Azoles and pseudohyperaldosteronism

Q: Which of the following azoles may cause pseudohyperaldosteronism? - select one

A) Fluconazole

B) Voriconazole

C) Isavuconazole

D) Itraconazole 

Answer: D

Itraconazole and posaconazole are two azoles known to cause pseudohyperaldosteronism with its triad of

• severe hypokalemia
• hypertension, and
• metabolic alkalosis

Itraconazole is also known to cause congestive heart failure, and all azoles are known to cause hepatotoxicity.

#pharmacology

#endocrinology

References:

1. Kuriakose K, Nesbitt WJ, Greene M, Harris B. Posaconazole-Induced Pseudohyperaldosteronism. Antimicrob Agents Chemother 2018; 62.

2. Brandi SL, Feltoft CL, Serup J, Eldrup E. Pseudohyperaldosteroism during itraconazole treatment: a hitherto neglected clinically significant side effect. BMJ Case Rep. 2021 Jun 18;14(6):e243191. doi: 10.1136/bcr-2021-243191. PMID: 34144953; PMCID: PMC8215247.

3. Katharina R. Beck, Lucija Telisman, Chris J. van Koppen, George R. Thompson III, Alex Odermatt - Molecular mechanisms of posaconazole- and itraconazole-induced pseudohyperaldosteronism and assessment of other systemically used azole antifungals - The Journal of Steroid Biochemistry and Molecular Biology, Volume 199, May 2020, 105605. Link: https://www.sciencedirect.com/science/article/abs/pii/S0960076019306958

Patient height and PES

Q: Which of the following is a risk factor for post-extubation stridor (PES)? - select one

A) High ratio of patient height (in mm) to ETT diameter (in mm)

B) Small ratio of patient height (in mm) to ETT diameter (in mm)

Answer: B

Post-extubation stridor is a common occurrence in the ICU. Various risk factors have been identified. One of the less discussed risk factors is:

A small ratio of patient height (in mm) to ETT diameter (in mm)

Some other well-known factors are:

• Prolonged intubation
• Old age
• Large ETT 
• Elevated APACHE score
• Low GCS score 
• Traumatic intubation
• Female gender
• Previous pulmonary history
• Excessive tube mobility due to insufficient fixation

#ventilators

#pulmonary

#procedures

References:

1. Maury E, Guglielminotti J, Alzieu M, et al. How to identify patients with no risk for postextubation stridor? J Crit Care 2004; 19:23.

2. Wittekamp BH, van Mook WN, Tjan DH, et al. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Crit Care 2009; 13:233.

3. Shinohara M, Iwashita M, Abe T, Takeuchi I. Association between post-extubation upper airway obstruction symptoms and airway size measured by computed tomography: a single-center observational study. BMC Emerg Med. 2022 Mar 31;22(1):55. doi: 10.1186/s12873-022-00615-7. PMID: 35361111; PMCID: PMC8974026.

4. Sunil Rathore, Adam Bates, Lawrence Nolan, Trevena Anton, Mckay Jarman, and Gwendolyn Lynch - Neurology - Neurocritical Care: Procedures - Identifying Post-extubation Stridor (PES) Risk Factors in a Neurocritical Care Population (P2-2.002) - April 9, 2024 issue 102 (7_supplement_1) 5689 https://doi.org/10.1212/WNL.0000000000205984

Vision in HELPP

Q: A 28-year-old female is admitted to the ICU with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). Delivery was planned. The patient began reporting bilateral blurring of vision. What could be your concern?

Answer: Retinal detachment

Retinal detachment is an unusual but very well-documented complication of severe preeclampsia and patients with HELLP syndrome. An emergent ophthalmic consultation should be obtained in conjunction with the planned delivery.

#ob-gyn

# ophthalmology

#hepatology

Reference:

1. Teodoru CA, Tudor C, Cerghedean-Florea ME, Dura H, Tănăsescu C, Roman MD, Hașegan A, Munteanu M, Popa C, Vică ML, Matei HV, Stanca H. Bilateral Serous Retinal Detachment as a Complication of HELLP Syndrome. Diagnostics (Basel). 2023 Apr 26;13(9):1548. doi: 10.3390/diagnostics13091548. PMID: 37174940; PMCID: PMC10178147.

2. Vigil-De Gracia P, Ortega-Paz L. Retinal detachment in association with pre-eclampsia, eclampsia, and HELLP syndrome. Int J Gynaecol Obstet. 2011 Sep;114(3):223-5. doi: 10.1016/j.ijgo.2011.04.003. Epub 2011 Jun 29. PMID: 21719013.

3. Li M, Qu J. Exudative retinal detachment and hypertensive choroidopathy in a patient with suspected HELLP syndrome: a case report. BMC Ophthalmol. 2025 Jul 1;25(1):353. doi: 10.1186/s12886-025-04176-8. PMID: 40597840; PMCID: PMC12210448.