Practical aspects in the management of hypokalemic periodic paralysis

Diagnosis, management and outcomes of primary hypokalemic periodic paralysis during pregnancy

Primary hypokalaemic periodic paralysis during pregnancy has been rarely reported. Four pregnant women with the acute onset of flaccid paralysis presented between January 2018 and December 2021. Focussed history and physical examination helped an appropriate radiological and laboratory investigation plan to be made. All women recovered within 4-7 days of potassium supplementation. Supplemental potassium continued until delivery. A pain management plan with continuous epidural infusion helped in avoiding stress-induced hypokalaemia. None of the women developed an episode of muscle weakness during the intervening period. In conclusion, a focussed history and targeted laboratory investigation are needed to diagnose primary hypokalaemic periodic paralysis. Early administration of oral or intravenous potassium is crucial in improving fetomaternal outcomes.

Hypokalemic Periodic Paralysis: A Rare Case of a Descending Flaccid Paralysis

Hypokalemic periodic paralysis (HPP) is an uncommon condition resulting from channelopathy, impacting skeletal muscles. It is distinguished by episodes of sudden and temporary muscle weakness alongside low potassium levels. The normalization of potassium resolves the associated paralysis. Most of these cases are hereditary. Few cases are acquired and are associated with an etiology related to endocrine disorders (e.g., thyrotoxicosis, hyperaldosteronism, and hypercortisolism). It is characterized by acute flaccid paralysis, usually of the ascending type, affecting the proximal region more than the distal region. Herein, we report the case of a 29-year-old male who instead of the ascending type presented with descending-type acute flaccid paralysis. Potassium level at presentation was 1.7 mEq/L. The patient was managed with parenteral and oral potassium supplementation, after which the weakness was completely resolved.

Physiotherapy Strategies in Hypokalemic Periodic Paralysis: A Case Report

The rare neuromuscular disease known as hypokalemic periodic paralysis (hypoKPP), which results in severe muscle weakness in the extremities, is brought on by abnormalities in potassium transport within cells. Laboratory testing is confirmatory, which reveals notably low potassium levels, causing paralysis, which improves once the low potassium is restored. The patient generally complains of muscle weakness with difficulty in performing activities of daily living and impaired participation in functional tasks, with few suffering from coexisting sensory impairments. Physiotherapy generally plays a symptomatic role with motion exercises for the affected muscle groups. There is no standardized physiotherapy protocol for disease-specific impairments. A 46-year-old man complained of bilateral upper and lower limb muscular weakness and was admitted to the neurology ward. The patient also complained of having tingling numbness throughout their entire limbs and had experienced similar episodes of symptoms six months prior. During laboratory evaluation, a significantly low potassium level was found, leading to a diagnosis of hypoKPP. Following medical management, neurophysiotherapy was initiated. Physiotherapy strategy shows significant improvement in muscular strength and functional activities. Thus, this case report concludes that physiotherapy plays a vital role in managing hypoKPP by enhancing muscular strength, functional activities, and quality of life.

Hypokalemic periodic paralysis in a teenage boy after an intense period of exercise: A rare case report

Key Clinical Messages

Diagnosis of rare even can be missed due to less familiarity with the disorder.In patients with muscle weakness, infectious causes are prioritized.Electrolyte profile not only identifies the problem, but also prevents unnecessary workup.

Abstract

In underdeveloped countries, diagnosis of rare disorders is usually delayed due to less familiarity of the clinicians to such disorders. As a result, infectious and inflammatory causes for an ailment are prioritized as compared to non-infectious etiologies. Hypokalemic periodic paralysis (PP) is a rare disorder, characterized by episodic muscle weakness that can rarely be associated with life-threatening cardiac arrhythmia. A teenage Afghan boy presented to the emergency department with an acute flaccid paralysis, that started 1 h after intense exercise The weakness involved both, the upper and lower extremities. Laboratory investigations, led to the impression of hypokalemic PP, precipitated by intense exercise. Accordingly, intravenous potassium chloride infusion diluted with normal saline led to the complete resolution of paralysis as well as correction of electrocardiographic changes. The list of differential diagnosis for flaccid muscle paralysis is wide, which generally requires a extensive investigations, but in hypokalemic PP, a cardinal electrolytes profile can lead towards early diagnosis. High degree of clinical suspicion with appropriate history taking and physical examination helps with the immediate identification and management of this disorder.

Newly Diagnosed Hypokalemic Periodic Paralysis Triggered by COVID-19

Hypokalemic periodic paralysis (HypoPP) is a rare genetic disorder characterized by low potassium levels and episodic periods of muscle weakness. HypoPP has previously been attributed to numerous viral infections; however, cases related to coronavirus disease 2019 (COVID-19) are extremely limited. The current case is thus unique and involves a healthy 23-year-old male who presented to the emergency department after several uncharacteristic falls and three days of upper and lower extremity weakness. Initial labs revealed a potassium level of 1.1 mmol/L as well as being COVID-19 positive. Potassium supplementation helped stabilize his levels and relieved all of his symptoms. Based on an extensive clinical workup and significant family history of the mother and maternal grandmother with weakness in the setting of hypokalemia, a diagnosis of HypoPP was made. Upon discharge, he was placed on potassium-sparing diuretics to help prevent further symptom relapse and advised to complete genetic testing. With the high likelihood of the virus being endemic for years to come, clinicians should remember to consider HypoPP with patients with muscle weakness, especially in patients with concurrent COVID-19 infection, to minimize unnecessary workup and prevent potentially life-threatening symptoms of hypokalemia.

A Successful Obstetric Outcome in a Woman With Familial Hypokalemic Periodic Paralysis: Challenges in Management

Hypokalemic periodic paralysis during pregnancy is a rare disease condition that presents during pregnancy. It manifests with acute muscular weakness associated with low potassium levels. We report a case of an antenatal woman presenting with leaking per vagina and weakness of four limbs at 33 weeks of gestation. She had similar episodes in the past but defaulted on taking oral potassium. On physical examination, she had hyporeflexia and flaccid paralysis of all limbs without sensory involvement. A neurology consultation was sought and diagnosed to have flaccid quadriparesis. Her investigations showed low serum potassium along with electrocardiography (ECG) changes. With potassium correction, her weakness improved within four days of initiating treatment. A week later, she had a spontaneous labour onset and delivered a healthy male baby. The peripartum period was uneventful. A timely diagnosis and management, avoiding precipitating factors, and preventing future attacks should be the primary goal of management.

Atypical Fracture of Femur in Association with Familial Hypokalemic Periodic Paralysis: A Case Report

INTRODUCTION

Hypokalemic periodic paralysis (HPP) is an important and a reversible but rare cause of paralysis. Periodic paralyses are of two types. The first one is primary which is also known as familial type and the second one is secondary periodic paralysis which is due to other underlying pathologies [1]. Important secondary causes can be categorized as metabolic, infectious and losses from the body, etc. [2]. HPP associated with bony abnormalities in form of spontaneous atypical fractures in femoral shaft with coxa vara is an unusual presentation.

CASE REPORT

Here is a case report of 26 year old lady who presented with pain in the proximal part of right thigh and weakness in both the upper and the lower limbs. She was diagnosed as familial HPP (FHPP) with atypical fracture of proximal third diaphysis of femur. Confirmation of the expected diagnosis was done with history, laboratory tests, and plain radiographs. Previously also, she had similar episode of weakness and opposite side femur atypical fracture.

CONCLUSION

Association of atypical femur diaphysis fracture and FHPP is a rare presentation of an uncommon disease but should be kept in mind whenever treating any HPP patient. The patient complaining of pain in limbs should be taken seriously as atypical fractures are prone to be missed. In future, further genetic studies are required to establish this rare association.

The Role of Nutrition and Physical Activity as Trigger Factors of Paralytic Attacks in Primary Periodic Paralysis

Background:

Primary periodic paralysis (PPP) are rare inherited neuromuscular disorders including Hypokalemic periodic paralysis (HypoPP), Hyperkalemic periodic paralysis (HyperPP) and Andersen-Tawil syndrome (ATS) characterised by attacks of weakness or paralysis of skeletal muscles. Limited effective pharmacological treatments are available, and avoidance of lifestyle related triggers seems important.

Objective:

Our aim was to search and assess the scientific literature for information on trigger factors related to nutrition and physical activity in PPP.

Methods:

We searched Ovid Medline and Embase database for scientific papers published between January 1, 1990, to January 31, 2020.

Results:

We did not identify published observation or intervention studies evaluating effect of lifestyle changes on attacks. Current knowledge is based on case-reports, expert opinions, and retrospective case studies with inadequate methods for description of nutrition and physical activity. In HypoPP, high carbohydrate and salt intake, over-eating, alcohol, dehydration, hard physical activity, and rest after exercise are frequently reported triggers. Regarding HyperPP, fasting, intake of potassium, alcohol, cold foods or beverages, physical activity, and rest after exercise are frequently reported triggers. No nutrition related triggers are reported regarding ATS, exercise can however induce ventricular arrhythmias.

Conclusions:

Our results support that dietary intake and physical activity may play a role in causing paralytic attacks in PPP, although the current scientific evidence is weak. To provide good evidence-based patient care, several lifestyle aspects need to be further assessed and described.

Thyrotoxic periodic paralysis: A retrospective, observational study from India

Background & objectives:

Thyrotoxic periodic paralysis (TPP) is an endocrine emergency presenting with acute-onset flaccid paralysis in a patient having thyrotoxicosis accompanied by hypokalaemia. This study was conducted to evaluate the clinical profile of patients with TPP presenting to three centres in India.

Methods:

This retrospective, observational study was conducted at three tertiary care Armed Forces medical centres, located at Lucknow, Kolkata and Delhi. The history, clinical features, treatment details and outcomes were evaluated.

Results:

Of the 244 patients with thyrotoxicosis, 15 were diagnosed with TPP and included in the study. These 15 patients (14 male and 1 female) had 32 episodes of TPP which were analyzed. The mean age was 30.2±6.2 yr (range: 21-39), and overt thyrotoxicosis was seen in all patients except one who had subclinical hyperthyroidism. Graves’ disease was the most common cause of thyrotoxicosis (13/15) and the remaining two patients had subacute thyroiditis and gestational thyrotoxicosis. Hypokalaemia (serum potassium <3.5 mmol/l) was seen in 12 patients, and the mean serum potassium was 3.2±0.9 mmol/l (range: 2.1-4.9). All patients had flaccid weakness, predominantly involving the lower limb with no bulbar, respiratory or cranial nerve involvement. The average duration of paralysis was 10.6±5.7 h (range: 3-28 h).

Interpretation & conclusions:

Our study demonstrated an early age of presentation and presence of clinical and biochemical thyrotoxicosis in majority of patients with TPP. Hypokalaemia may not always be evident in patients with TPP.

First-Onset Hypokalemic Periodic Paralysis Following Surgery for Myxopapillary Ependymoma

BACKGROUND

Hypokalemic periodic paralysis is a rare skeletal muscle channelopathy characterized by intermittent episodes of acute flaccid paralysis with associated hypokalemia. We present here the case of a first-onset hypokalemic periodic paralysis triggered by lumbar spinal surgery for tumor resection.

CASE DESCRIPTION

A 37-year-old male without any known prior medical conditions presented with a first-onset attack of hypokalemic paralysis 1.5 days after lumbar spinal surgery for myxopapillary ependymoma. Initially, the patient presented paraparesis mimicking a spinal cord compression, and while en route for imaging there was an abrupt onset of flaccid paralysis with significant respiratory distress. The emergency blood tests revealed extreme hypokalemia with a serum potassium of 1.42 mm/L. The patient was transferred to the intensive care unit, intubated, sedated, and administered intravenous reperfusion with an infusion dose of 20 mEq/hour potassium in a solution of 5% mannitol. Following reperfusion, the patient recovered completely in 12 hours. Renal potassium hyperexcretion and hyperthyroidism were excluded by laboratory tests. The diagnosis was confirmed by genetic tests showing mutation of the CACNA1S gene.

CONCLUSIONS

To the best of our knowledge, this is the first described case with the first onset triggered by a neurosurgical intervention and the second case following any kind of surgery. Neurosurgeons should consider hypokalemic periodic paralysis when encountering a rapidly evolving tetraparesis, even in an apparently healthy patient.

A Case of Thiazide-induced Hypokalemic Paralysis

We describe the case of a patient presenting with odd neurologic symptoms initially thought to represent somatization who was found to have critical hypokalemia manifesting as hypokalemic non-periodic paralysis. It was determined that the patient had baseline hypokalemia as a function of alcohol abuse, exacerbated by self overmedication with hydrochlorothiazide for elevated blood pressure readings at home. The diagnosis was suspected when an electrocardiogram was obtained demonstrating a pseudo-prolonged QT interval with ST depression, consistent with T-U wave fusion and a QU interval with an absent T wave.1 The patient received oral and intravenous potassium and magnesium supplementation with resolution of symptoms.

Familial hypokalemic periodic paralysis in pregnancy: A case report

Familial hypokalemic periodic paralysis (f-hypoPP) is a rare neuromuscular disorder causing intermittent muscle paralysis. Pregnancy can exacerbate f-hypoPP, yet obstetric management is not well documented. We present a case of a nulliparous woman with f-hypoPP, outlining a complete prenatal care plan generalizable to other women with known f-hypoPP. To our knowledge, this is the first obstetric f-hypoPP case to prioritize intrapartum oral potassium over intravenous potassium, as well as to outline the importance of multidisciplinary care. The patient had a spontaneous vaginal delivery at term with an uneventful postpartum period. Muscle weakness and episodes of relative hypokalemia in the second trimester and during labor were effectively treated with oral potassium supplementation. Care was provided by a multidisciplinary team, and caution was taken to avoid known triggers of paralytic episodes.

Clinical and Etiological Spectrum of Hypokalemic Periodic Paralysis in a Tertiary Care Hospital in Pakistan

Introduction Hypokalemic periodic paralysis (HPP) is characterized by muscle weakness secondary to low serum potassium levels. It may be primary in origin or there may be secondary causes like thyrotoxic periodic paralysis, renal or suprarenal causes, or non-renal causes like gastroenteritis. Aim To study the etiology, clinical manifestations, and outcome after therapy of patients with hypokalemic paralysis. Methodology The study was conducted from January 2016 to December 2016. Patients fulfilling the diagnostic criteria for hypokalemic paralysis, i.e., flaccid muscle weakness involving two or more limb muscles due to serum potassium < 3.5 mmol/L and with no objective sensory signs were included in the study. Relevant investigations were done. Those with other causes of flaccid weakness or on diuretic therapy were excluded from the study. Data was analyzed using SPSS Version 20.0 (IBM Corp., Armonk, NY). Results In our study, 14 patients out of a total of 18 (14/18, i.e., 77.78%) were male and 4/18 (22.22%) were female [Male: Female ratio: 3.5:1]. The mean age of onset of HPP in males (29.5±10.14 yrs.) was lesser than that of females (41±10.8 yrs.), but this difference was statistically not significant (p<0.066). In the entire sample there were 15/18 cases (83.33%) of primary and 3/18 (16.67%) cases of secondary HPP [2/3 had thyrotoxic periodic paralysis and 1/3 had gastroenteritis]. Furthermore, 12/18 patients (66.66%) had symmetrical weakness (five cases of paraparesis and all were male; seven cases of quadriparesis: six males and one female) and 6/18 (33.33%) had asymmetrical weakness (two paraparesis: one male, one female; four quadriparesis: two males, two females). Statistically, no significant difference (p<0.709) was seen in those with symmetrical versus those with asymmetrical weakness. In this study 7/18 (38.89%) cases had absent, 1/18 (5.55%) had diminished, and 10/18 (55.55%) cases had intact deep tendon reflexes. None of the cases had cranial, bulbar, or respiratory involvement. The mean serum potassium of sample was 3.18±0.5 standard deviation (SD). The reduction in serum potassium was moderate (2.5-3.5 mmol/L) in primary and severe (<2.5 mmol/L) in secondary HPP. Those with quadriparesis had severe hypokalemia with a mean serum potassium of 2.1 mmol/L. Only 3/18 patients had concomitant magnesium deficiency. Patients given intravenous potassium replacement (except one with moderate hypokalemia and given oral replacement) recovered dramatically. The mean recovery time was 38.6±20.3 hours. The recovery time in quadriparesis was about 24 hours and in paraparesis was 12 hours. Only one patient with thyrotoxic periodic paralysis (TPP) and with severe serum potassium deficiency (0.9 meq/L) died due to cardiac arrhythmia. No atypical presentation was seen. Conclusion HPP has male preponderance. The age of onset of HPP is earlier in males than in females. Moreover, males are more prone to have symmetrical weakness. Asymmetrical weakness has almost an equal gender distribution. Primary hypokalemic paralysis is more frequent than secondary. Thyrotoxic periodic paralysis is the commonest cause of secondary periodic paralysis. The recovery time in quadriparesis is almost double the recovery time in paraparesis. Respiratory involvement is rare. HPP is an important differential in the diagnosis of acute flaccid muscle weakness. It should be promptly addressed to prevent recurrence of paralysis.

Integrative Medicine Strategies for Changing Health Behaviors: Support for Primary Care

Until system reforms allow adequate time and reimbursement for primary care providers to focus on lifestyle change to prevent and mitigate chronic disease, primary care providers need a manageable, defined role to support lifestyle change. The authors suggest this role is to serve as a catalyst, priming the patient for change; educating and pointing the patient to appropriate, evidence-based resources for additional guidance and hands-on support; and providing ongoing encouragement throughout the long journey of change while patients work more intensely with health coaches or allied health providers.

An Unusual Etiology of Hypokalemia in a Patient With an Eating Disorder

Patients with eating disorders are at risk for electrolyte imbalances that can lead to life-threatening complications. Timely recognition and evaluation of electrolyte abnormalities, including hypokalemia, are essential. In this case report, we describe an uncommon etiology of hypokalemia in a patient with disordered eating.

Treatment and management of neuromuscular channelopathies

OPINION STATEMENT

Neuromuscular channelopathies are heterogeneous disorders with marked phenotypic and genotypic variability. These include non-dystrophic myotonia (NDM), periodic paralysis (PP), and congenital myasthenic syndrome (CMS). Their diverse clinical manifestations remain a challenge in diagnosis and management to this date. These disorders impact quality of life and cause lifelong disabling symptoms. Treatment options are few and not FDA-approved. This is largely due to a paucity of large, randomized clinical trials in these rare diseases. Challenges of conducting such trials include the rarity of these disorders and the genetic heterogeneity. Physicians rely on off-label use of drugs to treat muscle channelopathies to reduce morbidity and improve quality of life. Besides pharmacological treatment, dietary modifications, lifestyle changes, awareness of triggers, and genetic counseling also play an important role in long-term disease management. This article reviews the current management strategies for neuromuscular channelopathies.

Cardiac arrhythmias in hypokalemic periodic paralysis: Hypokalemia as only cause?

It is unknown how often cardiac arrhythmias occur in hypokalemic periodic paralysis (HypoPP) and if they are caused by hypokalemia alone or other factors. This systematic review shows that cardiac arrhythmias were reported in 27 HypoPP patients. Cases were confirmed genetically (13 with an R528H mutation in CACNA1S, 1 an R669H mutation in SCN4A) or had a convincing clinical diagnosis of HypoPP (13 genetically undetermined) if reported prior to the availability of genetic testing. Arrhythmias occurred during severe hypokalemia (11 patients), between attacks at normokalemia (4 patients), were treatment-dependent (2 patients), or unspecified (10 patients). Nine patients died from arrhythmia. Convincing evidence for a pro-arrhythmogenic factor other than hypokalemia is still lacking. The role of cardiac expression of defective skeletal muscle channels in the heart of HypoPP patients remains unclear. Clinicians should be aware of and prevent treatment-induced cardiac arrhythmia in HypoPP.

Hypokalemic paraplegia in pregnancy

Hypokalemic myopathy may range from numbness/weakness to complete paralysis. The aetiology may be congenital or acquired. It is characterized by acute muscular weakness with low levels of potassium (<3.5 meq/L). We present a case of 26-year-old multigravida at 36 weeks of gestation with gestational hypertension on treatment, who came with acute onset of pain, numbness and weakness of both legs which worsened following betamethasone injection. She was diagnosed to have Hypokalemic paralysis with potassium levels of 2.1 meq/L. The medical profile remitted promptly on intravenous potassium replacement. Pregnancy was continued till 37 weeks with oral potassium supplements, antihypertensives and regular monitoring of serum potassium levels. The pregnancy was terminated after 37 weeks in view of gestational hypertension. Postpartum period was uneventful, patient was discharged after two weeks when potassium levels and BP returned to normal.

A case of hypokalemic paralysis in a patient with neurogenic diabetes insipidus

Acute hypokalemic paralysis is characterized by muscle weakness or paralysis secondary to low serum potassium levels. Neurogenic diabetes insipidus (DI) is a condition where the patient excretes large volume of dilute urine due to low levels of antidiuretic hormone. Here, we describe a patient with neurogenic DI who developed hypokalemic paralysis without a prior history of periodic paralysis. A 30-year-old right-handed Hispanic male was admitted for refractory seizures and acute DI after developing a dental abscess. He had a history of pituitary adenoma resection at the age of 13 with subsequent pan-hypopituitarism and was noncompliant with hormonal supplementation. On hospital day 3, he developed sudden onset of quadriplegia with motor strength of 0 of 5 in the upper extremities bilaterally and 1 of 5 in both lower extremities with absent deep tendon reflexes. His routine laboratory studies revealed severe hypokalemia of 1.6 mEq/dL. Nerve Conduction Study (NCS) revealed absent compound motor action potentials (CMAPs) with normal sensory potentials. Electromyography (EMG) did not reveal any abnormal insertional or spontaneous activity. He regained full strength within 36 hours following aggressive correction of the hypokalemia. Repeat NCS showed return of CMAPs in all nerves tested and EMG revealed normal motor units and normal recruitment without myotonic discharges. In patients with central DI with polyuria, hypokalemia can result in sudden paralysis. Hypokalemic paralysis remains an important differential in an acute case of paralysis and early recognition and appropriate management is key.

Etiological spectrum of hypokalemic paralysis: A retrospective analysis of 29 patients

Background:

Hypokalemic paralysis is characterized by episodes of acute muscle weakness associated with hypokalemia. In this study, we evaluated the possible etiological factors in patients of hypokalemic paralysis.

Materials and Methods:

We reviewed the records of 29 patients who were admitted with a diagnosis of hypokalemic paralysis. Modified Guillain-Barre´ Syndrome disability scale was used to grade the disability.

Results:

In this study, 15 (51.7%) patients had secondary causes of hypokalemic paralysis and 14 patients (42.3%) had idiopathic hypokalemic paralysis. Thyrotoxicosis was present in six patients (20.6%), dengue infection in four patients (13.7%), distal renal tubular acidosis in three patients (10.3%), Gitelman syndrome in one patient (3.4%), and Conn's syndrome in one patient (3.4%). Preceding history of fever and rapid recovery was seen in dengue infection-induced hypokalemic paralysis. Approximately 62% patients had elevated serum creatinine phosphokinase. All patients had recovered completely following potassium supplementation. Patients with secondary causes were older in age, had significantly more disability, lower serum potassium levels, and took longer time to recover.

Conclusion:

In conclusion, more than half of patients had secondary causes responsible for hypokalemic paralysis. Dengue virus infection was the second leading cause of hypokalemic paralysis, after thyrotoxicosis. Presence of severe disability, severe hypokalemia, and a late disease onset suggested secondary hypokalemic paralysis.

Hypokalemic periodic paralysis

Hypokalemic periodic paralysis is a rare genetic disorder characterized by recurrent attacks of skeletal muscle weakness with associated hypokalemia which is precipitated by stress, cold, carbohydrate load, infection, glucose infusion, hypothermia, metabolic alkalosis, anesthesia, and steroids. We encountered one such incidence of prolonged recovery after general anesthesia, which on further evaluation revealed a case of hypokalemic paralysis. The key to successful management of such a patient was vigilant pre-operative evaluation, perioperative monitoring, and aggressive treatment of hypokalemia when it occurs.

Fatality after cardiac arrest in thyrotoxic periodic paralysis due to profound hypokalemia resulting from intravenous glucose administration and inadequate potassium replacement

BACKGROUND

Thyrotoxic periodic paralysis (TPP) is a variant of periodic paralysis (PP) that occurs in patients with underlying mutations in genes for cation channels, if they develop thyrotoxicosis. It is disabling, and fatalities sometimes occur. Here, we present a patient with TPP who developed hypokalemic paralysis that was probably aggravated by the administration of a carbohydrate, probably contributing to, if not causing, a fatal outcome.

SUMMARY

A 30-year-old Chinese patient received (131)I treatment for Graves' disease (GD) in our hospital. Three days later in the middle of the night, he developed aggravating paralytic symptoms after a heavy evening meal. The next morning, he was seen in a small clinic and was treated with 1250 mL 5% glucose containing 25 mL 10% potassium chloride (KCl). By early afternoon, he had not improved and was transferred to a city hospital, arriving with grade I muscle strength and severed facial and bulbar paralysis that was shortly followed by cardiac arrest with failure of resuscitation. Shortly before he died, his serum K(+) was 1.15 mEq/L (normal=3.5-5).

CONCLUSIONS

We postulate that severe hypokalemia developed in our patient in part in response to the high intravenous glucose load that he received. We advocate caution against using intravenous glucose solutions for potassium administration in patients with TPP and recommend a review of guidelines suggesting this form of treatment. In rural settings with limited resources, we favor oral potassium, not to exceed 100 mEq per day, and transfer to a modern medical facility in settings where muscle weakness is developing in patients with TPP.

Thyrotoxic Periodic Paralysis: Case Reports and an Up-to-Date Review of the Literature

Objectives. To describe 2 cases of thyrotoxic periodic paralysis. Methods. We report of 2 cases of thyrotoxic periodic paralysis in 2 individuals from 2 different backgrounds with emphasis on their presentation and treatment. We also conducted a literature search to put together an update review of thyrotoxic periodic paralysis. Results. A 47-year-old Chinese and 28-year-old Caucasian male presented with profound yet reversible weakness associated with hypokalemia on admission bloods and thyrotoxicosis. Both were given definitive therapy to prevent recurrence of attacks with any future relapse of thyrotoxicosis. Conclusion. Thyrotoxic periodic paralysis (TPP) is a rare but potentially serious complication of thyrotoxicosis resulting in temporary but severe muscle weakness. Recent discovery of a novel mutation in the KCNJ18 gene which codes for an inwardly rectifying potassium channel and is controlled by thyroid hormones may provide greater insight into the pathogenesis of TPP.