Yasir Saeed, MD1, Raji Mohammed, MD2, Affaf Gul, MBBS3; 1Lincoln Medical Center, Bronx, NY; 2Lincoln Medical Center, Bronx, NY; 3Khyber Teaching Hospital, Peshawar, North-West Frontier, Pakistan
Introduction: Sodium polystyrene sulfonate (SPS) is used to treat hyperkalemia. Its use with sorbitol has been historically shown to cause colon ischemia, necrosis, ulceration, and perforation, but now SPS without sorbitol is also causing the same. The overall incidence is 0.27%-1.8%. We present this case to increase the awareness of clinicians and pathologists about this rare yet lethal complication of SPS.
Methods: 67 Year Male with History of Hypertension, Peripheral Neuropathy Presented to the Emergency with Shortness of breath, Syncope, Myalgias for two days, and Rt foot Plantar Ulcer with Pain. Vital Signs HR:112, BP:97/46, RR:28, Sat O2:75%. Exam: Respiratory Distress, Purulent Rt Foot Deep Ulcer.Labs: WBC:18 x103/mcl, CK:40,000, BUN:60 mg/dl, Creatnine:2 mg/dl, K:6 mmol/L. CXR showing Bilateral lower lobe multifocal Infiltrates.He was Intubated for Acute Respiratory failure secondary to Pneumonia, Developed Septic shock From PNA, and Cellulitis of Rt Foot Ulcer.Acute kidney injury(AKI) likely from ATN and Rhabdomyolysis. Started on Norepinephrine and Renally dosed Antibiotics. Blood Culture Grew Methicillin-sensitive Staphylococcus aureus. Received Aggressive Hydration, but Oliguric AKI progressively Worsened. Patent Received Multiple 15 g Doses of Sodium polystyrene sulfonate without sorbitol orally, a Total of 180 g over a week Before Starting HD. He was Off-Pressor and Extubated after a week, but soon after Started to have Bright red blood Per Rectum and Diffuse Abdominal Pain with an Acute drop in Hgb.CTA and EGD were unremarkable, Colonoscopy showed Necrosis and Mucosal Friability in Descending and Transverse colon and mucosal congestion plus Ulcer with suspected Perforation in Rectum. (Image 1,2) Emergent Laparotomy showed gross contamination from four perforations in the left colon, with gross evidence of colonic ischemia from sigmoid to the cecum. Subtotal colectomy with ileostomy was performed. Pathology showed mural necrosis with mosaic fish scale pattern basophilic Crystals consistent with SPS throughout the bowel wall (Image 3). Thus, a diagnosis of SPS induced colon ischemia and necrosis was made. He had a successful recovery. Discussion: The pathogenesis of bowel injury related to SPS is complex and remains unclear. Patients at risk for such adverse events were found to have uremia and hypomotility of bowel from any cause.The clinical and endoscopic findings are similar to the ischemia-induced injury. Definite diagnosis relies on histological examination.
Colonoscopy showing Necrosis and Mucosal Friability with nodular mucosal elevations in Transverse colon (Top), mucosal congestion and Ulcer with suspected Perforation in Rectum(Bottom)
Gross pathology of the resected colon showing extensive ulceration and necrosis with a perforation at the probe site.
Basophilic Sodium polystyrene sulfonate (SPS) crystals with mosaic or fish scale pattern in the Mucosa, Lamina propria, and Exudate (H & E stain,x100)(Top), The same Crystals in the pericolic fat (H & E stain,x40) (Bottom)
Disclosures: Yasir Saeed indicated no relevant financial relationships. Raji Mohammed indicated no relevant financial relationships. Affaf Gul indicated no relevant financial relationships.