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McKittrick-Wheelock syndrome is characterized by secretory diarrhea and severe electrolyte and fluid depletion caused by a large, distal colon, villous adenoma. It was first described in 1940 as a 'pre-renal uremia due to papilloma of the rectum'. Due to its hypersecretory nature, the tumor may cause more than 4 L of secretory diarrhea per day, with a content of sodium that is approximately four times higher than in normal stool. Unbelievably, it can be unreported by patients and thus overlooked as a cause of severe hyponatremia and acute kidney injury.
We present the case of a patient with acute kidney injury and chronic secretory diarrhea, who was diagnosed with McKittrick-Wheelock syndrome and received necessary surgical treatment, as a result of the prompt reaction, multidisciplinary approach, and good collaboration between nephrologist, gastroenterologist, and surgeon.
A 70-year-old female patient presented to the Nephrology Department with acute kidney injury and oliguria. Physical examination revealed dehydration and hypotension. The most prominent laboratory features on admission were severe hyponatremia and hypokalemia, and the rest of the laboratory results are summarized in Table 1. A thorough medical history was obtained and only when asked explicitly about the bowel movement, the patient admitted having watery diarrhea of 8 months duration. A colonoscopy and CT scan showed a 10-cm long polypoid tumor located at the rectosigmoid level and a biopsy was taken. The patient was started on intensive therapy for fluid and electrolyte replacement, however, COVID-19-related staff and bed shortages led to her early discharge from the hospital. A few days later, she presented again with a marked worsening of the sodium depletion, provoked by the intense physical activity of transporting and shoveling coal at her home earlier that day. In the meantime, her biopsy result showed villous adenoma, and consultation with a gastroenterologist led to the diagnosis of Mckittrick-Wheelock syndrome. Once resuscitated with fluid and electrolyte replacement, the patient was transferred from the Nephrology Department to the operating room. Her postsurgical recovery was difficult, with lingering infectious complications. However, renal function was stable and she maintained a normal serum creatinine and electrolyte profile at 6-month follow-up (Table 1).
McKittrick-Wheelock syndrome is not common but it is also often overlooked. It may persist for years until compensatory mechanisms such as increased fluid and salt intake and renal adaptation collapse. Also, in our experience, patients living with chronic symptoms may become used to them and forget to report them, or feel ashamed and hide them, which contributes significantly to the delay in diagnosis. We emphasize the importance of asking focused clinical questions about conditions that often cause kidney damage when taking a patient’s history. This case report demonstrates our experience of how taking a proper patient history prevented, not only future acute kidney injury episodes that represent a risk factor for permanent kidney damage, but also potential death.