Hyperkalemia is a complex laboratory abnormality. There are varying degrees of true hyperkalemia, pseudohyperkalemia, and even reverse pseudohyperkalemia which must be distinguished from one another. We present a case of reverse pseudohyperkalemia in an elderly male with a hematologic malignancy found to have an elevated potassium level on admission. Both plasma and serum levels were measured, plasma level was high while serum levels were normal, and a diagnosis of reverse pseudohyperkalemia was made. Awareness and increased suspicion result in rapid diagnosis, and prevent overtreatment and iatrogenic complications.

Myxomatous degeneration generally involves the atrioventricular valves (mitral and tricuspid). Rarely, it may affect the aortic or pulmonary valve. We report a case of an acute severe aortic insufficiency due to a rupture of a commissure of the aortic valve in a patient who had previously undergone mitral valve surgery for myxomatous mitral valve prolapse.

53-year-old man with history of hypertension, type 2 diabetes, peripheral vascular disease, and end-stage renal disease on continuous cycling peritoneal dialysis presented to the emergency department with generalized weakness and found to have findings concerning for severe sepsis. Vital signs on presentation: T-max 35.7 C, BP 92/59 mm Hg, HR 97 per minutes, and RR 25 per minutes. Physical examination revealed painful blackish necrotic discoloration of the perimeatal tissues and ventral side of glans penis with no evidence of infection as shown in Figure 1. Urology was consulted and recommended supportive care with local wound care for presumed penile calciphylaxis. Biopsy was discussed but deferred due to high likelihood that the biopsy site will never heal and will lead to further decline. Laboratories revealed serum calcium 9.6 mg/dL, serum phosphorus 6.7 mg/dL, and PTH 163 pg/mL and elevated WBCs 19.2 ×10(3) cells/mcL. With the presumptive diagnosis of penile Calciphylaxis, CTA pelvis was taken, revealing extensive calcification of penile vasculature. The patient was treated with broad-spectrum IV antibiotics, switched to hemodialysis, received adequate wound care, pain control, aggressive phosphorus control, and lower dialysate calcium with palliative care to improve quality of life. On follow up, patient is getting better with resolution of skin ulcers and improvement of pain symptoms. Calciphylaxis or calcific uremic arteriolopathy is a syndrome characterized by calcification of vessels located in the dermis and adipose tissue. It commonly occurs in patients with end-stage renal disease, diabetes mellitus, hypertension, and obesity. 1 Penile involvement is an uncommon but severe manifestation. Pathologic evaluation should be used

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