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Gadi F, Schueler T. Atypical Normokalemic Case of Thyrotoxic Periodic Paralysis in a Pediatric Patient. Cureus 2024; 16:e57467. [PMID: 38699133 PMCID: PMC11065321 DOI: 10.7759/cureus.57467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 05/05/2024] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism characterized by typical muscular symptoms, ranging from paresis to complete paralysis, commonly associated with low potassium blood levels (<3 mmol/l). It is more commonly reported in adult Asian individuals and can lead to life-threatening situations. Therefore, early clinical diagnosis and targeted therapy are of crucial importance. In this article, we report the case of a 17-year-old adolescent with a Vietnamese background and known Graves' disease who was admitted with typical TPP-related symptoms but no hypokalemia. After treatment with an antithyroid medication and oral potassium supplementation, no new episode of TPP was observed. Using next-generation sequencing, a genetic analysis of TPP-related ion channel genes (KCNJ2, KCNJ18, KCNE3, SCN4A, and CACNA1S) found no known/likely pathogenic variants or variants of unknown significance. To the best of our knowledge, this is only the second reported case of quite normokalemic TPP in the pediatric population. Prompt diagnosis of TPP is essential to prevent harmful complications. Supplementation with potassium appears to be successful alongside non-selective beta-blockers. Normalization of thyroid function should be pursued to prevent new attacks, which is considered the best preventive measure.
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Affiliation(s)
- Fahad Gadi
- Pediatrics, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, SAU
| | - Tim Schueler
- Pediatrics, Charité - Universitätsmedizin Berlin, Berlin, DEU
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Penfold MP, Starnes K, Corredor M. Acute Ascending Flaccid Paralysis in a Healthy 16-year-old. Pediatr Rev 2024; 45:96-99. [PMID: 38296775 DOI: 10.1542/pir.2021-005164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
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Hoshina Y, Setterquist H, McConnell TD, Renner DR. Thyrotoxic periodic paralysis presenting with quadriparesis and hyperreflexia. BMJ Case Rep 2023; 16:e256550. [PMID: 38160034 PMCID: PMC10759007 DOI: 10.1136/bcr-2023-256550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism that manifests as painless flaccid paralysis. An East Asian man in his late 20s presented to the emergency department with an acute onset of quadriparesis associated with hypertonia and hyperreflexia. His initial symptoms and signs suggested involvement of the brain and spinal cord; however, MRI of the neuroaxis was normal. His serum potassium concentration was low, and thyroid test results were consistent with hyperthyroidism. The patient was diagnosed with TPP associated with Graves' disease and was treated with potassium supplementation, propranolol and methimazole. Motor strength improved to his baseline level of power; bulk was normal, and tone was increased. Although flaccid paralysis is a typical presentation of TPP, brisk reflexes and muscle spasticity cannot rule out this condition. This case highlights the importance of considering TPP as a possible diagnosis in patients presenting with acute quadriparesis.
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Affiliation(s)
- Yoji Hoshina
- Neurology, University of Utah Health, Salt Lake City, Utah, USA
| | - Hana Setterquist
- Psychiatry, University of Utah Health, Salt Lake City, Utah, USA
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Mebane NB, Khan A, Bevinal M, Davis E. Thyrotoxic Periodic Paralysis With Hypokalemia: A Case Study. Cureus 2023; 15:e40757. [PMID: 37485151 PMCID: PMC10361783 DOI: 10.7759/cureus.40757] [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] [Accepted: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare life-threatening condition most commonly seen in individuals between the ages of 20-40 years. It is most prevalent in Hispanic and Asian populations. Here we present a case report of a young male patient admitted to our facility with an acute onset of paralysis. He was found to have new-onset hyperthyroidism and severe hypokalemia. TPP was exacerbated by the intake of a high-carbohydrate meal as well as a steroid injection within 24 hours of symptom onset.
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Affiliation(s)
- Nova B Mebane
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Aisha Khan
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Manzoor Bevinal
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Erin Davis
- Internal Medicine, Texas College of Osteopathic Medicine, Fort Worth, USA
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Reda H. Neurologic Complications of Endocrine Disorders. Continuum (Minneap Minn) 2023; 29:887-902. [PMID: 37341334 DOI: 10.1212/con.0000000000001262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article provides an overview of the neurologic complications of the most prevalent endocrine disorders in adults with an emphasis on relevant neurologic symptoms, signs, and laboratory and neuroimaging findings. LATEST DEVELOPMENTS Although the mechanisms of many of the neurologic complications discussed here remain unclear, our understanding of the impacts of diabetes and hypothyroidism on the nervous system and muscle, including complications of rapid correction of chronic hyperglycemia, has advanced in recent years. Recent large studies have not demonstrated a convincing association between subclinical or overt hypothyroidism and cognitive decline. ESSENTIAL POINTS Neurologists must become familiar with the neurologic complications of endocrine disorders not only because they are common and treatable (and often reversible) but also because they may be iatrogenic, as is the case with adrenal insufficiency in the setting of long-term corticosteroid therapy.
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Al‐Mashdali AF, Alfatih M, Umer W, Eldeeb Y. Thyrotoxic periodic paralysis as the first presentation of Graves' disease: A case report. Clin Case Rep 2023; 11:e7188. [PMID: 37197293 PMCID: PMC10183649 DOI: 10.1002/ccr3.7188] [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: 08/22/2022] [Revised: 03/16/2023] [Accepted: 03/24/2023] [Indexed: 05/19/2023] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare disease seen predominantly in men of Asian origin. It should be considered in the differential diagnosis of patients with acute onset of weakness, and it is reversible after the correction of serum potassium. TPP can rarely be the initial presentation of Graves' disease.
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Affiliation(s)
| | | | - Waseem Umer
- Department of Internal MedicineHamad Medical CorporationDohaQatar
| | - Yasser Eldeeb
- Department of Infectious DiseasesHamad Medical CorporationDohaQatar
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Scheive M, Patel N, Saeed Z. High-dose intravenous hydrocortisone for the treatment of hyperthyroidism: a rare precipitant of thyrotoxicosis periodic paralysis. Endocrinol Diabetes Metab Case Rep 2023; 2023:22-0358. [PMID: 36752701 PMCID: PMC9986374 DOI: 10.1530/edm-22-0358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 01/17/2023] [Indexed: 02/09/2023] Open
Abstract
Summary Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism triggered by precipitants that increase the activity of the sodium-potassium pump in the skeletal muscle. In our case study, a previously healthy 34-year-old male presented to the emergency department with new onset thyrotoxicosis, secondary to Graves' disease. Given the severity of his triiodothyronine (T3) thyrotoxicosis, he was admitted and started on a high dose of beta-blocker, thioamides, and intravenous hydrocortisone. On the second day of his hospitalization, he developed acute flaccid paralysis of his lower extremities. Subsequent stroke workup was negative, and his electrolytes revealed severe hypokalemia and hyperglycemia consistent with TPP. He was treated with potassium and had a complete recovery of his paralysis and hypokalemia within hours. The patient has not had any recurrence since this singular episode in the hospital. This case highlights the scenario where the treatment of hyperthyroidism with high-dose corticosteroids to reduce the conversion of thyroxine to T3 inadvertently resulted in TPP. Clinicians should be aware of this potentially rare but serious consequence of using steroids to manage hyperthyroidism. Learning points High-dose steroids used to treat hyperthyroidism in hospitalized patients may rarely precipitate thyrotoxic periodic paralysis (TPP) by inducing hypokalemia and hyperglycemia. TPP should be included in the differential diagnosis for acute flaccid paralysis in hospitalized patients with hyperthyroidism. Since TPP is associated with trans-cellular shifts in potassium instead of total body potassium depletion, conservative repletion of potassium is recommended to avoid rebound hyperkalemia.
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Affiliation(s)
- Melanie Scheive
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Neha Patel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Zeb Saeed
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Gulde A, Zhang S, Hussain I. Thyrotoxic Periodic Paralysis: An Under-Recognized Cause of Paralysis in Young Hispanic Men. J Emerg Med 2023; 64:200-207. [PMID: 36710091 DOI: 10.1016/j.jemermed.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/13/2022] [Accepted: 10/21/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patients presenting to the emergency department with paralysis can have a wide differential diagnosis. Thyrotoxic periodic paralysis (TPP) is a rare disorder causing transient flaccid paralysis in the setting of thyrotoxicosis and hypokalemia. It has been reported in Asian male populations predominantly, and the diagnosis is rarely considered in non-Asian populations. Recent research has identified cases in patients with diverse ethnic backgrounds, although epidemiologic data from the United States are very limited. OBJECTIVE Our aim was to report our experience with TPP at a tertiary care center in the United States. METHODS A retrospective chart review was conducted between January 2006 and February 2022 to identify cases of TPP and determine their demographic and clinical characteristics. Prevalence of TPP was estimated using the institutional hyperthyroidism registry. RESULTS Thirty-three patients with TPP were identified. All of the patients were male; median age was 28 years, and 85% were Hispanic. All patients had hypokalemia at presentation and 23% had rebound hyperkalemia after treatment. Prevalence of TPP in our population of patients with hyperthyroidism was approximately 0.5%. CONCLUSIONS Young Hispanic men presenting with paralysis should be evaluated for TPP, as the prevalence in this population may be higher than estimated previously. Management of TPP involves treatment of underlying hyperthyroidism and cautious potassium repletion, with an initial dose of no more than 60 mEq/L of potassium chloride to avoid rebound hyperkalemia.
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Affiliation(s)
- Andrew Gulde
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shuyao Zhang
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Iram Hussain
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Muacevic A, Adler JR, Tiwari K, Kansakar S, Gautam S. A Case of Thyrotoxic Periodic Paralysis: "I Can't Move!". Cureus 2023; 15:e34301. [PMID: 36860235 PMCID: PMC9969901 DOI: 10.7759/cureus.34301] [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] [Accepted: 01/28/2023] [Indexed: 01/30/2023] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a form of hypokalemic periodic paralysis associated with hyperthyroidism. It is characterized by hypokalemia associated with acute proximal symmetrical lower limb weakness and can progress to involve all four limbs and the respiratory musculature. We present a case of a 27-year-old Asian male with recurrent attacks of weakness in all four extremities. A subsequent diagnosis of thyrotoxic periodic paralysis was made, which was secondary to a previously undiagnosed Grave's disease. TPP should be a differential in a young male of Asian ethnicity who presents to the hospital with acute onset of paralysis.
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Idham M, Prajitno JH. Management of hypokalemia in patients with thyrotoxicosis periodic paralysis in Soetomo general hospital: A case report. Ann Med Surg (Lond) 2022; 84:104925. [PMID: 36582870 PMCID: PMC9793236 DOI: 10.1016/j.amsu.2022.104925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/08/2022] [Accepted: 11/13/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction The prevalence of Graves' disease varies widely between 21 and 80% of all cases of hyperthyroidism. Research conducted in 2018 at the Dr. Soetomo Regional General Hospital Surabaya found Graves' disease in as many as 66.7% of all cases of hyperthyroidism. Thyrotoxicosis Periodic Paralysis (TPP) is a disorder characterized by reversible muscle weakness and paralysis, accompanied by hypokalemia, which usually accompanies hyperthyroidism, mostly caused by Graves' disease. Management of severe hypokalemia in TPP is challenging. Case illustration male, 29 years patient complained that both lower legs felt weak in the last 6 hours before coming to the hospital emergency department. The patient was diagnosed with hyperthyroidism in 2018. A fine tremor was found, and the patient was admitted to the hospital for 4 days and routinely controlled at the endocrine polyclinic. Clinical discussion The underlying disease or causative etiology of thyrotoxicosis must be determined before treatment is conducted. The main concern when performing potassium replacement therapy is the occurrence of rebound hyperkalemia because this hypokalemia condition is caused not by total potassium depletion. Conclusion The principles of management for thyrotoxicosis periodic paralysis are proper diagnosis, exclusion of other causes of paralysis, and other causes of hypokalemia, slow and gradual correction of hypokalemia, and close and careful clinical monitoring, ECG, and laboratory.
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Affiliation(s)
- Muhammad Idham
- Corresponding author. Internal Medicine Departement, Faculty of Medicine Universitas Airlangga, Dr. Soetomo General Hospital, Jl. Mayjend Prof. Dr. Moestopo No. 6-8, Surabaya, 60285, Indonesia.
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Nadeem S, Aziz A, Ali D. Thyrotoxic Periodic Paralysis: A case report. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2022. [DOI: 10.1016/j.jecr.2022.100122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Murashita M, Wada N, Baba S, Sugawara H, Miyoshi A, Obara S. Subacute thyroiditis associated with thyrotoxic periodic paralysis after COVID-19 vaccination: a case report. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0236. [PMID: 35578985 PMCID: PMC9175599 DOI: 10.1530/edm-22-0236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/25/2022] [Indexed: 12/18/2022] Open
Abstract
Summary We report a 26-year-old Japanese man who visited our outpatient clinic presenting fever immediately after i.m. injection of the second dose of a coronavirus disease 2019 (COVID-19) vaccine (Moderna®). At the first visit, the patient had a fever of 37.7°C and a swollen thyroid gland with mild tenderness. He was diagnosed with subacute thyroiditis (SAT) based on the presence of thyrotoxicosis (free tri-iodothyronine, 32.3 pg/mL; free thyroxine, >7.77 ng/dL; and thyroid-stimulating hormone (TSH) < 0.01 μIU/mL), high C-reactive protein level (7.40 mg/dL), negative TSH receptor antibody, and characteristic ultrasound findings. His HLA types were A*02:01/24:02, B*15:11/35:01, Cw*03:03, DRB1*09:01/12:01, DQB1*03:03, and DPB1*05: 01/41:01. He was initially administered prednisolone 15 mg/day, following which the fever subsided. After 10 days, he developed limb weakness and could not walk. The serum potassium level decreased to 1.8 mEq/L, which confirmed the diagnosis of thyrotoxic periodic paralysis (TPP). Potassium supplementation was initiated. The muscle weakness gradually decreased. Prednisolone therapy was terminated 6 weeks after the first visit. His thyroid function returned to normal 5 months after the first visit, through a hypothyroid state. To our knowledge, this is the first reported case of TPP-associated SAT following COVID-19 vaccination. Persistent fever following vaccination should be suspected of SAT. Additionally, TPP may be associated with SAT in Asian male patients. Learning points Following coronavirus disease 2019 (COVID-19) vaccination, subacute thyroiditis may develop regardless of the vaccine type. If persistent fever, anterior neck pain, swelling and tenderness of thyroid gland, and symptoms of thyrotoxicosis are observed immediately after the COVID-19 vaccination, examination in consideration of the onset of subacute thyroiditis is recommended. HLA-B35 may be associated with the onset of subacute thyroiditis after the COVID-19 vaccination. Although rare, subacute thyroiditis can be associated with thyrotoxic periodic paralysis, especially in Asian men. Glucocorticoid therapy for subacute thyroiditis may induce thyrotoxic periodic paralysis through hypokalemia.
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Affiliation(s)
- Mone Murashita
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Shuhei Baba
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Hajime Sugawara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Arina Miyoshi
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Shinji Obara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
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Lu A, Lin SH. Thyrotoxic periodic paralysis in two sexagenarian men: A case report. Medicine (Baltimore) 2021; 100:e27795. [PMID: 34964743 PMCID: PMC8615408 DOI: 10.1097/md.0000000000027795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/29/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Thyrotoxic periodic paralysis (TPP) characterized by the triad of muscle paralysis, acute hypokalemia, and the presence of hyperthyroidism is often reported in young adults but rarely reported in age >60 year-old. PATIENT CONCERNS Two sexagenarian males (age 61 and 62) presenting to the emergency department with progressive muscle paralysis for hours. There was symmetrical flaccid paralysis with areflexia of lower extremities. Both of them did not have the obvious precipitating factors and take any drugs. DIAGNOSIS Their Wayne scores, as an objective index of symptoms and signs associated with thyrotoxicosis, were <19 (7 and 14, respectively). Their blood pressure stood 162/78 and 170/82 mm Hg, respectively. Their thyroid glands were slightly enlarged. Both of them had severe hypokalemia (1.8 and 2.0 mmol/L). Their presumptive diagnosis of mineralocorticoid excess disorders with severe potassium (K+) deficit were made. However, low urine K+ excretion and relatively normal blood acid-base status were suggestive of an intracellular shift of K+ rather than K+ deficit. Hormone studies confirmed hyperthyroidism due to Graves disease. INTERVENTIONS A smaller dose of K+ supplementation (only a total of 50 and 70 mmol K+, respectively) were prescribed for the patient. OUTCOMES After treatment, their serum K+ levels became normal with a full recovery of muscle strength. LESSONS Our 2 cases highlight the fact that thyrotoxic periodic paralysis must be still kept in mind as the underlying cause of hypokalemia with paralysis and hypertension in elderly patients to avoid missing curable disorders.
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Affiliation(s)
- Ang Lu
- Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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An Unusual Presentation of Thyrotoxicosis: Leg Weakness and Hypokalemia in a 21-Year-Old Male. Case Rep Endocrinol 2021; 2021:1776538. [PMID: 34725573 PMCID: PMC8557043 DOI: 10.1155/2021/1776538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/06/2021] [Indexed: 11/18/2022] Open
Abstract
Patients with hyperthyroidism or thyrotoxicosis present with an unspecific constellation of signs or symptoms such as palpitations, tremors, weight loss, or diarrhea. In some severe cases, hyperthyroidism can predispose patients to metabolic abnormalities and arrhythmias. Thyrotoxic periodic paralysis (TTP) is a rare, life-threatening complication or variant of hyperthyroidism associated with hypokalemia and muscle weakness that affects young Asian or Hispanic males between 20–40 years. TTP is reversible, and the management consists of beta-blockers, antithyroid therapy, and conservative potassium correction to prevent severe cardiovascular events such as ventricular arrhythmias with the improvement of transient muscle paralysis. We present a case of a 21-year-old Hispanic male complaining with symptoms of thyrotoxicosis, marked hypokalemia, and severe generalized muscle weakness. Physicians must be aware of this uncommon complication of thyrotoxicosis called thyrotoxic periodic paralysis (TTP) to avoid potassium overcorrection and all the endocrine associations with this pathology.
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Bonnar CE, Brazil JF, Okiro JO, Giblin L, Smyth Y, O'Shea PM, Finucane FM. Making weight: acute muscle weakness and hypokalaemia exacerbated by thyrotoxicosis factitia in a bodybuilder. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210060. [PMID: 34612209 PMCID: PMC8558893 DOI: 10.1530/edm-21-0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/17/2021] [Indexed: 12/13/2022] Open
Abstract
SUMMARY A 32-year-old Caucasian male presented to the emergency department with a one-day history of acute severe bilateral lower limb weakness, three days after competing in a bodybuilding competition. He consumed large quantities of carbohydrate-rich foods following the competition. His past medical history was significant for anxiety, and family history was non-contributory. Examination was normal except for reduced power and hyporeflexia in both legs, despite his muscular physique. He was noted to have severe hypokalaemia (K+= 1.9 mmol/L). His thyroid function tests were consistent with thyrotoxicosis. He reported taking thyroxine and several other agents to facilitate muscle mass generation before the bodybuilding competition. His presentation was reminiscent of thyrotoxic periodic paralysis, albeit uncommon with Caucasian ethnicity. He also had transient hyperglycaemia at presentation with concomitant hyperinsulinaemia, which could be attributed to the carbohydrate load and may have exacerbated his hypokalaemia through a transcellular shift. Urine toxicology screen subsequently ruled out the use of diuretics but confirmed the presence of a long-acting beta agonist (clenbuterol) which, along with other substances, may have aggravated the hypokalaemia further. After 12 h of i.v. replacement, the potassium level normalised and leg weakness resolved. The patient agreed to stop taking thyroxine and beta agonists and was well during the clinic visit at one month follow-up. This case highlights the potential for thyrotoxicosis factitia to exacerbate hypokalaemia and muscle weakness from other causes in bodybuilders presenting with acute severe weakness, irrespective of ethnicity. LEARNING POINTS In patients presenting with muscle weakness and hypokalaemia, early consideration of thyrotoxicosis is essential, even in the absence of a past history of thyroid disease or specific symptoms of thyrotoxicosis, in order to allow prompt initiation of appropriate treatment and to prevent recurrence. Bodybuilders may constitute a uniquely 'at-risk' group for thyrotoxic periodic paralysis secondary to thyrotoxicosis factitia, especially where there is concomitant use of beta-adrenergic agonists, even in the absence of diuretic use. Although rare and usually described in patients of Asian or Polynesian ethnicity, this case highlights that thyrotoxic periodic paralysis secondary to thyrotoxicosis factitia can also occur in patients with Caucasian ethnicity. We speculate that consuming large quantities of carbohydrates may induce hyperinsulinaemia, which could theoretically contribute to worse hypokalaemia, though mechanistic studies would be needed to explore this further.
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Affiliation(s)
| | | | - Julie O Okiro
- Department of Nephrology, Endocrinology & Metabolism
| | - Louise Giblin
- Department of Nephrology, Endocrinology & Metabolism
| | | | - Paula M O'Shea
- Department of Clinical Biochemistry, Galway University Hospitals, Saolta University Healthcare Group, Galway, Ireland
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Patel M, Ladak K. Thyrotoxic Periodic Paralysis: A Case Report and Literature Review. Clin Med Res 2021; 19:148-151. [PMID: 34531272 PMCID: PMC8445659 DOI: 10.3121/cmr.2021.1610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 04/07/2021] [Accepted: 04/22/2021] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Matthew Patel
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karim Ladak
- Division of Education and Innovation, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Lin C, Lin CS, Lee DJ, Lee CC, Chen SJ, Tsai SH, Kuo FC, Chau T, Lin SH. Artificial Intelligence-Assisted Electrocardiography for Early Diagnosis of Thyrotoxic Periodic Paralysis. J Endocr Soc 2021; 5:bvab120. [PMID: 34308091 PMCID: PMC8294684 DOI: 10.1210/jendso/bvab120] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Indexed: 12/19/2022] Open
Abstract
Context Thyrotoxic periodic paralysis (TPP) characterized by acute weakness, hypokalemia, and hyperthyroidism is a medical emergency with a great challenge in early diagnosis since most TPP patients do not have overt symptoms. Objective This work aims to assess artificial intelligence (AI)-assisted electrocardiography (ECG) combined with routine laboratory data in the early diagnosis of TPP. Methods A deep learning model (DLM) based on ECG12Net, an 82-layer convolutional neural network, was constructed to detect hypokalemia and hyperthyroidism. The development cohort consisted of 39 ECGs from patients with TPP and 502 ECGs of hypokalemic controls; the validation cohort consisted of 11 ECGs of TPP patients and 36 ECGs of non-TPP individuals with weakness. The AI-ECG–based TPP diagnostic process was then consecutively evaluated in 22 male patients with TTP-like features. Results In the validation cohort, the DLM-based ECG system detected all cases of hypokalemia in TPP patients with a mean absolute error of 0.26 mEq/L and diagnosed TPP with an area under curve (AUC) of approximately 80%, surpassing the best standard ECG parameter (AUC = 0.7285 for the QR interval). Combining the AI predictions with the estimated glomerular filtration rate and serum chloride boosted the diagnostic accuracy of the algorithm to AUC 0.986. In the prospective study, the integrated AI and routine laboratory diagnostic system had a PPV of 100% and F-measure of 87.5%. Conclusion An AI-ECG system reliably identifies hypokalemia in patients with paralysis, and integration with routine blood chemistries provides valuable decision support for the early diagnosis of TPP.
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Affiliation(s)
- Chin Lin
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 114, Taiwan, R.O.C.,School of Medicine, National Defense Medical Center, Taipei 114, Taiwan, R.O.C.,School of Public Health, National Defense Medical Center, Taipei 114, Taiwan, R.O.C
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan, R.O.C
| | - Ding-Jie Lee
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan, R.O.C
| | - Chia-Cheng Lee
- Planning and Management Office, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan, R.O.C.,Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan, R.O.C
| | - Sy-Jou Chen
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan, R.O.C.,Graduate Institute of Injury Prevention and Control, College of Public Health and Nutrition, Taipei Medical University, Taipei 114, Taiwan, R.O.C
| | - Shi-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan, R.O.C
| | - Feng-Chih Kuo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan, R.O.C
| | - Tom Chau
- Department of Medicine, Providence St. Vincent Medical Center, Portland, Oregon 97225,USA
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan, R.O.C
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18
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Duarte Torres J, Marschall A, Fraile Sanz C, Biscotti Rodíl B, Del Castillo Carnevali H, Martí Sánchez D. Ventricular tachycardia secondary to thyrotoxic periodic paralysis: A case report. J Electrocardiol 2021; 67:107-109. [PMID: 34139616 DOI: 10.1016/j.jelectrocard.2021.06.005] [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: 05/19/2021] [Revised: 06/02/2021] [Accepted: 06/05/2021] [Indexed: 11/30/2022]
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare but potentially life-threatening entity, which is characterized by sudden onset of muscle weakness and can in exceptional cases be associated with more severe symptoms, such as severe hypokalemia. We present the rare case of a young patient presenting with monomorphic ventricular tachycardia secondary to hypokalemia due to TPP. This case report highlights the importance of recognition of TPP as a rare cause of VT. A high index of suspicion is needed since signs of hyperthyroidism may be subtle. However, early diagnosis is crucial in order to avoid cardiovascular complications and improve outcomes.
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Affiliation(s)
- Juan Duarte Torres
- Department of Cardiology, Central Defense Hospital Gómez Ulla, Madrid, Spain
| | - Alexander Marschall
- Department of Cardiology, Central Defense Hospital Gómez Ulla, Madrid, Spain.
| | | | | | | | - David Martí Sánchez
- Department of Cardiology, Central Defense Hospital Gómez Ulla, Madrid, Spain
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19
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Retracted: Thyrotoxic Periodic Paralysis: Clinical Challenges. J Thyroid Res 2021; 2021:7814159. [PMID: 33815741 PMCID: PMC7987436 DOI: 10.1155/2021/7814159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 01/22/2021] [Indexed: 11/17/2022] Open
Abstract
[This retracts the article DOI: 10.1155/2014/649502.].
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20
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Banavathu T, Tripathi S, Sukhadiya P, Ahari K, Meena DS, Garg MK. Thyrotoxic Periodic Paralysis with Thyroid Storm as the First Presentation of Graves' disease; a Case Report. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021; 9:e19. [PMID: 33870206 PMCID: PMC8035699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Thyrotoxic periodic paralysis is a rare endocrine emergency that manifests as acute onset muscle weakness and hypokalaemia secondary to thyrotoxicosis. It mainly occurs due to rapid and dramatic intracellular shift of potassium resulting in hypokalaemia and acute flaccid paralysis. This condition predominantly affects males of Asian descent, and presentation can range from mild generalized weakness to complete quadriplegia, as seen in our case. We herein report a case of a 40-year-old female, who presented to us with acute onset flaccid quadriplegia and thyroid storm, which is the first ever manifestation of previously undiagnosed Grave's disease. Liver abscess was found to be the underlying trigger for thyrotoxic paralysis and thyroid storm.
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Affiliation(s)
- Tejaswee Banavathu
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Swapnil Tripathi
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Pankaj Sukhadiya
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Kamlesh Ahari
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Durga Shankar Meena
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Mahendra Kumar Garg
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
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21
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Banavathu T, Tripathi S, Sukhadiya P, Ahari K, Meena DS, Garg MK. Thyrotoxic Periodic Paralysis with Thyroid Storm as the First Presentation of Graves' disease; a Case Report. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021. [PMID: 33870206 PMCID: PMC8035699 DOI: 10.22037/aaem.v9i1.1083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Thyrotoxic periodic paralysis is a rare endocrine emergency that manifests as acute onset muscle weakness and hypokalaemia secondary to thyrotoxicosis. It mainly occurs due to rapid and dramatic intracellular shift of potassium resulting in hypokalaemia and acute flaccid paralysis. This condition predominantly affects males of Asian descent, and presentation can range from mild generalized weakness to complete quadriplegia, as seen in our case. We herein report a case of a 40-year-old female, who presented to us with acute onset flaccid quadriplegia and thyroid storm, which is the first ever manifestation of previously undiagnosed Grave's disease. Liver abscess was found to be the underlying trigger for thyrotoxic paralysis and thyroid storm.
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Affiliation(s)
- Tejaswee Banavathu
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Swapnil Tripathi
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Pankaj Sukhadiya
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Kamlesh Ahari
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Durga Shankar Meena
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Mahendra Kumar Garg
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
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22
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Hung SY, Liu WJ, Wu PC, Yang MC, Wu YK, Lan CC. Noninvasive ventilator prevents intubation in thyrotoxic hypokalemic periodic paralysis-associated respiratory failure: A case report and literature review. Tzu Chi Med J 2021; 33:91-95. [PMID: 33505885 PMCID: PMC7821826 DOI: 10.4103/tcmj.tcmj_248_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 12/06/2019] [Accepted: 12/21/2020] [Indexed: 11/05/2022] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism, often presents with limb muscle paralysis, hypokalemia with elevated-free T3, T4, and low thyroid-stimulating hormone (TSH). We herein reported an unusual presentation of TPP with acute hypercapnic respiratory failure. A 28-year-old female had complaints of nausea and vomiting. Laboratory investigations showed a serum potassium level of 1.2 mEq/L. Thyroid function test revealed the TSH level of 0.021 μlU/mL and free T4 at 2.01 ng/dL. She suddenly suffered from dyspnea and drowsiness. Acute hypercapnic respiratory failure with CO2 retention was found. Noninvasive ventilation was used. Rapid correction of hypokalemia and administration of propylthiouracil, propranolol, and 5% Lugol's solution were performed. After the normalization of potassium levels, the patient's respiratory pattern stabilized and noninvasive ventilator (NIV) use was discontinued. Respiratory failure is an unusual but lethal complication of TPP. Rapid correction of hypokalemia and temporarily NIV can successfully avoid endotracheal intubation for respiratory failure.
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Affiliation(s)
- Shu-Ya Hung
- Division of Respiratory Therapy, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Wen-Jing Liu
- Division of Respiratory Therapy, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Pei-Chan Wu
- Division of Respiratory Therapy, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Mei-Chen Yang
- Division of Pulmonary Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yao-Kuang Wu
- Division of Pulmonary Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chou-Chin Lan
- Division of Pulmonary Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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23
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Verma V, Kumar Y, Kotwal N, Upreti V, Hari Kumar KVS, Singh Y, Menon AS. Thyrotoxic periodic paralysis: A retrospective, observational study from India. Indian J Med Res 2021; 151:42-46. [PMID: 32134013 PMCID: PMC7055170 DOI: 10.4103/ijmr.ijmr_335_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Vishesh Verma
- Department of Endocrinology, Command Hospital, Lucknow, Uttar Pradesh, India
| | - Yogesh Kumar
- Department of Endocrinology, Command Hospital, Kolkata, West Bengal &, India
| | - Narendra Kotwal
- Department of Endocrinology, Army Hospital (R & R), New Delhi, India
| | - Vimal Upreti
- Department of Endocrinology, Army Hospital (R & R), New Delhi, India
| | - K V S Hari Kumar
- Department of Endocrinology, Army Hospital (R & R), New Delhi, India
| | - Yashpal Singh
- Department of Endocrinology, Army Hospital (R & R), New Delhi, India
| | - Anil S Menon
- Department of Endocrinology, Command Hospital, Lucknow, Uttar Pradesh, India
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24
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Karndumri K, Thewjitcharoen Y, Chatchomchuan W, Porramatikul S, Krittiyawong S, Wanothayaroj E, Butadej S, Nakasatien S, Rajatanavin R, Himathongkam T. Impact of first-line treatment choice on long-term outcomes of hyperthyroid Graves' disease patients with thyrotoxic periodic paralysis. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2020; 21:100235. [PMID: 32953456 PMCID: PMC7486682 DOI: 10.1016/j.jcte.2020.100235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 08/29/2020] [Accepted: 08/30/2020] [Indexed: 11/28/2022]
Abstract
Background Thyrotoxic periodic paralysis (TPP) is a unique manifestation of Graves’ disease. While it is uncommon in Asian, it is extremely rare in Caucasian patients (0.1–0.2%). Previous studies suggested that TPP indicate more severity of Graves’ disease and definitive treatments should be used to prevent relapses. Aim To describe clinical features and impact of first-line treatment on long-term outcomes of TPP patients. Method A retrospective cohort study over 35 years (1985–2019) of TPP from Graves’ disease patients was conducted. All cases were analyzed and their clinical courses were compared between those who received anti-thyroid drugs (ATD) versus radioactive iodine (RAI) as a primary treatment. None of them underwent surgery. Results A total of 2964 hyperthyroid Graves’ disease patients were treated and followed-up at least 3 months over the study period. TPP was identified in 63 cases (2.1%) of all patients. There were 60 males and only 3 females with age at presentation of 35.0 ± 8.2 years. TPP was the first presentation of hyperthyroid Graves’ disease in 82.5% of them. During the acute attack of TPP, all patients presented with bilateral lower limb flaccid weaknesses with median serum potassium of 2.1 mmol/L. No fatal TPP cases were found. RAI was selected as primary treatment in 27 patients (42.9%). Nearly all RAI-treated patients rendered hypothyroidism with the median RAI dose at 15 mCi. No patients who were in remission after RAI treatment developed recurrent attack of TPP. In the remaining 36 ATD-treated patients with mean follow-up time at 9.1 years, relapse was found in 10 patients (27.8%) after the drug discontinuation and 6 patients suffered recurrent TPP. Only 8 ATD-treated TPP patients (22.2%) went into remission. Conclusions TPP is a rare complication of hyperthyroid Graves’ disease. Definitive treatment with RAI or thyroidectomy should be employed to prevent relapse and further attacks of TPP.
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Affiliation(s)
| | | | | | | | | | | | - Siriwan Butadej
- Diabetes and Thyroid Center, Theptarin Hospital, Bangkok, Thailand
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25
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Polamaung W, Kongkit J, Yimnoi P, Boonchaya-Anant P, Snabboon T. Thyrotoxic Hypokalemic Periodic Paralysis Triggered by Dexamethasone Administration. ACTA MEDICA (HRADEC KRÁLOVÉ) 2020; 63:91-93. [PMID: 32771076 DOI: 10.14712/18059694.2020.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Thyrotoxic hypokalemic periodic paralysis (THPP) is a disease characterized by recurrent episodes of muscle weakness due to intracellular potassium shifting in the presence of high levels of thyroid hormone. It occurs more commonly amongst young Asian men with underlying Graves' disease. Attacks are commonly precipitated by ingestion of carbohydrate-rich meals or alcohols, stress or strenuous exercise. Herein, we describe an adult Thai man suffering from a hypokalemic periodic paralysis attack after receiving a dexamethasone injection. The diagnosis of Graves' disease was confirmed by his thyroid function test and a presence of thyrotropin-receptor antibody. His weakness and hypokalemia responded well to potassium supplement and a non-selective beta blocker, while his thyrotoxicosis was initially controlled by an anti-thyroid medication and subsequently with a subtotal thyroidectomy. Clinicians should beware of this manifestation when administering steroids in the thyrotoxic patients, especially of Asian male descent.
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Affiliation(s)
- Waraporn Polamaung
- Department of Medicine, Prapokklao Hospital, Chanthaburi Province, Thailand
| | - Jaruwan Kongkit
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Medicine, Vachira Phuket Hospital, Phuket Province, Thailand
| | - Parichat Yimnoi
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Patchaya Boonchaya-Anant
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center in Diabetes, Hormone and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Thiti Snabboon
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. .,Excellence Center in Diabetes, Hormone and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
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26
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Bilha S, Mitu O, Teodoriu L, Haba C, Preda C. Thyrotoxic Periodic Paralysis-A Misleading Challenge in the Emergency Department. Diagnostics (Basel) 2020; 10:E316. [PMID: 32443393 PMCID: PMC7277936 DOI: 10.3390/diagnostics10050316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022] Open
Abstract
Despite its' life-threatening potential due to cardiac severe dysrhythmia in the context of severe hypokalemia, thyrotoxic periodic paralysis (TPP) often goes unrecognized. Although classically confined to young Asian men, it can occur irrespective of age, sex, and race. We report a short series of three cases of TPP as first presentation of Graves' disease in a young Caucasian male and in two Caucasian elderly and middle-aged women, respectively. The first patient developed malignant ventricular arrhythmias due to severe hypokalemia and was defibrillated, with recovery after prompt potassium correction and administration of antithyroid agents and propranolol. The other two cases developed persistent hypokalemia despite adequate potassium chloride (KCl) repletion, with slow recovery of motor deficit and serum potassium normalization up to day 5. In the first case, long-term euthyroid state was achieved via total thyroidectomy due to the presence of a suspicious nodule that proved to be malignant. In the other two cases, medical treatment was the choice of therapy for thyrotoxicosis. None experienced recurrent TPP. Thyroid hormone evaluation is mandatory in the presence of hypokalemic paralysis, even in the absence of clinical signs of thyrotoxicosis. If TPP is confirmed, initial therapy should comprise antithyroid drugs and propranolol, besides hypokalemia correction.
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Affiliation(s)
- Stefana Bilha
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700111 Iasi, Romania; (S.B.); (C.P.)
| | - Ovidiu Mitu
- Cardiology Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700111 Iasi, Romania;
| | - Laura Teodoriu
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700111 Iasi, Romania; (S.B.); (C.P.)
| | - Cristian Haba
- Cardiology Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700111 Iasi, Romania;
| | - Cristina Preda
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700111 Iasi, Romania; (S.B.); (C.P.)
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27
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Abstract
Thyrotoxic periodic paralysis is a rare presentation of thyrotoxicosis where the patient develops a transient motor deficit secondary to acute hypokalemia. The thyroid hormone augments gene transcription and post-transcriptional modification of Na-K ATPase, a cell membrane protein that regulates the electrical potential of the cell. Na-K ATPase increases active transport of potassium (K+) ions into the intracellular compartment causing hypokalemia without total body potassium deficit. Severe hypokalemia affects depolarization of the muscle cell membrane, clinically evidenced as paralysis. Other factors that may trigger hypokalemia and paralysis in the setting of hyperthyroidism include diet intake high in carbohydrates and salt, alcohol ingestion, trauma, infections, certain medication, and strenuous exercise. This rare but possible clinical presentation of thyrotoxicosis is significantly more predominant in males of Asian descent. We are reporting a case of a 44-year-old Asian-American male who presented to the emergency department with complaints of acute onset of bilateral lower extremity weakness. He had severe hypokalemia and was diagnosed with primary hyperthyroidism due to Graves' disease.
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28
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Antonelli A, Fallahi P, Elia G, Ragusa F, Paparo SR, Ruffilli I, Patrizio A, Gonnella D, Giusti C, Virili C, Centanni M, Shoenfeld Y, Ferrari SM. Graves' disease: Clinical manifestations, immune pathogenesis (cytokines and chemokines) and therapy. Best Pract Res Clin Endocrinol Metab 2020; 34:101388. [PMID: 32059832 DOI: 10.1016/j.beem.2020.101388] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Graves' disease (GD) is characterized by thyrotoxicosis, caused by the presence of circulating thyroid stimulating antibodies (TSAb), that are determinant also in the pathogenesis of its extrathyroidal manifestations [Graves' ophthalmopathy (GO), pretibial myxedema]. T helper (Th)1 immune response prevails in the immune-pathogenesis of GD and GO, during the active phase, when Th1 chemokines, and their (C-X-C)R3 receptor, play a key role. In GD, the existing treatments are not ideal for hyperthyroidism (long-term remission with anti-thyroid-drugs only in 50% of patients; while radioiodine and surgery cause hypothyroidism). In GD, antigen-specific therapy has been recently published, with the induction of T cell tolerance via an immunization by TSH-R peptides. In GO, rituximab and drugs targeting cytokines have been evaluated. Furthermore, teprotumumab (a human monoclonal anti-IGF-1R blocking antibody) showed to be very effective in GO patients. Further researches are necessary to identify novel effective therapies targeting GD, or GO.
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Affiliation(s)
- Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Poupak Fallahi
- Department of Translational Research and of New Technologies in Medicine and Surgery, University of Pisa, 56126, Pisa, Italy.
| | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | | | - Ilaria Ruffilli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Armando Patrizio
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Debora Gonnella
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Claudia Giusti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Camilla Virili
- Sapienza University of Rome, 9311, Medicosurgical Sciences and Biotechnologies, C.so della Repubblica 79, Latina, 04100, Italy.
| | - Marco Centanni
- Sapienza University of Rome, 9311, Medicosurgical Sciences and Biotechnologies, C.so della Repubblica 79, Latina, 04100, Italy; ASL Latina, 217138, Endocrinology Unit, Latina, Lazio, Italy.
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Russia.
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29
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Al-Refaie N, Appiah S, Mandal AKJ, Missouris CG. Don't Trip Over the Trop: An Unusual Presentation of Thyrotoxic Periodic Paralysis. Am J Med 2019; 132:1166-1169. [PMID: 31077655 DOI: 10.1016/j.amjmed.2019.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Norildin Al-Refaie
- Department of Cardiology, Buckinghamshire NHS Foundation Trust, Wycombe Hospital, High Wycombe, UK
| | - Shweta Appiah
- Department of Cardiology, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Amit K J Mandal
- Department of Cardiology, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Constantinos G Missouris
- Department of Cardiology, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK; Department of Cardiology, University of Cyprus Medical School, Nicosia, Cyprus.
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30
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Thyrotoxic periodic paralysis complicated by life-threatening acute hypercapnic respiratory failure in a Chinese male with painless thyroiditis. Am J Emerg Med 2019; 37:379.e1-379.e3. [DOI: 10.1016/j.ajem.2018.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 10/05/2018] [Accepted: 11/06/2018] [Indexed: 11/24/2022] Open
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Aggarwal A, Wadhwa R, Pande A, Sahu M, Kapoor D, Khanna R. Hypokalemic Periodic Paralysis and Spectrum of Thyroid Disorders: Analysis of 7 Cases from Northern India. Indian J Endocrinol Metab 2019; 23:168-170. [PMID: 31016175 PMCID: PMC6446676 DOI: 10.4103/ijem.ijem_619_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ajay Aggarwal
- Department of Endocrinology, Fortis Hospital, Shalimar Bagh, New Delhi, India
| | - Roopak Wadhwa
- Department of Endocrinology, Fortis Hospital, Shalimar Bagh, New Delhi, India
| | - Arun Pande
- Department of Endocrinology, Sahara Hospital, Lucknow, Uttar Pradesh, India
| | - Monashish Sahu
- Department of Endocrinology, Vidyasagar Institute of Mental Health and Sciences, Nehru Nagar, New Delhi, India
| | - Dheeraj Kapoor
- Department of Endocrinology, Artemis Hospital, Gurugram, Haryana, India
| | - Rajeev Khanna
- Department of Endocrinology, Dr. Khanna's Endocrinology Clinic, Amritsar, Punjab, India
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Cheema MA, Zain MA, Cheema K, Ullah W. Thyroxine-induced periodic paralysis: a rare complication of nutritional supplements. BMJ Case Rep 2018; 11:11/1/e227946. [PMID: 30567254 DOI: 10.1136/bcr-2018-227946] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The consumption of daily nutritional supplements has risen dramatically all over the world. Many people believe that dietary supplements, if not useful, are at least safe to fulfil small dietary gaps. Many nutritional supplements have not been approved by Federal Drug Administration due to their unregulated active ingredients, but they are available as over the counter. One of the active ingredients, exogenous triiodothyronine (T3), has been reported in dietary supplements. We present a case of sudden onset of tetraparesis. Laboratory workup showed hypokalaemia, low thyroid-stimulating hormone and thyroxine (T4) but normal T3 and thyroglobulin levels. The radioiodine uptake scan also showed reduced uptake. After aggressive serum potassium correction and stopping supplements, his condition got improved. So the suspicion of exogenous T3-induced thyrotoxic periodic paralysis was confirmed.
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Affiliation(s)
| | | | | | - Waqas Ullah
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, PA, USA
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Affram KO, Reddy TL, Osei KM. A Rare Case of Thyrotoxic Periodic Paralysis After Epidural Steroid Injection: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1453-1458. [PMID: 30531678 PMCID: PMC6293861 DOI: 10.12659/ajcr.911270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patient: Male, 36 Final Diagnosis: Epidural steroid induced thyrotoxic periodic paralysis Symptoms: Paralysis Medication: — Clinical Procedure: Epidural steroid injection Specialty: Endorinology and Metabolic
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Affiliation(s)
- Kwame Ofori Affram
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
| | - Tanya Luke Reddy
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
| | - Kofi M Osei
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
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Abstract
RATIONALE Thyrotoxic periodic paralysis is characterized by a sudden onset of hypokalemia and paralysis. This condition mainly affects the lower extremities and is secondary to thyrotoxicosis. The underlying hyperthyroidism is often subtle without typical symptoms such as palpitations, tremors, anxiety, and weight loss; this causes a difficulty in early diagnosis. Here, we reported a case of periodic paralysis in a patient with hyperthyroidism whose potassium level was within the normal range. PATIENT CONCERNS A 33-year-old Taiwanese man presented to the emergency department with bilateral limb weakness (more severe in the lower limbs than in the upper limbs). On arrival, the patient's vital status was stable with clear consciousness. He denied experiencing recent trauma, back pain, chest pain, abdominal pain, headache or dizziness, or a fever episode. Physical examination showed no specific findings. Neurological examination showed weakness in the muscles of the bilateral upper and lower limbs. Muscle weakness was more severe in the proximal site than in the distal site. DIAGNOSIS Blood examination showed normal complete blood count, normal renal and liver function, and normal potassium (3.5 mmol/L, normal range 3.5-5.1 mmol/L), sodium, and calcium levels; however, the examination showed impaired thyroid function (thyroid stimulating hormone: 0.04 uIU/mL, normal range 0.34-5.60 uIU/mL; free T4: 1.96 ng/dL, normal range 0.61-1.12 ng/dL). Brain computed tomography without contrast showed no obvious intra-cranial lesion. INTERVENTIONS Intravenous potassium infusion (20 mEq/L) with normal saline was prescribed for the patient. OUTCOMES After treatment, the patient felt a decrease in limb weakness. He was discharged from our emergency department with a scheduled follow-up in the endocrine outpatient department. LESSONS TPP should be considered as a differential diagnosis in young Asian men presenting with limb paralysis that is more severe in the proximal site and in the lower limbs than in the distal site and in the upper limbs, respectively. It is important for emergency department physicians to consider TPP as a differential diagnosis as it can occur even if the patient's potassium level is within the normal range.
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Affiliation(s)
- Pin-Han Wang
- Department of Emergency Medicine, Kaohsiung Medical University Hospital
| | - Kuan-Ting Liu
- Department of Emergency Medicine, Kaohsiung Medical University Hospital
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Hung Wu
- Department of Emergency Medicine, Kaohsiung Medical University Hospital
| | - I-Jeng Yeh
- Department of Emergency Medicine, Kaohsiung Medical University Hospital
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Graves' Disease Presenting with Periodic Paralysis to the Emergency Department. Case Rep Endocrinol 2018; 2018:9763452. [PMID: 29984010 PMCID: PMC6011162 DOI: 10.1155/2018/9763452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/13/2018] [Indexed: 01/07/2023] Open
Abstract
Thyrotoxic periodic paralysis is an infrequent manifestation of hyperthyroidism and an uncommon cause of muscle weakness in western countries. The diagnosis should be considered in the differential when a patient presents with transient and recurrent weakness associated with hypokalaemia. We present a case of a 26-year-old Asian male presenting with sudden onset muscle weakness affecting predominantly his lower limbs on a background of weight loss. Physical examination demonstrated symmetrical proximal muscle weakness with normal sensation and reflexes. Initial biochemical investigations revealed hypokalaemia, hypomagnesaemia, and hyperthyroidism. Intravenous electrolyte replacement was administered in the emergency department. The patient's symptoms resolved during inpatient admission. Subsequent TSH receptor antibody testing and radionuclide thyroid scan confirmed a diagnosis of Graves' disease. The patient was discharged on antithyroid medication with no further episodes of weakness on follow-up. Therefore, thyrotoxic periodic paralysis can be the presenting feature of previously undiagnosed Graves' disease and should be considered in the differential diagnosis in patients presenting with weakness.
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Abstract
Thyrotoxic Periodic Paralysis (TPP) belongs to a group of muscle diseases called channelopathies, which present with painless generalized muscle weakness without exertion. TPP can be precipitated by a large carbohydrate meal, stress, strenuous exercise, alcohol, a high-salt diet, menstruation, and cold temperatures. Rarely, steroids such as dexamethasone can also precipitate a TPP attack. A 29-year-old Hispanic male, with a history of hyperthyroidism, presented to the emergency department with progressive weakness, predominantly in the lower extremities since morning. Earlier that day, the patient was seen in the same emergency department for difficulty in swallowing. He was diagnosed with uvulitis and received intramuscular dexamethasone and was discharged with amoxicillin for ten days. At home, he started to develop cramps in his lower extremities associated with paresthesias, which progressed to severe weakness to the point where he could not get out of bed. He returned to the hospital and revealed that he had suffered a similar episode following a steroid injection five years ago. He had not sought medical attention as it resolved spontaneously. He denied strenuous exercise, carbohydrate-rich meal, or alcohol ingestion. The patient had been noncompliant with atenolol and methimazole for the past month after losing his medical insurance. On examination, the patient appeared alert and calm. His vitals were significant for tachycardia of 123 beats per minute. Thyromegaly and tenderness were absent on examination of the neck. Muscle strength was 5/5 in the ankle dorsiflexors and ankle plantar flexors bilaterally, but the strength of the iliopsoas, quadriceps, and hamstrings was only 2/5 bilaterally. Deep tendon reflexes were diminished throughout to 1+. Laboratory findings were significant for profound hypokalemia, hypophosphatemia, low thyroid stimulating hormone, and elevated free T3 and T4 levels suggestive of hyperthyroidism. His electrolytes were replaced aggressively and his home medications were restarted. His electrolyte imbalance corrected and his symptoms resolved within a day and he was discharged home. The overwhelming majority of TPP cases reported are male patients, hence this case demonstrates the need to be aware of this complication while treating hyperthyroid male patients with steroids. Hyperthyroidism potentiates catecholamine-mediated Na/K ATPase transport of potassium into the cells. Glucocorticoids are used in the treatment of thyroid storm as it prevents the peripheral conversion of T4 to T3. Moreover, glucocorticoids increase glucose levels stimulating insulin release, which shifts potassium intracellularly accentuating muscle weakness. Although the incidence of glucocorticoids causing TPP is low and not many cases are documented, it is still an important condition to be aware of and can have major clinical implications. Clinicians should be aware of this small subset of hyperthyroidism patients where the use of glucocorticoids can precipitate paralysis.
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Affiliation(s)
- Rizwan Ahamed
- Internal Medicine, St. Joseph Mercy Oakland Hospital
| | | | - Anupam A Sule
- Internal Medicine, St. Joseph Mercy Oakland Hospital
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Abstract
PURPOSE OF REVIEW This article discusses the clinical features, pathophysiology, and management of toxic and endocrine myopathies. RECENT FINDINGS Early detection and expeditious correction of metabolic disturbances in endocrinopathies such as Cushing syndrome, thyroid and parathyroid diseases, and acromegaly can minimize and prevent neurologic complications including myopathy. Recently proposed mechanisms of injury in patients with critical illness myopathy include inhibition of protein synthesis, mitochondrial dysfunction, disruption of the ubiquitin-proteasome system, oxidative stress, and disruption of intramuscular calcium homeostasis, which can cause a myosin-loss myopathy. Mechanisms underlying toxic myopathies include myosin loss; damage to cellular structures, including myofibrils and organelles such as lysosomes and mitochondria; inflammation; and necrosis. Presentations range anywhere from acute, painful, and necrotic myopathies, as can occur in statin myopathy, to more insidious presentations such as steroid myopathy. SUMMARY Endocrinopathies known to cause myopathy include thyroid and parathyroid diseases, disorders of the adrenal axis such as Cushing syndrome, and acromegaly. Patients in the intensive care unit are at risk for developing critical illness myopathy, also known as myosin-loss myopathy, which should be considered if intensive care unit acquired weakness develops. The most common toxic agents associated with myopathy include statins and other lipid-lowering medications, corticosteroids, colchicine, amiodarone, hydroxychloroquine, and chloroquine.
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Long Exercise Test in the Interattack Period of Periodic Paralysis: A Useful and Sensitive Diagnostic Tool. J Clin Neurophysiol 2017; 34:497-501. [PMID: 28742635 DOI: 10.1097/wnp.0000000000000405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The reference values of long exercise test are inconsistent in previous studies. Our research aims to determine the reference values and improve diagnostic efficiency of long exercise test in periodic paralysis. METHODS In this study, 100 healthy controls, 35 non-periodic paralysis patients, and 47 patients with periodic paralysis were recruited. The procedures of long exercise test were conducted following McMannis(1986) method. RESULTS The decrease rate in compound muscle action potential amplitudes was correlated with gender, and it was not influenced by age, height, weight, and exercise. After analyzing receiver operating characteristic curves, the compound muscle action potential amplitude decrease rate was stratified by sex. The mean area under the curve, sensitivity, and specificity were higher in male and female than all pooled subjects. The reference values of compound muscle action potential amplitude decrease rate were 46.8% in male and 26.9% in female, respectively. CONCLUSIONS The long exercise test is a useful and sensitive diagnostic tool for primary periodic paralysis and thyrotoxic periodic paralysis. However, the reference values should be set by sex, which has better diagnostic performance, sensitivity, and specificity.
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Alqahtani SF, Aleithan MM. Thyrotoxic periodic paralysis as an initial presentation of Graves' disease in a Saudi patient. BMJ Case Rep 2017. [PMID: 28630226 DOI: 10.1136/bcr-2017-220224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a well-known complication of hyperthyroidism, characterised by recurrent flaccid paralysis with hypokalaemia. To date, only five cases of this rare disorder have been reported in Saudi Arabia. Here, we report an additional case involving a 25-year-old Saudi man who presented with lower limb paralysis and severe hypokalaemia. Clinically, he showed symptoms and signs suggestive of Graves' disease, which was confirmed by laboratory investigations. Carbimazole, a beta-blocker and potassium replacement were administered, resulting in dramatic improvement of the TTP. This case emphasises the importance of considering TPP in patients with acute muscle weakness and the importance of promptly initiating treatment and preventing relapse of TPP.
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Affiliation(s)
- S F Alqahtani
- Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - M M Aleithan
- Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Cano Megías M, Fernández Rodríguez L, Mancha Ramos J, Espinosa Figueroa JL. Parálisis periódica hipopotasémica familiar asociada a tiroiditis autoinmune. Med Clin (Barc) 2016; 146:375-6. [DOI: 10.1016/j.medcli.2015.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 10/19/2015] [Accepted: 10/22/2015] [Indexed: 10/22/2022]
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Hakami O, Ahmad MM, Al Johani N. A Case of Nonfatal Ventricular Arrhythmia Due to Thyrotoxic Periodic Paralysis in a Saudi Patient as an Initial Presentation of Graves' Disease. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2016; 9:5-9. [PMID: 26843815 PMCID: PMC4734662 DOI: 10.4137/ccrep.s34560] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/12/2015] [Accepted: 11/21/2015] [Indexed: 12/26/2022]
Abstract
Thyrotoxic periodic paralysis (TPP) is a potentially lethal complication of hyperthyroidism characterized by recurrent muscle weakness and hypokalemia. It has been commonly reported in non-Asian populations. Four cases were reported in Saudis so far, and one had a life-threatening arrhythmia. We describe an additional case of a 28-year-old apparently healthy Saudi male patient, who presented with acute paraparesis associated with hypokalemia (K: 2.0 mmol/L), complicated by ventricular tachycardia and cardiac arrest. He was successfully resuscitated and his hypokalemia was corrected. A diagnosis of Graves’ disease associated with TPP was made. He was initially treated with carbimazole and β-blockers and then given a definitive therapy with radioactive iodine, which showed a good response. This case highlights the importance of early recognition and prompt treatment of TPP as a differential diagnosis for muscle weakness. A brief review of TPP and associated arrhythmia is included.
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Affiliation(s)
- Osamah Hakami
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Maswood M Ahmad
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Naji Al Johani
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia.; Faculty of Medicine, King Saud Bin Abdulaziz University, Riyadh, Saudi Arabia.; Prince Mutaib Chair for Biomarkers of Osteoporosis, Biochemistry Department, College of Science, King Saud University, Riyadh, Saudi Arabia
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Parálisis hipocalémica tirotóxica. A propósito de un caso. Semergen 2015; 41:e6-8. [DOI: 10.1016/j.semerg.2014.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 05/23/2014] [Accepted: 05/31/2014] [Indexed: 11/20/2022]
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Li X, Yao S, Xiang Y, Zhang X, Wu X, Luo L, Huang H, Zhu M, Wan H, Hong D. The clinical and genetic features in a cohort of mainland Chinese patients with thyrotoxic periodic paralysis. BMC Neurol 2015; 15:38. [PMID: 25885757 PMCID: PMC4371807 DOI: 10.1186/s12883-015-0290-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 02/25/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Thyrotoxic periodic paralysis (TPP) is a life-threatening channelopathy manifesting as recurrent episodes of hypokalemia and muscle weakness in the presence of hyperthyroidism. Recent findings indicate defects of inward rectifying K+ (Kir) channels are associated with some TPP patients. The associations are not only found in Caucasian population (mainly Brazilian), but also in Singaporean population. However, potential genetic risk factors for mainland Chinese patients, the largest group of TPP cases in the world, have been largely unexplored. METHODS Samples of DNA from 127 individuals with TPP and 102 hyperthyroidism male controls self-reported as mainland Chinese were collected from 5 clinical centers from Jan 2011 to Jan 2014. The KCNJ2 gene, KCNJ18 gene, as well as loci polymorphisms (rs623011and rs312691) at 17q24.3 were directly sequenced in TPP patients and controls. Clinical data were summarized from TPP participants for genotype/phenotype correlations. RESULTS 3.1% of TPP cases harbored KCNJ18 gene mutations in mainland Chinese patients. Patients with KCNJ18 mutation had shorter attack duration, higher prevalence of muscle soreness and weakness recurrence than patients without KCNJ18 mutation. The alleles at 17q24.3 (rs623011and rs312691) were more common in patients with TPP than in controls, and therefore were significant risk factors for TPP (odds ratio, 11.94 and 10.57; 95% CI, 5.93-24.05 and 5.48-20.40; P = 1.81 × 10(-14) and 1.07 × 10(-14) respectively). CONCLUSIONS This study demonstrates that the KCNJ18 variants are only responsible for a small proportion of TPP patients in mainland China. There are significant clinical differences between patients with KCNJ18 mutations and patients without KCNJ18 mutations. In addition, the rs623011and rs312691 loci are significantly associated with TPP patients in mainland China, and highlight the Kir2.1 channel as a causative target in TPP.
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Affiliation(s)
- Xiaobing Li
- Department of Emergency, The First Affiliated Hospital of Nanchang University, Nanchang, China. .,Department of Neurology, The First Affiliated Hospital of Nanchang University, 17# Yong Wai Zheng Street, Nanchang, PRC.
| | - Sheng Yao
- Department of Neurology, The Navy General Hospital of China, Beijing, China.
| | - Yining Xiang
- Department of Pathology, The Affiliated Hospital Guiyang Medical College, Guiyang, China.
| | - Xiaolei Zhang
- Department of Neurology, The People Hospital of Shanxi Province, Taiyuan, China.
| | - Xiangbing Wu
- Department of Neurology, The Affiliated Hospital of Jiujiang College, Jiujiang, China.
| | - Laimin Luo
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China.
| | - Haihua Huang
- Department of Endocrinology, The First Affiliated Hospital of Nanchang University, Nanchang, China.
| | - Min Zhu
- Department of Neurology, The First Affiliated Hospital of Nanchang University, 17# Yong Wai Zheng Street, Nanchang, PRC.
| | - Hui Wan
- Department of Neurology, The First Affiliated Hospital of Nanchang University, 17# Yong Wai Zheng Street, Nanchang, PRC.
| | - Daojun Hong
- Department of Neurology, The First Affiliated Hospital of Nanchang University, 17# Yong Wai Zheng Street, Nanchang, PRC.
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Sung CC, Cheng CJ, Chiang WF, Chau T, Hsu YJ, Yang SS, Lin SH. Etiologic and therapeutic analysis in patients with hypokalemic nonperiodic paralysis. Am J Med 2015; 128:289-96.e1. [PMID: 25447623 DOI: 10.1016/j.amjmed.2014.09.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 09/23/2014] [Accepted: 09/24/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hypokalemic nonperiodic paralysis represents a group of heterogeneous disorders with a large potassium (K(+)) deficit. Rapid diagnosis of curable causes with appropriate treatment is challenging to avoid the sequelae of hypokalemia. We prospectively analyzed the etiologies and therapeutic characteristics of hypokalemic nonperiodic paralysis. METHODS Over an 8-year period, patients with hypokalemic nonperiodic paralysis were enrolled by excluding those with hypokalemic periodic paralysis due to acute shift of K(+) into cells. Blood and spot urine samples were collected for the measurements of electrolytes, pH, and biochemistries. Intravenous potassium chloride (KCl) at a rate of 10-20 mmol/h was administered until muscle strength recovered. RESULTS We had identified 58 patients with hypokalemic nonperiodic paralysis from 208 consecutive patients with hypokalemic paralysis, and their average K(+) concentration was 1.8 ± 0.2 mmol/L. Among patients with low urinary K(+) excretion (n = 17), chronic alcoholism, remote diuretic use, and anorexia/bulimia nervosa were the most common causes. Among patients with high urinary K(+) excretion (n = 41) and metabolic acidosis, renal tubular acidosis and chronic toluene abuse were the main causes, while primary aldosteronism, Gitelman syndrome, and diuretics were the leading diagnoses with metabolic alkalosis. The average KCl dose needed to restore muscle strength was 3.8 ± 0.8 mmol/kg. Initial lower plasma K(+), volume depletion, and high urinary K(+) excretion were associated with higher recovery KCl dosage. During therapy, patients with paradoxical hypokalemia (n = 32) who required more KCl supplementation than patients without (4.1 ± 0.7 vs 3.4 ± 0.7 mmol/kg, P < 0.001) often exhibited significantly higher plasma renin activity and received a higher volume of normal saline before its appearance. CONCLUSIONS Understanding the common etiologies of hypokalemic nonperiodic paralysis may aid in early diagnosis. Patients with initial lower plasma K(+), renal K(+) wasting, and hypovolemia required higher recovery K(+) dosage. Paradoxical hypokalemia is prone to develop in hypovolemic patients even during K(+) supplementation with volume repletion.
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Affiliation(s)
- Chih-Chien Sung
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Jen Cheng
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Fang Chiang
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Medicine, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan
| | - Tom Chau
- Department of Medicine, Providence St. Vincent Medical Center, Portland, Ore
| | - Yu-Juei Hsu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Sung-Sen Yang
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan.
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45
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Belayneh DK, Kellerth T. Thyrotoxic hypokalemic periodic paralysis in an African male: a case report. Clin Case Rep 2014; 3:102-5. [PMID: 25767707 PMCID: PMC4352363 DOI: 10.1002/ccr3.165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 08/21/2014] [Accepted: 09/15/2014] [Indexed: 11/11/2022] Open
Abstract
Thyrotoxic hypokalemic periodic paralysis is a rare manifestation of thyrotoxicosis and is rarely reported in non-Asian populations. A 26-year-old Ethiopian male who presented with recurrent flaccid tetraparesis, hypokalemia, and hyperthyroidism is reported here. Thyroid function should be routinely checked in patients with acute or recurrent hypokalemic paralysis.
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Affiliation(s)
| | - Thomas Kellerth
- Department of Cardiology, Örebro University Hospital Örebro, Sweden
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46
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Rolim ALR, Lindsey SC, Kunii IS, Crispim F, Moisés RCMS, Maciel RMB, Dias-da-Silva MR. The insulin-sensitivity sulphonylurea receptor variant is associated with thyrotoxic paralysis. J Mol Endocrinol 2014; 53:295-301. [PMID: 25143473 DOI: 10.1530/jme-14-0083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thyrotoxicosis is the most common cause of the acquired flaccid muscle paralysis in adults called thyrotoxic periodic paralysis (TPP) and is characterised by transient hypokalaemia and hypophosphataemia under high thyroid hormone levels that is frequently precipitated by carbohydrate load. The sulphonylurea receptor 1 (SUR1 (ABCC8)) is an essential regulatory subunit of the β-cell ATP-sensitive K(+) channel that controls insulin secretion after feeding. Additionally, the SUR1 Ala1369Ser variant appears to be associated with insulin sensitivity. We examined the ABCC8 gene at the single nucleotide level using PCR-restriction fragment length polymorphism (RFLP) analysis to determine its allelic variant frequency and calculated the frequency of the Ala1369Ser C-allele variant in a cohort of 36 Brazilian TPP patients in comparison with 32 controls presenting with thyrotoxicosis without paralysis (TWP). We verified that the frequency of the alanine 1369 C-allele was significantly higher in TPP patients than in TWP patients (61.1 vs 34.4%, odds ratio (OR)=3.42, P=0.039) and was significantly more common than the minor allele frequency observed in the general population from the 1000 Genomes database (61.1 vs 29.0%, OR=4.87, P<0.005). Additionally, the C-allele frequency was similar between TWP patients and the general population (34.4 vs 29%, OR=1.42, P=0.325). We have demonstrated that SUR1 alanine 1369 variant is associated with allelic susceptibility to TPP. We suggest that the hyperinsulinaemia that is observed in TPP may be linked to the ATP-sensitive K(+)/SUR1 alanine variant and, therefore, contribute to the major feedforward precipitating factors in the pathophysiology of TPP.
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Affiliation(s)
- Ana Luiza R Rolim
- Laboratory of Molecular and Translational EndocrinologyDepartment of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo, 669, 11° andar, 04039-032 São Paulo, SP, Brazil
| | - Susan C Lindsey
- Laboratory of Molecular and Translational EndocrinologyDepartment of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo, 669, 11° andar, 04039-032 São Paulo, SP, Brazil
| | - Ilda S Kunii
- Laboratory of Molecular and Translational EndocrinologyDepartment of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo, 669, 11° andar, 04039-032 São Paulo, SP, Brazil
| | - Felipe Crispim
- Laboratory of Molecular and Translational EndocrinologyDepartment of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo, 669, 11° andar, 04039-032 São Paulo, SP, Brazil
| | - Regina Célia M S Moisés
- Laboratory of Molecular and Translational EndocrinologyDepartment of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo, 669, 11° andar, 04039-032 São Paulo, SP, Brazil
| | - Rui M B Maciel
- Laboratory of Molecular and Translational EndocrinologyDepartment of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo, 669, 11° andar, 04039-032 São Paulo, SP, Brazil
| | - Magnus R Dias-da-Silva
- Laboratory of Molecular and Translational EndocrinologyDepartment of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Rua Pedro de Toledo, 669, 11° andar, 04039-032 São Paulo, SP, Brazil
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Senthilkumaran S, Jena NN, Jayaraman S, Thirumalaikolundusubramanian P. Thyrotoxic Periodic Paralysis, β2-ADrenergic Bronchodilator, and Insulin—An Interesting Interplay. CAN J EMERG MED 2014; 16:343. [DOI: 10.2310/8000.2014.141448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Jung SY, Song KC, Shin JI, Chae HW, Kim HS, Kwon AR. A case of thyrotoxic periodic paralysis as initial manifestation of Graves' disease in a 16-year-old Korean adolescent. Ann Pediatr Endocrinol Metab 2014; 19:169-73. [PMID: 25346923 PMCID: PMC4208265 DOI: 10.6065/apem.2014.19.3.169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/09/2014] [Accepted: 09/19/2014] [Indexed: 12/31/2022] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism, with recurrent muscle paralysis and hypokalemia that are caused by an intracellular shift of potassium. TPP is relatively common in Asian males, but is extremely rare in children and adolescents, even for those of Asian descent. We describe a 16-year-old Korean adolescent presenting with a two-week history of episodic leg weakness in the morning. He showed sinus tachycardia, lower leg weakness, and hypokalemia. Thyroid function test showed hyperthyroidism, and thyroid ultrasonography revealed a diffuse enlarged thyroid with increased vascularity, consistent with Graves' disease. He was treated with β-adrenergic blocker and antithyroid drugs. He has been symptom free for one year, as his hyperthyroidism has been controlled well with antithyroid drugs. TPP should be considered in children and adolescents with acute paralysis of the lower extremities and hypokalemia.
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Affiliation(s)
- Se Yong Jung
- Department of Pediatric Endocrinology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Chul Song
- Department of Pediatric Endocrinology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Il Shin
- Department of Pediatric Neprhology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Wook Chae
- Department of Pediatric Endocrinology, Yonsei University College of Medicine, Seoul, Korea
| | - Ho-Seong Kim
- Department of Pediatric Endocrinology, Yonsei University College of Medicine, Seoul, Korea
| | - Ah Reum Kwon
- Department of Pediatric Endocrinology, Yonsei University College of Medicine, Seoul, Korea
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Cheng CJ, Lin SH. In Reply to “Thyrotoxic Periodic Paralysis, β2-Adrenergic Bronchodilator, and Insulin—An Interesting Interplay”. CAN J EMERG MED 2014; 16:344. [DOI: 10.2310/8000.2014.141452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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