The Decade-Long Potassium Puzzle: Betel Nut Chewing as the Etiology of Chronic Hypokalemia

Introduction: Alternative medicines can have overlooked side effects. Betel nut, widely used in Asia and Africa for its purported health benefits, poses significant health risks, including metabolic abnormalities and addiction. This case shows how betel nut chewing can cause chronic hypokalemia, hypophosphatemia, and hypercalcemia, highlighting the need to consider cultural practices and the use of alternative medicines when diagnosing electrolyte disorders. Unlike previous reports focusing on hypercalcemia and metabolic alkalosis, we highlight severe, recurrent hypokalemia. Case Description: A 48-year-old Karen-speaking woman from Thailand, with type 2 diabetes and hepatitis B, presented in 2014 with asymptomatic hypokalemia. For the next decade, she had severe, recurrent hypokalemia (1.9-3.3 mmol/L), frequently requiring ED visits for temporary fixes. Lab testing also showed hypercalcemia (10.2-10.8 mg/dL), hypophosphatemia (0.8-1.9 mg/dL), and metabolic alkalosis. A urine potassium-to-creatinine ratio was high (17 meq/g), indicating renal potassium wasting. A renal ultrasound revealed medullary nephrocalcinosis, suggesting hypercalciuria. Ultimately, daily betel nut use was identified as the cause of her renal potassium losses. Low health literacy, medication non-adherence, and a language barrier complicated her management. Despite counseling, the patient declined to discontinue use. Discussion: The electrolyte abnormalities linked to betel nut result from mixing it with alkaline calcium salts to enhance taste. These salts increase intestinal calcium absorption causing hypercalcemia. They also bind phosphate in the gut, causing hypophosphatemia. The resulting hypercalcemia induces a Bartter's-like syndrome, inhibiting the Na-K-2Cl cotransporter in the loop of Henle, causing renal potassium loss and increased bicarbonate reabsorption in the proximal tubule. Her age makes a genetic form of Bartter’s syndrome unlikely. Learning points: -Betel nut chewing can cause hypokalemia, hypercalcemia, hypophosphatemia and metabolic alkalosis. -Healthcare providers should always take a detailed supplement history and consider how cultural background may affect disease presentation.The process by which betel nut causes multiple electrolyte abnormalities.