Thyrotoxic periodic paralysis

HYPOKALEMIC PERIODIC PARALYSIS IN A PATIENT WITH EUTHYROID GRAVES DISEASE AND CELIAC DISEASE

Objective

Thyrotoxic periodic paralysis is a sporadic form of hypokalemic periodic paralysis (HPP) that is most commonly seen in patients with Graves disease (GD) in association with acute thyrotoxicosis. A very few cases of HPP have been reported in patients with GD while the patient was euthyroid.

Methods

We describe a case of a 62-year-old Caucasian male with a history of GD, who presented with acute progressive bilateral lower extremity weakness.

Results

The patient was found to have severe hypokalemia, with no evidence of diarrhea or increased urinary potassium excretion. He was diagnosed as having HPP. He remained clinically and biochemically euthyroid during the admission. There was no history of high-carbohydrate meal intake, intense exercise, recent steroid exposure, or unusual stress. His symptoms improved gradually over the next 3 to 4 days with potassium supplementation. Nine months later, he progressed to overt hyperthyroidism and was treated with 25 mCi of iodine-131 and following that he has been on levothyroxine replacement for post-ablative hypothyroidism. Other unusual features in this patient were hypocalcemia, hypomagnesemia, and vitamin D deficiency during the acute presentation. Serum calcium and magnesium normalized 2 days after admission, while serum vitamin D continued to be low. He was later diagnosed to have celiac disease.

Conclusion

Our case adds a rare presentation of HPP in a euthyroid patient with a known history of GD with associated celiac disease, hypomagnesemia, and hypocalcemia to the literature.

Thyrotoxic Periodic Paralysis: A Case of Two Brothers

In this article, we describe the presentation of thyrotoxic periodic paralysis of two brothers at the same time. A positive family history in this condition is rare. Early identification and cautious potassium supplementation in this entity prevents complications arising from potassium shifts. (Hong Kong j.emerg. med. 2001;8:159–162)

Thyrotoxic periodic paralysis: correct hypokalemia with caution

BACKGROUND

Thyrotoxic periodic paralysis is rare in Caucasian populations, but affects approximately 2% of East Asians with thyrotoxicosis (13% of males, 0.17% of females). The presentation is characterized by abrupt-onset hypokalemia and profound proximal muscular weakness, and commonly occurs after carbohydrate loading or exercise.

OBJECTIVES

To raise awareness of this condition through the description of a typical case of thyrotoxic periodic paralysis; to remind readers that, despite intravascular hypokalemia, total body potassium is normal and that correction must be done with caution; to highlight the differences in treatment compared to familial hypokalemic periodic paralysis.

CASE REPORT

We describe the presentation of a 36-year-old Filipino man with a background history of Graves disease. Over-administration of intravenous potassium was narrowly averted in this case.

CONCLUSION

It may be important to check thyroid function in patients presenting with acute paralysis, especially those of Asian origin. In patients with thyrotoxic periodic paralysis, administration of potassium, with cardiac monitoring and a total dose of <50 mmol, limits the dysrhythmia risk. Patients are likely to benefit from the prescription of non-selective beta-blockers until they become euthyroid. In contrast to familial periodic paralysis, regular oral potassium supplementation is ineffective in thyrotoxic periodic paralysis, and acetazolamide precipitates, rather than prevents, attacks.

Thyrotoxic periodic paralysis and anesthesia report of a case and literature review

Thyrotoxic periodic paralysis (TPP) is a disease characterized by recurrent episodes of paralysis and hypokalemia during a thyrotoxic state. The disease primarily affects people of Asian descent, but can affect other ethnic groups. In Asians, the symptoms of thyrotoxicosis are distinct and usually precede the first paralytic episode, whereas in non-Asian populations, paralysis is the presenting symptom. If TPP has not been diagnosed and the patient has a surgical procedure during general or regional anesthesia, symptoms of the disease may be confused with other adverse perioperative events such as delayed recovery from neuromuscular paralysis. No specific anesthetic regimen is superior. Current TTP treatment recommendations involve treating the underlying hyperthyroid state. Other modalities such as beta-blockade and potassium replacement are also important in the acute paralytic state. Future diagnostic and treatment innovations may lie in the genetic and molecular understanding of this disease. We present a case of an Asian male with known TPP undergoing general anesthesia, a brief case series involving 5 patients, and a review of the literature.

Thyrotoxic periodic paralysis in a Turkish male; the recurrence of the attack after radioiodine treatment

Thyrotoxic hypokalemic periodic paralysis (THPP) is a rare complication of hyperthyroidism and an uncommon form of hypokalemic periodic paralysis. Its differentiation of more common forms of periodic paralysis is important because aggressive treatment can place the patient at risk for rebound hyperkalemia. Treatment of the underlying thyroid dysfunction cures the muscle symptoms. Here we describe a 37-year-old Turkish male with THPP whose paralysis attack recurred soon after administration of radioactive iodine.

Paralisia periódica hipocalêmica tireotóxica: relato de 3 casos

Paralisia Periódica Hipocalêmica Tireotóxica (PPHT) é uma complicação rara do hipertireoidismo, mais freqüente em orientais que brancos. Apresentamos três pacientes do sexo masculino, brasileiros, cujas idades eram de 28 anos (caso 1), 29 anos (caso 2) e 60 anos (caso 3) com diagnóstico de PPHT. Foram admitidos com tetraparesia das extremidades, tendo o caso 1 relatado crises recorrentes de paralisia e os casos 2 e 3, apenas um episódio. No caso 1, estavam presentes sinais e sintomas de hipertireoidismo como emagrecimento, sudorese, tremor de extremidades, palpitação e bócio difuso discreto, enquanto no caso 2 manifestou-se apenas oftalmopatia, e o terceiro paciente referia diagnóstico de fibrilação atrial pregressa sem avaliação da função tireoidiana. Exames laboratoriais mostraram hipocalemia, TSH suprimido e T4 livre elevado em todos os pacientes. Foram tratados com potássio intravenoso, propranolol e tiamazol via oral, com remissão dos sintomas. O relato dos casos destaca a freqüente dificuldade diagnóstica desta enfermidade que apresenta evolução favorável quando diagnosticada e tratada adequadamente.

Thyrotoxic periodic paralysis: an overview

Thyrotoxic periodic paralysis (TPP) is a fairly common manifestation of hyperthyroidism in Asian populations, with an incidence of about 1.9% in thyrotoxic patients, but it is rarely diagnosed among Caucasians and blacks in the Western world. The diagnosis often can be made on the basis of the clinical manifestations alone. Sometimes, periodic paralysis precedes hyperthyroidism or occurs in silent hyperthyroidism. As a result, physicians may easily overlook it even when life-threatening hypokalemia is present. The pathophysiology of this disorder is still not well understood. Correction of the thyrotoxic state is the definitive treatment. Potassium supplementation, propranolol, and spironolactone may be helpful both in the acute state and in preventing attacks.

Thyrotoxicosis and paraparesis in a young woman: case report and review of the literature

We describe a 23-year-old woman with a 3-week history of episodic leg weakness. The onset of weakness always occurred in the evening after dinner and the attacks resolved spontaneously by morning. Physical examination revealed a resting tachycardia and symmetrical, proximal weakness involving both arms and legs. Electrocardiogram (ECG) and electrolyte analysis showed a severe hypokalemia and thyroid function tests showed hyperthyroidism. The patient was diagnosed as having Graves' thyrotoxicosis and thyrotoxic periodic paralysis (TPP) and was initially treated with propranolol and subsequently carbimazole. No recurrence of the paralysis has been noted. TPP is most common in males of Asian extraction and is rare in women even in the Asian population. With increasing immigration, TPP is likely to occur more frequently in both Europe and North America and awareness of the condition is vital. Treatment of the underlying thyroid dysfunction cures the muscle symptoms.

Answer

The correct diagnosis is D. In this case, a routine electrolyte screen revealed a serum potassium of 1.7 mmol/L (normal = 3.5−5.0) and a serum phosphate of 0.39 mmol/L (0.80–1.60). Calcium, magnesium, creatine kinase and ESR (erythrocyte sedimentation rate) were normal.

Hypokalemic periodic paralysis associated with hypophosphatemia in a patient with hyperinsulinemia

A 34-year-old man was admitted to the hospital because of acute quadriplegia. On admission, serum potassium was 2.1 mEq/L and serum inorganic phosphate was 1.4 mg/dL. Thyroid function was normal. Serum levels of aldosterone, cortisol, and intact parathyroid hormone were normal. Fasting plasma glucose was 109 mg/dL, and fasting serum insulin was 25.0 U/mL. Shortly after intravenous supplementation of potassium, muscle strength was normalized. Oral glucose tolerance test revealed impaired glucose tolerance and hyperresponse of insulin. During the oral glucose tolerance test, serum potassium and phosphate decreased significantly. These findings suggest that hyperinsulinemia and insulin-induced transmembrane shift of extracellular potassium and phosphate may have been involved in the abnormalities of serum electrolytes and development of hypokalemic periodic paralysis in the present patient.

Normokalemic thyrotoxic periodic paralysis: a new therapeutic strategy

An unusual presentation of periodic paralysis in a Mexican man with thyrotoxicosis is presented. The patient suffered paralysis of the lower extremities without apparent precipitating factors such as hypokalemia, exercise, carbohydrate or alcohol ingestion. Hyperthyroidism was managed first with a thyroid suppressant (methimazole) and propranolol. Prednisone was added after another episode of paralysis. Definitive treatment of hyperthyroidism was achieved with radioactive iodine, which subsequently required substitution therapy with thyroxine. A moderate dose of thyroxine (100 microg) caused muscular weakness. Treatment of thyrotoxicosis and flaccid paralysis as well as the effects of glucocorticoids on thyroid function are discussed.

Thyrotoxic periodic paralysis associated with hypokalemia and hypophosphatemia

We report the rare case of a 43-year-old African-American man with thyrotoxic periodic paralysis associated with hypokalemia and hypophosphatemia. Both serum potassium and serum phosphate levels returned to normal after supplementation with only potassium. We consider the unusual condition of hyperthyroid-related hypokalemia and hypophosphatemia to have contributed to the acute paralysis in this patient.

Clinical and socioeconomic predispositions to complicated thyrotoxicosis: a predictable and preventable syndrome?

PURPOSE

To identify the clinical, demographic, and hormonal features that characterize and place patients at greater risk for complicated thyrotoxicosis.

PATIENTS AND METHODS

Fifty-nine patients with documented thyrotoxicosis complicated by cardiovascular, neuropsychiatric, gastrointestinal, or thermoregulatory dysfunction, were retrospectively identified among 498,000 hospital admissions between 1979 and 1992. Clinical, demographic, and hormonal information were obtained from these charts, as well as from the charts of 118 randomly selected thyrotoxic outpatients.

RESULTS

Age distribution of complicated thyrotoxicosis patients was bimodal, with a median of 41 years. Forty-nine percent of patients had been previously diagnosed with thyrotoxicosis, but most had been noncompliant with prescribed medication. Cardiovascular complications were among the primary causes for admission in 46% of patients, followed by neuropsychiatric indications in 42%, fever in 34%, and gastrointestinal dysfunction in 17%. Only 8% had primary involvement of > 2 organ systems. There was high correlation between organ systems with pre-existing dysfunction and those with a complication of thyrotoxicosis (P < 0.0001). Compared to uncomplicated controls, patients with complicated thyrotoxicosis were more likely to be uninsured or covered by Medicaid (OR, 2.64; 95% CI 1.78 to 3.91); to be < 30 or > 50 years old (OR, 1.93; 95% CI 1.23 to 3.03); and to have serum T4 concentrations greater than twice the upper limit of normal (OR, 1.67; 95% CI, 1.15 to 2.44).

CONCLUSIONS

Certain thyrotoxic patients are at greater risk for developing complications. By addressing the medical needs of these patients, it may be possible to reduce the likelihood of complications requiring hospitalization.

[Thyrotoxic periodic paralysis. Discussion of the role of Na-K-ATPase, apropos of a case]

We report a case of thyrotoxicosis periodic paralysis (TPP), occurring as a complication of a Grave's disease in a 31 year-old Caucasian male. It has been suggested that the membrane Na-K pump was involved in the pathogenesis of this complication. In our patient, before treatment, the activity of erythrocyte Na-K-ATPase was significantly decreased, as compared with healthy subjects (228nmol Pi/mg prot/h versus 298 + 60 nmol Pi/mg prot/h) and went back to normal levels post treatment. The activity of this enzyme seems to be prone to genetics factors as well as environmental ones. This would explain the higher incidence of TPP in male and in asiatic people. However, other reports emphasize the role of Na-K-pump-independent potassium influx, which would be more specific of TPP.

Thyrotoxic periodic paralysis terminated with intravenous propranolol

Thyrotoxic periodic paralysis (TPP) is an uncommon syndrome that can be fatal. We report the case of a patient with acute, severe muscle weakness and hypokalemia who was diagnosed in the emergency department to have thyrotoxicosis with acute TPP. The hypokalemia was treated aggressively with potassium without effect. After administration of i.v. propranolol, the patient had complete resolution of symptoms, with mild rebound hyperkalemia. The literature on the use of propranolol in TPP is reviewed, and the known pathophysiology of TPP is discussed.

Neurologic complications of thyroid and parathyroid disease

Common thyroid and parathyroid disorders present with reversible neurologic signs and symptoms affecting the central and peripheral nervous system, musculature, and mental function. Patients with thyrotoxicosis may have myopathy, spasticity, seizures, and multiple psychiatric symptoms. A deficiency of thyroid hormone also causes muscle weakness and may be accompanied by reversible muscle hypertrophy or movement disorders. The chronic hypercalcemia that develops secondary to hyperparathyroidism produces many psychiatric and cognitive symptoms, as well as a reversible myopathy. Calcium deficiency leads to neuromuscular irritability, paresthesias, and tetany. Psychiatric disorders are also common in this disorder.

Hyperthyroidism in identical adolescent male twins

Monozygous adolescent male twins with hyperthyroidism are presented. One twin had associated thyroiditis. The other twin presented with muscle weakness and paralysis. Treatment was successful with antithyroid medication and levothyroxine.