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Ebrahimi P, Taheri H, Mousavinejad SA, Nazari P. Hypokalemic paralysis following intramuscular betamethasone injection: A case report and review of literature. Clin Case Rep 2024; 12:e8923. [PMID: 38770411 PMCID: PMC11103555 DOI: 10.1002/ccr3.8923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 04/02/2024] [Accepted: 04/25/2024] [Indexed: 05/22/2024] Open
Abstract
Acute neuromuscular paralysis is a relatively common condition in emergency rooms (ERs). They can be caused by several reasons, including adverse drug reactions. Betamethasone is a glucocorticoid commonly used for various conditions, such as allergic conditions. One of the rare but known side effects of glucocorticoids is hypokalemia. Rare cases of hypokalemia following high- and low-dose glucocorticoid injections have been reported. This study presents the history of a young, healthy male without significant past medical history who presented with an inability to stand and walk due to four-limb paralysis (more prominent in the lower limbs) following an intramuscular injection of a 4 mg betamethasone, which was prescribed for the treatment of allergic rhinitis. The patient was stabilized with an intravascular injection of potassium chloride diluted in 1000 mL of normal saline and monitored for 24 h, ruling out any other endocrine condition. Hypokalemia and its severe form are defined as the serum level of lower than 3.5 and 2.5 mEq/Lit, respectively. One of the etiologies of drug-induced hypokalemic paralysis is systemic glucocorticoid administration. In severe cases, it can cause quadriplegia and other neuromuscular, respiratory, and cardiac complications. Therefore, it is an urgent condition that should be managed carefully. Pregnant women who are receiving these medications are a specific group at risk of hypokalemic paralysis. There are several safer treatments for seasonal allergic rhinitis compared to systemic glucocorticoids, which should be considered by physicians. Moreover, paralysis in patients receiving these medications should be approached attentively since it might be caused by hypokalemia, which can be life threatening if not treated. It is advisable that the blood level of electrolytes, especially potassium, be checked for patients who present with paralysis or weakness after glucocorticoid injections.
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Affiliation(s)
- Pouya Ebrahimi
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
| | - Homa Taheri
- Cedars‐Sinai Cardiology DepartmentLos AngelesCaliforniaUSA
| | | | - Pedram Nazari
- Cancer Research CenterAhvaz Jundishapur University of Medical SciencesAhvazIran
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Singh J, Dinkar A, Kumar N, Kumar K. Recurrent hypokalemic paralysis in hypothyroidism. Am J Med Sci 2023; 365:462-469. [PMID: 36754148 DOI: 10.1016/j.amjms.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/31/2022] [Accepted: 01/30/2023] [Indexed: 02/09/2023]
Abstract
Hypothyroidism, a commonly encountered thyroid disorder, usually manifests with readily recognizable typical features. However, an unusual presentation of a classic thyroid disorder may hinder accurate diagnosis in certain instances. One such rare initial presentation of hypothyroidism is recurrent hypokalemic paralysis, and existing reports in the literature are sparse. It has been more commonly reported in thyrotoxicosis. We report the case details and clinical outcomes of two middle-aged individuals (a 34-year-old male and a 37-year-old female) with recurrent episodes of hypokalemic paralysis. Their clinical examination revealed pure motor hyporeflexia quadriparesis with hypotonia and diminished deep tendon reflexes without any autonomic dysfunction. They had no significant previous medical history. Biochemical findings revealed hypokalemia in both cases (1.4 and 1.9 mEq/L, respectively) with elevated levels of thyroid‑stimulating hormone and thyroid‑related antibodies in both individuals, thus, confirming the diagnosis of autoimmune hypothyroidism. Immediate treatment with intravenous and oral potassium correction helped in the recovery. Thyroxine supplementation was considered a follow-up treatment, and for a one-year follow-up period there were no complaints of limb weakness reported in both individual.
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Affiliation(s)
- Jitendra Singh
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
| | - Anju Dinkar
- Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Nilesh Kumar
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Kailash Kumar
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Kantaputra P, Guven Y, Aksu B, Kalayci T, Doğan C, Intachai W, Olsen B, Tongsima S, Ngamphiw C, Noppakun K. Distal renal tubular acidosis, autoimmune thyroiditis, enamel hypomaturation, and tooth agenesis caused by homozygosity of a novel double-nucleotide substitution in SLC4A4. J Am Dent Assoc 2022; 153:668-676. [DOI: 10.1016/j.adaj.2021.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/22/2021] [Accepted: 12/29/2021] [Indexed: 01/10/2023]
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Kumar R, Singh AK, Sharma K, Talwar V. A rare case of cephalexin-induced acute interstitial nephritis with hypokalemic periodic paralysis. Indian J Pharmacol 2020; 52:210-212. [PMID: 32874004 PMCID: PMC7446675 DOI: 10.4103/ijp.ijp_532_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/17/2019] [Accepted: 07/13/2020] [Indexed: 11/08/2022] Open
Abstract
Drug-induced acute interstitial nephritis (AIN) is often encountered in clinical practice. Cephalexin is a first-generation cephalosporin with antimicrobial sensitivity ranging from Gram-positive to Gram-negative organisms. Cephalexin-induced AIN presenting with hypokalemic periodic paralysis (HPP) has been rarely reported. A 34-year-old female with recent history of oral cephalexin intake presented with acute onset paraplegia with deranged renal parameters and hypokalemia. She was treated conservatively with mechanical ventilator support. HPP could be a rare clinical presentation for cephalexin-induced AIN.
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Affiliation(s)
- Rajesh Kumar
- Department of Nephrology and Renal Transplant Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - Amit Kumar Singh
- Department of Nephrology and Renal Transplant Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - Kavish Sharma
- Department of Nephrology and Renal Transplant Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - Vandana Talwar
- Department of Anesthesiology, VMMC and Safdarjung Hospital, New Delhi, India
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Rawla P, Thandra KC, Aluru JS, Mageed SA, Sakr EE, Elsayed GG, Zidan M, Morra ME. Systematic review and case report: Systemic lupus erythematosus with renal tubular acidosis. Clin Case Rep 2020; 8:333-340. [PMID: 32128183 PMCID: PMC7044371 DOI: 10.1002/ccr3.2623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/05/2019] [Accepted: 12/02/2019] [Indexed: 11/08/2022] Open
Abstract
Immune profile assessment-particularly for SLE-and subsequent specific therapy are beneficial in patients with persisting unexplained hyperkalemic or hypokalemic paralysis, especially in case of isolated RTA.
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Affiliation(s)
| | - Krishna Chaitanya Thandra
- Department of Pulmonary and Critical Care MedicineSentara Virginia Beach General HospitalVirginia BeachVAUSA
| | - John Sukumar Aluru
- Senior Research AssociateBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMAUSA
| | - Sarah Abdel Mageed
- Department of Internal MedicineFaculty of MedicineTanta UniversityTantaEgypt
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Bruns N, Finkelberg I, Al-Attrach I, Hoyer PF, Büscher R. Unusual Presentation of Polyautoimmunity and Renal Tubular Acidosis in an Adolescent With Hashimoto's Thyroiditis and Central Pontine Myelinolysis. Front Endocrinol (Lausanne) 2020; 11:548877. [PMID: 33162932 PMCID: PMC7591671 DOI: 10.3389/fendo.2020.548877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/01/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Hashimoto's thyroiditis is frequently associated with other autoimmune diseases and may include renal involvement. Case description: A 17-year-old female with previously diagnosed Hashimoto's thyroiditis and vitiligo was admitted to a pediatric intensive care unit with hypokalemic paralysis and acidosis, after having suffered from recurrent muscular weakness for approximately one year. A few days later she developed central pontine myelinolysis. After initial stabilization she was also diagnosed with distal renal tubular acidosis (dRTA) and tubular proteinuria which can occur in Sjögren's syndrome. Extended screening for autoimmune diseases additionally revealed celiac disease. Treatment with Prednisone and substitution of potassium quickly lead to the resolution of proteinuria and dRTA, but unilateral paralysis of the sixth nerve as a result of central pontine myelinolysis was irreversible. Conclusions: This is the rare case of polyautoimmunity including autoimmune thyroiditis, Sjögren's syndrome, vitiligo and celiac disease in an adolescent with few disease-specific symptoms. The diagnoses were made via a complicating nephritis causing dRTA and proteinuria. Delay in diagnosis lead to permanent neurological damage. This case highlights the need for pediatricians to be aware of rare accompanying diseases and their complications in "common" pediatric autoimmune diseases like Hashimoto's thyroiditis and celiac disease.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
- Department of Pediatrics II, Pediatric Nephrology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
- *Correspondence: Nora Bruns
| | - Ilja Finkelberg
- Department of Pediatrics II, Pediatric Nephrology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Ibrahim Al-Attrach
- Department of Pediatrics II, Pediatric Nephrology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Peter F. Hoyer
- Department of Pediatrics II, Pediatric Nephrology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Rainer Büscher
- Department of Pediatrics II, Pediatric Nephrology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
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Meregildo-Rodríguez ED, Failoc-Rojas VE. Case Report: Recurrent hypokalemic periodic paralysis associated with distal renal tubular acidosis (type 1) and hypothyroidism secondary to Hashimoto's thyroiditis. F1000Res 2018; 7:1154. [PMID: 30647907 DOI: 10.12688/f1000research.15662.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2018] [Indexed: 12/14/2022] Open
Abstract
Background: Hypokalemic periodic paralysis (HypoKPP) is characterized by transient episodes of flaccid muscle weakness. We describe the case of a teenaged boy with HypoKPP and hyperthyroidism due to Hashimoto's thyroiditis with initial manifestation of renal tubular acidosis. This combination is rare and little described previously in men. Case presentation: A 17-year-old boy was admitted after three days of muscular weakness and paresthesia in the lower limbs with an ascending evolution, leading to prostration. Decreased strength was found in the lower limbs without a defined sensory level, reduced patellar and ankle reflexes. Positive antithyroid antibodies were found. He received hydration treatment, IV potassium and levothyroxine, with which there was a clinical improvement. Other examinations led to the diagnosis of type 1 renal tubular acidosis. Conclusion: HypoKPP is a rare disorder characterized by acute episodes of muscle weakness. Type 1 renal tubular acidosis can occur as a consequence of thyroiditis, which is explained by the loss of potassium. This combination is unusually rare, and has not been described before in men. The etiopathogenesis of the disease as well as a dynamic explanation of what happened with the patient are discussed in this report.
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Affiliation(s)
| | - Virgilio E Failoc-Rojas
- Servicio de Medicina Interna y emergencia, Hospital Regional Lambayeque, Lambayeque, Peru.,Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
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Meregildo-Rodríguez ED, Failoc-Rojas VE. Case Report: Recurrent hypokalemic periodic paralysis associated with distal renal tubular acidosis (type 1) and hypothyroidism secondary to Hashimoto's thyroiditis. F1000Res 2018; 7:1154. [PMID: 30647907 PMCID: PMC6325611 DOI: 10.12688/f1000research.15662.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Hypokalemic periodic paralysis (HypoKPP) is characterized by transient episodes of flaccid muscle weakness. We describe the case of a teenaged boy with HypoKPP and hyperthyroidism due to Hashimoto's thyroiditis with initial manifestation of renal tubular acidosis. This combination is rare and little described previously in men. Case presentation: A 17-year-old boy was admitted after three days of muscular weakness and paresthesia in the lower limbs with an ascending evolution, leading to prostration. Decreased strength was found in the lower limbs without a defined sensory level, reduced patellar and ankle reflexes. Positive antithyroid antibodies were found. He received hydration treatment, IV potassium and levothyroxine, with which there was a clinical improvement. Other examinations led to the diagnosis of type 1 renal tubular acidosis. Conclusion: HypoKPP is a rare disorder characterized by acute episodes of muscle weakness. Type 1 renal tubular acidosis can occur as a consequence of thyroiditis, which is explained by the loss of potassium. This combination is unusually rare, and has not been described before in men. The etiopathogenesis of the disease as well as a dynamic explanation of what happened with the patient are discussed in this report.
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Affiliation(s)
| | - Virgilio E Failoc-Rojas
- Servicio de Medicina Interna y emergencia, Hospital Regional Lambayeque, Lambayeque, Peru.,Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
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Kadeeja N, Senthilnathan N, Viswanathan S, Aghoram R. Sporadic hypothyroidism-related hypokalemic paralysis: Diagnosis in a resource-poor setting. J Family Med Prim Care 2018; 6:862-864. [PMID: 29564279 PMCID: PMC5848414 DOI: 10.4103/jfmpc.jfmpc_215_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hypothyroidism and distal renal tubular acidosis causing hypokalemic paralysis (HP) have been described only in four female patients. HP as the initial manifestation of uncomplicated diabetes has been reported only in three young males. We report two middle-aged patients presenting with gradual-onset areflexic quadriparesis and neck flop, associated with urinary potassium losses, and recovering over 3 days. The male patient with alcohol abuse had urine pH >5.5 and hyperchloremic metabolic acidosis due to renal tubular acidosis and hypothyroidism. The second, a hypertensive female, had metabolic alkalosis, hypomagnesemia, and diabetes mellitus diagnosed at admission. Both these patients improved with intravenous and oral potassium supplementation.
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Affiliation(s)
- Nadasha Kadeeja
- Department of General Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India
| | - Nivetha Senthilnathan
- Department of General Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India
| | - Stalin Viswanathan
- Department of General Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India
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