogenic)
• Skin loss (hyperemia), iatrogenic, reset osmostat
HYPERVOLEMIC HYPERNATREMIA
Increased total body water, markedly increased total body sodium and extracellular fluid
• Iatrogenic (administration of hypernatremic solutions)
• Mineralocorticoid excess (Conn’s syndrome, Cushing’s syndrome)
• Salt ingestion
HYPOVOLEMIC HYPERNATREMIA
Loss of H2O and Na+ (H2O Loss > Na+)
• Renal losses (e.g., diuretics, glycosuria)
• GI, respiratory, skin losses
• Adrenal deficiencies
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Symptoms and Signs – Differential Diagnosis of Serum Hyperosmolality
• Uremia
• Mannitol therapy
• Ingestion of toxins (ethylene glycol, methanol, ethanol), hypercalcemia, diuretics
• Hypernatremia
• Hyperglycemia
• Diabetes insipidus (DI)
• Dehydration
• Uremia
• Mannitol therapy
• Ingestion of toxins (ethylene glycol, methanol, ethanol), hypercalcemia, diuretics
• Hypernatremia
• Hyperglycemia
• Diabetes insipidus (DI)
• Dehydration
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Symptoms and Signs – Differential Diagnosis of Urine Hyperosmolality
• Syndrome of inappropriate antidiuretic hormone (SIADH)
• High-protein diet
• Glycosuria
• Dehydration
• Adrenal insufficiency
• Syndrome of inappropriate antidiuretic hormone (SIADH)
• High-protein diet
• Glycosuria
• Dehydration
• Adrenal insufficiency
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Symptoms and Signs – Differential Diagnosis of Hyperparathyroidism
• Malignant disease: neoplasms of breast, lung, kidney, ovary, pancreas; myeloma, lymphoma
• Granulomatous disorders (e.g., sarcoidosis)
• Paget’s disease
• Vitamin D intoxication, milk-alkali syndrome
• Thiazide diuretics
• Other: familial hypocalciuric hypercalcemia, thyrotoxicosis, adrenal insufficiency, prolonged immobilization, vitamin A intoxication, recovery from acute renal failure, lithium
administration, pheochromocytoma, disseminated systemic lupus erythematosus (SLE)
• Malignant disease: neoplasms of breast, lung, kidney, ovary, pancreas; myeloma, lymphoma
• Granulomatous disorders (e.g., sarcoidosis)
• Paget’s disease
• Vitamin D intoxication, milk-alkali syndrome
• Thiazide diuretics
• Other: familial hypocalciuric hypercalcemia, thyrotoxicosis, adrenal insufficiency, prolonged immobilization, vitamin A intoxication, recovery from acute renal failure, lithium
administration, pheochromocytoma, disseminated systemic lupus erythematosus (SLE)
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Symptoms and Signs – Differential Diagnosis of Hyperphosphatemia
• Excessive phosphate administration
• Excessive oral intake or IV administration
• Laxatives containing phosphate (phosphate tablets, phosphate
enemas)
• Decreased renal phosphate excretion
• Acute or chronic renal failure
• Hypoparathyroidism or pseudohypoparathyroidism
• Acromegaly, thyrotoxicosis
• Bisphosphonate therapy
• Tumor calcinosis
• Sickle cell anemia
• Transcellular shift out of cells
• Chemotherapy of lymphoma or leukemia, tumor lysis
syndrome, hemolysis
• Acidosis
• Rhabdomyolysis, malignant hyperthermia
• Artifact: in vitro hemolysis
• Pseudohyperphosphatemia: hyperlipidemia, paraproteinemia,
hyperbilirubinemia
• Excessive phosphate administration
• Excessive oral intake or IV administration
• Laxatives containing phosphate (phosphate tablets, phosphate
enemas)
• Decreased renal phosphate excretion
• Acute or chronic renal failure
• Hypoparathyroidism or pseudohypoparathyroidism
• Acromegaly, thyrotoxicosis
• Bisphosphonate therapy
• Tumor calcinosis
• Sickle cell anemia
• Transcellular shift out of cells
• Chemotherapy of lymphoma or leukemia, tumor lysis
syndrome, hemolysis
• Acidosis
• Rhabdomyolysis, malignant hyperthermia
• Artifact: in vitro hemolysis
• Pseudohyperphosphatemia: hyperlipidemia, paraproteinemia,
hyperbilirubinemia
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Symptoms and Signs – Differential Diagnosis of Hyperpigmentation
• Psoralen plus ultraviolet A (PUVA) therapy (psoralen administration) for psoriasis and vitiligo
• Progressive systemic sclerosis and related conditions
• Pregnancy
• Porphyrias (porphyria cutanea tarda and variegate porphyria)
• Pheochromocytoma
• Melanotropic hormone injection
• Melanoma
• Malabsorption syndrome (Whipple’s disease and celiac sprue)
• Hemochromatosis (“bronze” diabetes)
• Drug induced (e.g., antimalarials, some cytotoxic agents)
• Arsenic ingestion
• Adrenocorticotropic hormone (ACTH)– or melanocyte-stimulating hormone (MSH)–producing tumors (e.g., small cell carcinoma of the lung)
• Addison’s disease
• Psoralen plus ultraviolet A (PUVA) therapy (psoralen administration) for psoriasis and vitiligo
• Progressive systemic sclerosis and related conditions
• Pregnancy
• Porphyrias (porphyria cutanea tarda and variegate porphyria)
• Pheochromocytoma
• Melanotropic hormone injection
• Melanoma
• Malabsorption syndrome (Whipple’s disease and celiac sprue)
• Hemochromatosis (“bronze” diabetes)
• Drug induced (e.g., antimalarials, some cytotoxic agents)
• Arsenic ingestion
• Adrenocorticotropic hormone (ACTH)– or melanocyte-stimulating hormone (MSH)–producing tumors (e.g., small cell carcinoma of the lung)
• Addison’s disease
