Chronic Diarrhea and Metabolic Acidosis Associated With Topiramate Use

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This is a case of a 58-year-old woman who visited the Emergency Department because of recurrent mechanical falls and chronic joint pain over her left shoulder and right hip that got worse 4 days before her hospital visit. On review of systems, she reported chronic, nonbloody diarrhea for approximately 5 years, in no treatment. Her medical history was significant for osteoarthritis, epilepsy, migraine headaches, repaired intracranial aneurysm, bipolar disorder, hypertension, and asthma. Home medications are topiramate 225 mg orally twice a day, Zoloft 50 mg orally at bedtime, and albuterol as needed to treat her asthma.
Her vital signs were stable with blood pressure of 118/77 mm Hg, heart rate of 82 beats per minute, respiratory rate of 16 breaths per minute, temperature of 98°F, and oxygen saturation at room air of 100%. Physical examination showed limited active range of motion on the left shoulder and right hip because of pain; no overt signs of trauma or neurologic deficits were appreciated. The rest of physical evaluation was unremarkable.
Laboratory investigation was significant for a serum chloride of 114 mEq/L, bicarbonate of 16 mEq/L, potassium of 3.8 mEq/L, blood urea nitrogen of 15 mg/dL, creatinine of 0.8 mg/dL, and glucose of 104 mg/dL. Venous pH was 7.37. Hemoglobin was 13.1 g/dL and white blood cells was 10,000 mm3. Urine electrolytes showed sodium of 18 mmol/L, potassium of 27.5 mmol/L, and chloride of 29 mmol/L. Urine pH was 6.5. Skeletal x-rays were negative for fractures or osteoporosis.

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