American Journal of Emergency Medicine (2012) 30, 1309

Correspondence

Toluene-induced renal tubular acidosis: an easily missed cause of hypokalemic paralysis^?,??,?

To the Editor,

We thank Chiang et al for their article on “Unilateral paralysis associated with profound hypokalemia” [1]. The authors demonstrated an interesting case of idiopathic distal renal tubular acidosis (RTA) with hypokalemic paralysis.

Distal RTA is commonly associated with autoimmune disorders; however, the authors already ruled out these possibilities by a complete medical workup. We applaud the authors for their thorough presentation, especially the insignificant history of glue sniffing. Inhalation of toluene can cause distal RTA though several mechanisms [2]. Toluene inhibits collecting duct proton secretion. In addition, metabolism of toluene produces the organic acids including hippUric acid and benzoic acid. These are buffered by sodium bicarbonate, resulting in the production of sodium hippurate and sodium benzoate. Anion gap metabolic acidosis occurs when effective intravascular volume is decreased and urinary excretion is limited [3].

Patompong Ungprasert MD Pongsathorn Kue-A-Pai MD Nitipong Permpalung MD Wonngarm Kittanamongkolchai MD Wisit Cheungpasitporn MD Department of Internal Medicine

Bassett Medical Center, Cooperstown, NY 13326, USA E-mail addresses: [email protected],

[email protected], [email protected], [email protected], [email protected]

doi:10.1016/j.ajem.2012.04.034

References

1. Chiang WF, Yeh FC, Lin SH. c Am J Emerg Med. 2012 Mar 28. [Epub ahead of print].
2. Carlisle EJ, Donnelly SM, Vasuvattakul S, Kamel KS, Tobe S, Halperin ML. Glue-sniffing and distal renal tubular acidosis: sticking to the facts. J Am Soc Nephrol 1991;1(8):1019-27.
3. Batlle DC, Sabatini S, Kurtzman NA. On the mechanism of toluene- induced renal tubular acidosis. Nephron 1988;49(3):210-8.

0735-6757/$ – see front matter.