Fatal Refractory Hypokalemic Paralysis Secondary to Occupational Toluene Exposure: A Case Report

• nabila choubane

  University of Health Sciences, Faculty of Medicine Youcef El Khatib Department of Emergency Medicine, University Hospital of Algiers, Algeria

Background

Hypokalemic paralysis is a life-threatening emergency requiring rapid etiological identification. Distal renal tubular acidosis (dRTA) induced by chronic toluene exposure is a rare and underrecognized cause, most commonly reported in the context of recreational solvent inhalation. Fatal outcomes secondary to occupational exposure remain exceptionally uncommon in the published literature.

Case Presentation

We report a 42-year-old male carpenter with long-standing occupational exposure to organic solvents who presented with acute progressive flaccid quadriparesis. Laboratory evaluation revealed severe hypokalemia (1.0 mmol/L), hyperchloremic metabolic acidosis with a normal anion gap, hypomagnesemia, and preserved renal function. Urinalysis demonstrated inappropriate renal potassium wasting with a urine pH of 5,paradoxically elevated despite systemic acidemia (arterial pH 7.31),consistent with impaired distal tubular acidification. Electrocardiography showed typical hypokalemic changes including flattened T waves and prominent U waves. Guillain–Barré syndrome was excluded on the basis of normal cerebrospinal fluid analysis and non-demyelinating electroneuromyography. Despite aggressive intravenous potassium and magnesium replacement, hypokalemia remained refractory. The patient developed progressive respiratory muscle involvement and died on day 5 from refractory malignant ventricular arrhythmias.

Conclusion

This case highlights toluene-induced dRTA as a rare but potentially fatal cause of hypokalemic paralysis, even in occupational settings without deliberate solvent inhalation. The characteristic biochemical triad, normal anion gap metabolic acidosis, renal potassium wasting, and paradoxically alkaline urine, should prompt early consideration of this diagnosis. Clinicians must maintain a high index of suspicion in patients with relevant occupational exposure, as refractory hypokalemia carries a significant risk of fatal cardiac arrhythmias.

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