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alization was for treatment of decubitus ulcers over The trimethoprim-sulphamethoxazole (TMP-SMX) the sacral and bilateral trochanteric regions and a combination antibiotic is an extremely common medurinary tract infection. ication given for treatment of a variety of infections. On admission, the patient was febrile (39°C) and The most common side-e ects of this drug are neutrovital signs were stable. Complete blood count revealed penia and the dermal and systemic hypersensitivity a white blood cell count of 12.1×109/l, haematocrit reactions associated with sulphonamides [1]. TMPof 29.5%, and a platelet count of 220×109/l. Urinalysis SMX has also been associated with two major forms revealed 45–50 WBCs/HPF and a positive nitrite of nephrotoxicity, acute interstitial nephritis [2] and a test. The patient’s serum biochemistry showed Na+ decrease in creatinine clearance with mild elevation in 140 mmol/l, K+ 3.6 mmol/l, Cl− 108 mmol/l, glucose serum creatinine [3]. In recent years, the adverse e ect 5.2 mmol/l, urea 7.2 mmol/l, creatinine 106 mmol/l, of hyperkalaemia has been reported in AIDS patients pH 7.42 and 2 4.5 kPa (34 mmHg). For the decu7–10 days after the start of high doses of TMP-SMX bitus ulcers, the patient was treated with cefazolin (1 g therapy for treatment of Pneumocystis carinii pneumoi.v.q6 h) and gentamicin (80 mg i.v. q12 h) for 5 days. nia [4,5] and in hospitalized patients treated with Trimethoprim-sulphamethoxazole (TMP-SMX ) (2 standard doses of TMP-SMX [6 ]. The mechanism for tablets BID, each tablet containing trimethoprim the hyperkalaemia was established as blockade of 80 mg, sulphamethoxazole 400 mg) was given to treat sodium channels by TMP-SMX, leading to reduced the urinary tract infection. Culture of the urine resulted renal potassium excretion. The sodium-channel in greater than 105 E. coli sensitive to TMP-SMX. blocking e ect of TMP-SMX is similar to that of When we first evaluated the patient, he had been on amiloride [4–7]. TMP-SMX at the above dose for approximately 3–4 Voltage-dependent distal renal tubular acidosis weeks. The supine blood pressure was 112/78 mmHg (RTA) induced by standard doses of TMP-SMX has and the pulse was 100 beats per minute. The patient not been previously reported. Herein we present a case was clinically volume depleted, with reduced skin of this form of distal RTA with hyperkalaemia in a turgor, dry oral mucosa, and flat jugular veins. patient receiving standard doses of TMP-SMX for Cardiovascular, pulmonary and abdominal examinaprolonged treatment of a urinary tract infection. tions were unremarkable. Neurological examination revealed paraplegia without focal neurological abnormality. Laboratory analysis from the previous 5 days Case Report showed hyponatraemia, hyperkalaemia and hyperchloraemic metabolic acidosis (see Table 1). There had A 61-year-old Asian male was referred to us for been no exogenous or endogenous potassium load. consultation. He had an increasing degree of hyponaAbdominal sonography showed no evidence of hydro-

Reversible voltage-dependant distal renal tubular acidosis in a patient receiving standard doses of trimethoprim-sulphamethoxazole