Reverse pseudohyperkalemia in a newly diagnosed pediatric patient with acute T-cell leukemia and hyperleukocytosis: a case report and literature review

Background Hyperkalemia is a serious medical condition that requires immediate intervention. However, pseudohyperkalemia and reverse pseudohyperkalemia are misleading clinical manifestations that can result in incorrect diagnosis and consequent harmful intervention. Case presentation An 11-year-old girl manifested an incidental finding of hyperleukocytosis (WBC > 400 x 10.sup.9/L), with 90% blast cells during routine pre-operative investigations for adenotonsillectomy. Initial investigations demonstrated elevated serum potassium levels (7.5 mmol/L), despite concomitantly normal levels in venous blood gas samples (3.9-4.4 mmol/L) and being clinically stable with normal 12-lead ECG. Surprisingly, plasma potassium level was exacerbated, in comparison to the serum level by > 1 mmol/L. This finding is consistent with reverse pseudohyperkalemia that is associated with hyperleukocytosis in acute leukemia that does not require any active intervention. Conclusion This case report emphasizes the significance of interpreting potassium levels accurately, preferably utilizing whole-blood potassium level over serum and plasma level in newly diagnosed leukemia cases with hyperleukocytosis. Additionally, having a high index for the possibility of reverse pseudohyperkalemia, secondary to leakage from fragile leukocytes, avoids unnecessary treatment that might cause harm to the patient. Keywords: Hyperkalemia, Pseudohyperkalemia, Hyperleukocytosis, Leukemia