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Intravenous hydrocortisone in high doses is often prescribed when immunosuppression is required urgently, such as in the treatment of acute asthma. It is also sometimes used when patients are unable to take oral prednisolone. This practice is potentially dangerous, however, as high dose hydrocortisone may precipitate clinically significant hypokalaemia in susceptible patients. The importance of this effect is emphasised by the following report.A 63 year old man with a history of alcohol abuse presented with a two day history of haematemesis, melaena, and blackouts. He admitted drinking 3.4 litres of beer a day but denied drinking in the week before admission because of indigestion. On examination he was pale with a generalised purpuric rash. The liver was enlarged to 5 cm below the costal margin, and he had a small retinal haemorrhage. A full blood count showed a haemoglobin concentration of 51 g/l, a white cell count of 8.8x109/l, and a platelet count of 4x109/l. Electrolyte analysis showed the following plasma concentrations: sodium 131 mmol/l (normal 133-144 mmol/l), potassium 3.7 mmol/l (normal 3.4-5.2 mmol/l), total calcium 1.92 mmol/l (normal 2.26-2.60 mmol/l), urea 9 mmol/l (normal 2.5-7.5 mmol/l), and creatinine 91 μmol/l (normal 50-100 μmol/l). A coagulation screen gave a thrombin time of 12.5 s (control 13.0 s), a prothrombin time of 14.2 s (control 13.7 s), a kaolin cephalin clotting time of 39.3 s (control 40.8 s), and a reduced thrombotest result of 60%. (The thrombotest is a combined assay of the activities of factors II, VII, IX, and X.) Liver function tests showed the following serum bilirubin concentrations: 11 μmol/l (normal 1-17 μmol/l), albumin 24g/l (normal 35-50 g/l), and (gamma)-glutamyltrans-ferase 60 IU/l (normal <45 IU/l).An electrocardiogram showed a short PR interval of 0.08 s (figure 1). Heart size appeared normal on chest radiography, but there …

Lesson of the Week: The mineralocorticoid effects of high dose hydrocortisone