Hypophosphatemia in Emergency Medicine Clinical Presentation

  • Author: Devon J Moore, MD; Chief Editor: Erik D Schraga, MD   more...
 
Updated: Apr 26, 2012
 

History

  • Weakness is the most common symptom suggesting hypophosphatemia and may involve any muscular system to any extent.
    • Diplopia
    • Dysarthria
    • Dysphagia
    • Weakness of trunk or extremities, particularly the large muscle groups
  • Symptoms of respiratory insufficiency or myocardial depression may indicate hypophosphatemia.
  • Neurologic symptoms may vary, ranging from simple paresthesias to profound alterations in mental status.
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Physical

  • Muscle weakness is the most common physical finding; careful assessment of motor strength on neurologic examination is critical. Weakness may be subtle or profound and may involve any muscle group.
  • Diminished respiratory rate and tidal volume may reflect respiratory impairment due to hypophosphatemia; however, tachypnea may be present, an important clue to one of the most common etiologies of hypophosphatemia (respiratory alkalosis).[2]
  • Hypotension and cardiac compromise due to severe hypophosphatemia is rare.
  • The skin and conjunctivae may be pale secondary to the hemolytic anemia that may complicate hypophosphatemia.
  • Signs of rhabdomyolysis may be present on extremities.
  • Mental status abnormalities may occur with severe hypophosphatemia, ranging from simple irritability or confusion to florid altered mental status and coma.
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Causes

  • The ED physician is most likely to encounter hypophosphatemia in patients withdrawing from alcohol and in patients undergoing treatment for DKA.
  • Other risk factors
    • Chronic alcoholism
    • Chronic ingestion of phosphate-binding antacids
    • Patients on total parenteral nutrition (TPN) with inadequate phosphate supplementation
    • Refeeding after prolonged starvation (eg, anorexia nervosa)
  • Hypophosphatemia may also occur in the setting of thyrotoxic periodic paralysis (TPP). If considering this diagnosis, the presence of hypophosphatemia suggests TPP rather than spontaneous periodic paralysis, in which phosphorus levels are likely to be normal.
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Contributor Information and Disclosures
Author

Devon J Moore, MD  Resident Physician, Department of Emergency Medicine, Wayne State University Detroit Medical Center, Detroit Receiving Hospital

Devon J Moore, MD is a member of the following medical societies: American Medical Student Association/Foundation, Emergency Medicine Residents Association, and Wayne State School of Medicine Black Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Rosh, MD  Assistant Professor, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Robin R Hemphill, MD, MPH  Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Howard A Bessen, MD  Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

References

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  2. Datta BN, Stone MD. Hyperventilation and hypophosphataemia. Ann Clin Biochem. Mar 2009;46:170-1. [Medline].

  3. Mehanna H, Nankivell PC, Moledina J, Travis J. Refeeding syndrome - awareness, prevention and management. Head Neck Oncol. Jan 26 2009;1(1):4. [Medline].

  4. Nowik M, Picard N, Stange G, Capuano P, Tenenhouse HS, Biber J, et al. Renal phosphaturia during metabolic acidosis revisited: molecular mechanisms for decreased renal phosphate reabsorption. Pflugers Arch. Nov 2008;457(2):539-49. [Medline].

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  9. Bastepe M, Juppner H. Inherited hypophosphatemic disorders in children and the evolving mechanisms of phosphate regulation. Rev Endocr Metab Disord. Jun 2008;9(2):171-80. [Medline].

  10. Crook MA. Management of severe hypophosphatemia. Nutrition. Mar 2009;25(3):368-9. [Medline].

  11. Domrongkitchaiporn S, Disthabanchong S, Cheawchanthanakij R, Niticharoenpong K, Stitchantrakul W, Charoenphandhu N, et al. Oral Phosphate Supplementation Corrects Hypophosphatemia and Normalizes Plasma FGF23 and 25-Hydroxyvitamin D3 Levels in Women with Chronic Metabolic Acidosis. Exp Clin Endocrinol Diabetes. May 15 2009;[Medline].

  12. Fukumoto S. Physiological regulation and disorders of phosphate metabolism--pivotal role of fibroblast growth factor 23. Intern Med. 2008;47(5):337-43. [Medline].

  13. Ghosh AK, Joshi SR. Disorders of calcium, phosphorus and magnesium metabolism. J Assoc Physicians India. Aug 2008;56:613-21. [Medline].

  14. Juppner H. Novel regulators of phosphate homeostasis and bone metabolism. Ther Apher Dial. Oct 2007;11 Suppl 1:S3-22. [Medline].

  15. Moe SM. Disorders involving calcium, phosphorus, and magnesium. Prim Care. Jun 2008;35(2):215-37, v-vi. [Medline].

  16. Oud L. Transient hypoxic respiratory failure in a patient with severe hypophosphatemia. Med Sci Monit. Mar 2009;15(3):CS49-53. [Medline].

 
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