Neuromuscular manifestations of electrolyte disorders

  • James P. Knochel
    Requests for reprints should be addressed to Dr. James P. Knochel, Medical Service (111), VA Medical Center, 4500 South Lancaster Road, Dallas, Texas 75216.
    Dallas, Texas USA
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  • Author Footnotes
    1 From the Veterans Administration Medical Center, and the Department of Internal Medicine, University of Texas Southwestern Medical School, Dallas, Texas.
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      A large variety of diseases encountered in clinical medicine are associated with symptoms suggestive of neuromuscular dysfunction. The myalgia of viral prodromes, the muscular cramps of hyponatremia and the weakness of potassium deficiency are well known examples. Although investigation of the myopathic components of these illnesses is fragmentary, those that have been examined show abnormalities compatible with subtle alterations of ion transport and, when sought out, histologic changes of muscle fiber injury or necrosis. Certain electrolyte and divalent ion deficiencies are likely to cause such findings, especially those related to potassium and phosphorus. The precise mechanism by which cellular injury occurs in electrolyte derangements has not been clearly elucidated. However, in potassium deficiency, for example, at least three potentially harmful effects occur: (1) abnormally low muscle blood flow with exercise; (2) suppression of glycogen synthesis and storage in muscle; (3) deranged ion transport. In consonance with these observations, it can be shown that once a muscle cell is injured, even when the injury is subclinical, superimposition of any stress that demands substantial expenditure of energy so as to deplete muscle energy stores can apparently precipitate frank rhabdomyolysis. The combined influence of exericise and fasting is a prime example. New information based upon observations in patients and limited experimental studies in animals suggests that skeletal muscle cells, under conditions of certain specific electrolyte derangement, show a common pattern of changes characterized by abnormal electrogenesis (abnormal resting transmembrane potential difference) and elevation of intracellular Na concentration. Such changes could well set the stage for irreversible cellular injury by another important mechanism. Thus, depression of the normally high concentration ratio of sodium ions between extracellular and intracellular fluids or depression of membrane potential could impair the normal exchange of extracellular sodium for intracellular calcium ions. Impressive evidence suggests that if calcium ions thereby attain a critical elevated value in the sarcoplasm, autodestructive proteases are activated that can destroy the cell. The field of interest concerning electrolyte and divalent ion disorders and their implication in rhabdomyolysis is newly emerging. In this paper, the current information on these disorders is reviewed. With license, considerable speculation will be inserted on those disorders not yet adequately examined.
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