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A 40-year-old woman presented to the emergency department with pain, weakness, and poor oral intake. In the 3 months preceding presentation, she noticed the gradual onset of bilateral diffuse flank pain that progressed to affect her lower back, abdomen, and both arms and legs. She eventually became homebound. The patient reported poor appetite and reduced food intake and had lost approximately 4 kg. Nausea developed 2 days before presentation, and the patient became unable to take anything by mouth, which prompted her to seek evaluation.
The physical examination revealed a cachectic, ill-appearing woman in distress from pain. The medical history included an immature teratoma, which had been treated 10 years before presentation and a history of chronic infection with hepatitis B virus. Because the infection did not respond adequately to the prior regimens, treatment had been changed to tenofovir 10 months earlier.
Laboratory results revealed severe hypokalemia. A bone scan showed multiple abnormal areas with increased tracer uptake, particularly in the left humerus, the right femoral neck, and the bony thorax.
This patient had a dramatic presentation, which raised the suspicion for metastatic cancer. Although the findings on the bone scan strengthened this suspicion, several metabolic abnormalities — including profound hypokalemia and metabolic acidosis — were not consistent with this diagnosis.
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