This report details a case of hypermagnesemia associated wit | Figure 1
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This report details a case of hypermagnesemia associated with using milk of magnesia.
A 73-year-old man with end-stage renal disease, diabetes, hypertension, peripheral vascular disease, coronary artery disease, and past coronary artery bypass grafting was given multiple daily doses of milk of magnesia for constipation. After developing persistent nausea and vomiting, he was transported to the emergency department and during transit to the hospital, developed severe bradycardia followed by asystolic cardiac arrest. Resuscitation efforts were successful; however, he developed atrial fibrillation with severe widening of the QRS and diffuse ST elevation, hypothermia, hypotension and apnoea requiring intubation. Initial diagnoses included ST-elevation myocardial infarction, cardiogenic and/or septic shock and hyperkalaemia. However, serum magnesium was later found to be >4.1 mmol/L (equivalent to >10 mg/dL). He underwent haemodialysis (HD) to remove serum magnesium with remarkable overall improvement.
Severe hypermagnesemia can manifest with severe bradycardia and asystole, shock, hypothermia and respiratory failure and can mimic acute coronary syndromes complicated with cardiogenic shock or septic shock. Clinicians should be aware of this life-threatening condition in patients with significant renal dysfunction. Timely treatment with HD is highly effective and lifesaving.
Similar cases
A 56 year-old man with a history significant for hypertension and hyperlipidemia reported to the emergency department with rapid onset of severe, pressure like chest pain radiating to his left arm and jaw that was accompanied by diaphoresis and lightheadedness. On examination, he was hypotensive, tachycardic and diaphoretic with cool extremities and raised jugular venous pressure. ECG was characterised by massive anterior ST-segment elevation consistent with acute anterior wall infarct. Cardiogenic shock persisted, despite early resuscitative therapy with intravenous fluids and vasopressors.
The patient had urgent coronary angiography, which demonstrated a severe multivessel disease. The LAD had 100% stenosis, left main coronary artery 90% stenosis and circumflex artery 75% stenosed. An emergency percutaneous coronary intervention was performed in the LAD and left main arteries, with balloon angioplasty followed by insertion of drug-eluting stents. Following the procedure, the patient was transferred to the coronary care unit with inotropic and vasodilator support, dual antiplatelet therapy, anticoagulation and full medical management.
His hemodynamic condition continued to improve over the following 7 days, and he regained some left ventricular function. A repeat echocardiogram 2 weeks after the procedure showed an ejection fraction of 38% with multifocal areas of myocardial dyskinesis and akinesis in anterior and apical segments. He was clinically improved with persistent fatigue and mild exercise dyspnea, but otherwise continued to ambulate well and he advanced to formal cardiac rehabilitation. The patient continued to improve functionally after 1 month of intensive rehabilitation and medical treatment. His ejection fraction was improved to 45% and he could climb a few steps of stairs without dyspnea or chest pain. On repeat echocardiography, there was no change in EF, but mild diastolic noncompliance with post-infarction ventricular remodeling were documented. Lifelong follow-up was scheduled to maximize medical therapy, assess recovery of ventricular function and minimize risk for recurrent ischemic events.
You are called urgently to the operating room to aid cardiovascular imaging in a patient after coronary bypass grafting surgery who has just been taken off the cardiopulmonary bypass pump. The anesthesiologist has noted new ST segment elevation on the electrocardiogram monitor. You note heterogeneity in wall motion in the indicated area (arrows) and conclude:
A. Left anterior descending artery distribution ischemia B. Cardiogenic shock and global myocardial ischemia C. Left circumflex artery distribution ischemia D. Right coronary artery distribution ischemia
Image Description: (A) Angiogram of left anterior descending coronary artery showing 100% occlusion without evidence of atherosclerotic coronary artery disease concerning for a septic embolus (blue arrow). (B) Transesophageal echo view showing medium-sized, 1.3 cm (L) × 1.0 cm (W), mobile vegetation on the atrial aspect of the tip of the anterior leaflet of mitral valve (red arrow). (C) Gross specimen showing vegetation involving the mitral valve leaflets. Case Description: Acute myocardial infarction (AMI) is a rare but recognized and potentially serious complication of infective endocarditis (IE). This case describes the challenges surrounding the management of AMI in the setting of septic coronary embolism, brain, spleen, and kidney infarcts due to septic emboli from native mitral valve IE.