Thyrotoxic hypokalaemic periodic paralysis in a Turkish population: three new case reports and analysis of the case series

Thyrotoxic Periodic Paralysis: An Unusual Cause of Quadriparesis

Thyrotoxic periodic paralysis (TPP) is an uncommon disorder characterized by acute onset of hypokalemia (serum potassium level less than 3.5 mmol/L) and paralysis secondary to thyrotoxicosis. Patients can present with TPP as the first clinical manifestation of thyrotoxicosis. In patients presenting with acute episodes, the presence of hypokalemia and elevated levels of thyroid hormones with low thyroid-stimulating hormone levels (less than 0.35 µIU/mL) are important diagnostic clues.

We report one case of TPP in which the acute onset of paralysis was the first clinical presentation of underlying thyrotoxicosis. After treatment with propranolol and carbimazole, the patient became symptom-free and euthyroid.

Case report: Hyperthyroid hypokalemic periodic paralysis

Introduction and importance

HHPP is a rare type of hypokalemic PP that can occur when there is hyperthyroidism.Thyrotoxic periodic paralysis is due to increased influx of potassium into skeletal muscle cells which leads to profound hypokalemia and paralysis. Insulin and Epinephrine are also responsible for stimulating the Na–K-ATPase pumps which are over expressed during hyperthyroid state. Laboratory hypokalemia in the background of hyperthyroidism with sudden symmetric paralysis point toward the diagnosis.

Case

We present a case of 25 year old male with limb weakness for 3hours following heavy dinner.He felt weakness after waking up in the morning where he could not move his both lower limbs. He also had difficulty moving upper limbs.

Clinical findings and investigations

Examination revealed proximal muscle weakness with power of 2/5, decreased muscle tone, diminished deep tendon reflexes in all four limbs and equivocal plantar reflex bilaterally. Investigation sent were Total Leukocyte count, Hemoglobin, Renal function test, Liver Function test,Thyroid function test, Vitamin B12, Serology, ACTH, Serum calcium, Serum phosphate, Serum magnesium, Urine R/ME and Stool R/ME.

Intervention and outcome

Patient is treated with 10mEq/L/hr infusion of potassium chloride, methimazole and beta-blockers. He is stable and is in regular followup in medicine OPD.

Relevance and impact

Early diagnosis of HHPP is very essential to prevent fatal complications (cardiac and respiratory).

It can be treated by timely potassium supplementation, methimazole and beta-blockers.

Clinicians must be concerned about Hyperkalemia while supplementing Potassium in bed side.

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HHPP is a rare life-threatening complication of hyperthyroidism which is characterized by episodes of acute muscle weakness due to hypokalemia.

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Periodic paralysis (PP) is a muscle disease, characterized by episodes of painless muscle weakness. These episodes can be triggered by strenuous exercise, fasting, or consuming high-carbohydrate foods.

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Treatment cand be done by potassium supplementation until normalized serum potassium level. Patient must be kept in cardiac monitoring and serum potassium monitoring.

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Hyperthyroidism can be treated with methimazole. Patient must be kept under regular follow up in endocrinology department.

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Relapses can be prevented by treatment with radioactive iodine or surgery. Beta-blocking drugs have also been proven to reduce the frequency and severity of episodes.

Electrocardiographic Manifestation in Thyrotoxic Periodic Paralysis

Thyrotoxic periodic paralysis (TPP) is an unusual complication of hyperthyroidism that may cause diagnostic difficulties due to its clinical feature that may be similar to other diseases. However, TPP can be detected early based on the weakness presentation, which generally affects the lower extremity with proximal muscle involvement, and, additionally, the ECG findings presenting hypokalemia characteristics. This case illustrates a young Indonesian male presenting in the emergency department with paralysis and typical ECG findings suggesting TPP. Early identification of TPP is necessary for executing proper treatment and reducing complications.

"I'm so weak I feel paralyzed. Can you help me?" A case on thyrotoxic periodic paralysis

Thyrotoxic periodic paralysis (PP) is a rare condition characterized by muscle weakness in the form of hyperthyroidism and hypokalemia. We present the case of a 38-year-old Hispanic male with PP that had been occurring over the course of 4 years. After several emergency department visits, the cause of his symptoms was still unknown. Initial laboratory testing revealed critical hypokalemia with associated electrocardiogram (ECG) changes. Further laboratory evaluation revealed hyperthyroidism, and the diagnosis of thyrotoxic PP was made. The patient received potassium supplementation with complete resolution of his symptoms and resolution of pathologic ECG changes. Our patient was started on propranolol and methimazole to treat his hyperthyroidism. Not well documented in previous reports, we stress the importance of using serial ECGs as an adjunct to patient improvement.

Thyrotoxic Periodic Paralysis: A Case Report and Literature Review

Thyrotoxic periodic paralysis (TPP) is a rare presentation of thyrotoxicosis most commonly associated with Graves' disease. It is rare in Caucasians, but it affects approximately 2% of Asians (occurring in those of Chinese, Japanese, Vietnamese, Filipino, and Korean descent) with thyrotoxicosis of any cause. Typical thyrotoxic features may be absent despite biochemical thyrotoxicosis. Hypokalemia and muscle paralysis are the result of an acute intracellular shift of potassium and not due to total body potassium deficiency. TPP is a self-limiting condition that is easily corrected by treatment of the thyrotoxicosis. We present a case of a Filipino man, aged 47 years, who presented to the emergency department with acute bilateral lower extremity weakness and hypokalemia who was subsequently diagnosed with TPP due to Graves' disease.

Thyrotoxic periodic paralysis presenting in an African-American teenage male: case report

Background

Thyrotoxic periodic paralysis is a rare complication of hyperthyroidism and is associated with hypokalemia and muscle paralysis. This condition is most commonly seen in Asian men.

Case presentation

We report on a 14-year-old African American male with Graves’ disease and intermittent asthma who presented with bilateral leg weakness. The patient demonstrated signs of thyrotoxicosis and laboratory evaluation revealed hypokalemia and hyperthyroidism. Following the administration of potassium supplementation clinical status improved and the patient was discharged home on a high dose of methimazole and propranolol. At a 6-month follow up visit, he was found to be clinically euthyroid and demonstrated no signs of hyperthyroidism or muscle weakness.

Conclusion

Children presenting with weakness and hypokalemia should be investigated for thyroid dysfunction. Correction of hypokalemia improves acute presentation, but the patient will remain at risk for paralysis until euthyroid state is achieved.

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: An Underdiagnosed and Under-recognized Condition

Thyrotoxic hypokalemic periodic paralysis (TPP) is a condition characterized by the triad of acute hypokalemia without total body potassium deficit, episodic muscle paralysis, and thyrotoxicosis.

We describe two cases of thyrotoxic periodic paralysis who presented to our hospital with potassium values of 1.3 MeQ/l and 1.2 MeQ/l, respectively. Surprisingly, the two patients had no documented past medical history. Based on the clinical features of high heart rate, palpitations (seen in both the patients), and exophthalmos (seen in one patient), thyrotoxic periodic paralysis was suspected. A thorough laboratory workup confirmed the diagnosis of thyrotoxicosis. Beta blockers were initiated promptly, along with intravenous potassium chloride, and the patients eventually improved symptomatically. These patients were eventually diagnosed with Graves’ disease and were placed on methimazole, which prevented further attacks.

Thyroid periodic paralysis (TPP) is a rare clinical manifestation of hyperthyroidism. Patients present with sudden onset paralysis associated with severe hypokalemia. The presence of paralysis and hypokalemia in a patient who has a history of hyperthyroidism should prompt the physician about thyrotoxic periodic paralysis. A high index of suspicion, prompt diagnosis, and management of the condition can prevent severe complications, such as cardiac arrhythmias.

Thyrotoxic hypokalaemic periodic paralysis: a rare presentation of Graves' disease in a Hispanic patient

A 26-year-old Hispanic man with no significant medical history presented to our emergency room with gradual onset weakness of his lower extremities. He was haemodynamically stable and examination revealed loss of motor function in his lower limbs up to the level of hips. Laboratory data revealed hypokalaemia. The patient was started on potassium supplementation and he recovered his muscle strength. Differential diagnosis included familial hypokalaemic periodic paralysis and thyrotoxic periodic paralysis (TPP). Further investigations revealed a low thyroid-stimulating hormone and high free thyroxine levels. Radio iodine 123 scan revealed an enhanced homogeneous uptake in the thyroid suggesting Graves' disease. Thyroid stimulating antibodies were also found to be elevated. The patient was started on methimazole and propranolol and he never had another attack of TPP even at 1 year follow-up.

Thyrotoxic periodic paralysis: clinical challenges

Thyrotoxic periodic paralysis (TPP), a disorder most commonly seen in Asian men, is characterized by abrupt onset of hypokalemia and paralysis. The condition primarily affects the lower extremities and is secondary to thyrotoxicosis. The underlying hyperthyroidism is often subtle causing difficulty in early diagnosis. Factors like high-carbohydrate meal exercise, steroid, and stress can precipitate an attack of TPP. Evidence is building up showing role of genetic mutations in Kir2.6 channel in the pathogenesis of TPP. Loss of function of Kir2.6 together with increased activity of Na(+)/K(+) ATPase may trigger a positive feed-forward cycle of hypokalemia. Biochemical hyperthyroidism with normal urinary potassium excretion and ECG changes are characteristic of TPP. Treatment with low-dose potassium supplements and nonselective beta-blockers should be initiated upon diagnosis, and the serum potassium level should be frequently monitored to prevent rebound hyperkalemia.

Three cases of thyrotoxic periodic paralysis due to painless thyroiditis

We present three cases of thyrotoxic periodic paralysis (TPP) due to painless thyroiditis presenting as acute quadriparesis. All responded to potassium supplementation and propranolol. TPP may be due to thyrotoxicosis of any etiology, commonly Grave's disease. The absence of clinical signs of thyrotoxicosis can delay diagnosis and treatment. Thyroid function tests should be a routine evaluation in all cases of hypokalemic periodic paralysis.

[Thyrotoxic periodic paralysis: a case series of four patients and literature review]

PURPOSE

Periodic thyrotoxic hypokalemic paralysis (TPP) is a neuromuscular complication of hyperthyroidism. It is more common in young Asian males than in Caucasian and African patients. We report four new cases and review the literature.

CASE REPORTS

Four consecutive patients were diagnosed with TPP. They were all men with a median age of 34.5 years at presentation. Two patients originated from the Philippines, one was African and one was Caucasian ethnic background. They all presented with a paresis or flaccid paralysis, without respiratory failure. Previous similar episodes in their past medical history, the presence of profound hypokalemia (mean serum potassium level of 2 mmol/L) and the presence of clinical and biological signs of hyperthyroidism led to the diagnosis of TPP. All four patients were diagnosed with Graves' disease. Outcome was favourable in all four patients with the symptomatic treatment of TPP and treatment of Graves' disease.

CONCLUSION

TPP is a severe condition, due to a dysfunction of the Na(+)-K(+) ATPase pump. Initial management relies on β-blocker treatment and careful potassium supplementation. Then, medical or surgical etiological treatment of the thyrotoxicosis is essential to prevent a recurrence. The disease is probably underdiagnosed: it must be suspected when a profound hypokaliema resolves very quickly (<12hours); hyperthyroidism should always be included in the differential diagnosis of a paresis associated with hypokalemia.

Thyrotoxic periodic paralysis: clinical and molecular aspects

Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism that most often affects young East Asian males but increasingly also in other ethnic groups. The typical presentation is acute attacks varying from mild weakness to total paralysis starting at night or in the early morning a few hours after a heavy meal, alcohol abuse or strenuous exercise with complete recovery within 72 h. Signs and symptoms of hyperthyroidism may not be obvious. The hallmark is hypokalemia from increased cellular sodium/potassium-ATPase pump activity with transport of potassium from the extracellular to the intracellular space in combination with reduced potassium output. Recently, KCNJ18 gene mutations which alter the function of an inwardly rectifying potassium channel named Kir2.6 have been detected in 0-33 % of cases. Hence, the pathophysiology in TPP includes a genetic predisposition, thyrotoxicosis and environmental influences and the relative impact from each of these factors may vary. The initial treatment, which is potassium supplementation, should be given with caution due to a high risk of hyperkalemia. Propranolol is an alternative first-line therapeutic option based on the assumption that hyperadrenergic activity is involved in the pathogenesis. If thyroid function tests are unobtainable in the acute situation the diagnosis is supported by the findings of hypokalemia, low spot urine potassium excretion, hypophosphatemia with hypophosphaturia, high spot urine calcium/phosphate ratio, and electrocardiographic abnormalities as tachycardia, atrial fibrillation, high QRS voltage, and atrioventricular block. Definitive treatment is cure of the hyperthyroidism. The underlying mechanisms of TPP remain, however, incompletely understood awaiting further studies.

Surgical treatment for thyrotoxic hypokalemic periodic paralysis: case report

Thyrotoxic hypokalemic periodic paralysis (THPP) is a rare, potentially life-threatening endocrine emergency. It is characterized by recurrent muscle weakness and hypokalemia. Because many THPP patients do not have obvious symptoms and signs of hyperthyroidism, misdiagnosis may occur. The published studies revealed that definitive therapy for THPP is control of hyperthyroidism by medical therapy, radioactive iodine or surgery, but the long-term post-operative follow-up result was not observed. We reported two cases of medically refractory THPP with recurrent paralysis of extremities and hypokalemia, and both were combined with thyroid nodules. Both patients were treated with total thyroidectomy; the pathology revealed that one is Graves' disease with thyroid papillary carcinoma, and the other is adenomatous goiter with papillary hyperplasia. No episode of periodic paralysis was noted and laboratory evaluation revealed normal potassium level during the post-operative follow up. Our experience suggests that total thyroidectomy by experienced surgeon is an appropriate and definite treatment for medically refractory THPP, especially in cases combined with thyroid nodules.

Novel etiopathophysiological aspects of thyrotoxic periodic paralysis

Thyrotoxicosis can lead to thyrotoxic periodic paralysis (TPP), an endocrine channelopathy, and is the most common cause of acquired periodic paralysis. Typically, paralytic attacks cease when hyperthyroidism is abolished, and recur if hyperthyroidism returns. TPP is often underdiagnosed, as it has diverse periodicity, duration and intensity. The age at which patients develop TPP closely follows the age at which thyrotoxicosis occurs. All ethnicities can be affected, but TPP is most prevalent in people of Asian and, secondly, Latin American descent. TPP is characterized by hypokalemia, suppressed TSH levels and increased levels of thyroid hormones. Nonselective β adrenergic blockers, such as propranolol, are an efficient adjuvant to antithyroid drugs to prevent paralysis; however, an early and definitive treatment should always be pursued. Evidence indicates that TPP results from the combination of genetic susceptibility, thyrotoxicosis and environmental factors (such as a high-carbohydrate diet). We believe that excess T(3) modifies the insulin sensitivity of skeletal muscle and pancreatic β cells and thus alters potassium homeostasis, but only leads to a depolarization-induced acute loss of muscle excitability in patients with inherited ion channel mutations. An integrated etiopathophysiological model is proposed based on molecular findings and knowledge gained from long-term follow-up of patients with TPP.

Analytic review: thyrotoxic periodic paralysis: a review

Thyrotoxic periodic paralysis (TPP) is an unusual complication of hyperthyroidism that frequently presents in a dramatic fashion, necessitating treatment in an emergency department or admission to an intensive care unit. Thyrotoxic periodic paralysis is characterized by transient, recurrent episodes of flaccid muscle paralysis affecting proximal more severely than distal muscles. Thyrotoxic periodic paralysis is most commonly a complication of Graves' disease in Asian males, although in recent decades, an increasing number of patients from all racial and ethnic backgrounds have been reported. Thyrotoxic periodic paralysis has a higher predilection for men than women despite the fact that thyroid disease is more frequently diagnosed in women. The presence of both hypokalemia and elevated levels of triiodothyronine (T3) and thyroxine (T4) are important diagnostic features during the acute episode. Treatment of TPP involves 2 steps, immediate action to reverse the paralysis followed by measures to prevent future attacks by restoration of a euthyroid state. Although the mainstay of treating an acute attack of TPP is correction of hypokalemia to avoid fatal cardiac arrhythmias and reverse muscle weakness, it must be appreciated by treating physicians that patients with TPP do not have a total body deficiency of potassium. Close attention must be given to potassium replacement as overly aggressive treatment can result in hyperkalemia. Correction of hypokalemia and the underlying thyrotoxic state usually results in amelioration of the acute attack. This review summarizes the epidemiology, clinical manifestations, pathogenesis, diagnosis, and treatment of TPP.

Chest pain and paralysis after pulse prednisolone therapy an unusual case presentation of thyrotoxic periodic paralysis: a case report

Thyrotoxic periodic paralysis is a disease characterized by recurrent episodes of paralysis and hypokalemia during a thyrotoxic state. Thyrotoxic periodic paralysis is a common complication of hyperthyroidism in Asian populations, but can affect other ethnic groups as well. Due to population mobility, Thyrotoxic periodic paralysis is increasingly common in Western countries. Early diagnosis and prompt treatment of the thyrotoxic state and potassium supplementation prevent life-threatening complications associated with hypokalemia and muscle weakness. We present a young Turkish man who developed acute flaccid paralysis after receiving pulse prednisolone therapy for treatment of Pityriasis versicolor. His muscle strength and serum potassium fully recovered after potassium replacement and treatment of the thyrotoxic state which was a consequence of underlying Graves' disease.