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Heydorn A, Bertelsen B, Nolsöe RLM, Eiken P, Kristensen PL. Thyrotoxic periodic paralysis in a Caucasian man without identifiable genetic predisposition: a case report. Thyroid Res 2023; 16:10. [PMID: 37122018 PMCID: PMC10150465 DOI: 10.1186/s13044-023-00152-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/04/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Thyrotoxic periodic paralysis (TPP) is a rare condition characterized by muscle paralysis, thyrotoxicosis, and hypokalemia. It presents with paralysis of both proximal and distal musculature in upper and lower limbs and may affect respiratory musculature and the cardiac conduction system. Early diagnosis is essential, as the condition is potentially reversible by oral or intravenous potassium treatment, leading to rapid resolution without lasting weakness. Overlooking the diagnosis may result in respiratory failure and cardiac arrhythmias including QT prolongation, Torsades de points, and ventricular arrhythmias. CASE PRESENTATION A 19-year-old Caucasian man was admitted acutely with paralysis in upper and lower limbs and tachycardia. Over several months, he had experienced anxiousness, sweating more than usual, had daily palpitations, shortness of breath on exertion, and loose stools, and had lost 21 kg over the last year. Initial blood gas showed very low potassium of 1.4 mM, and blood tests showed decreased Thyroid-stimulating hormone (TSH) < 0.01 × 10- 3 IU/L, elevated free thyroxine (fT4) of 63.5 pM (reference interval (RI): 12.0-22.0 pM), and elevated total triiodothyronine (T3) of 8.2 nM (RI: 1.0-2.6 nM). He was diagnosed with TPP and treated with liquid oral potassium chloride (30 mmol every 30 minutes) and propylthiouracil (initial dose of 400 mg followed by 200 mg three times daily). TSH-receptor antibodies (TRAB) and thyroid-peroxidase antibodies (TPO-ab) were highly elevated. Thyroid ultrasound showed a normal-sized gland and color Doppler sonography showed increased vascularity throughout the gland, compatible with Graves' disease. He was discharged on day 4 with a normal potassium level and followed in the outpatient clinic where he received standard care for Graves' disease. Genetic testing using whole-genome sequencing found no genetic variants in genes previously associated with TPP. CONCLUSION TPP is very rare in Caucasians but more often affects young men in East Asian populations. The case presents a Caucasian man with TPP where genetic testing of CACNA1S, KCNJ18, SCN4A, KCNJ2, KCNE3, and ABCC8 shows no pathogenic variants in genes previously associated with TPP.
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Affiliation(s)
- Arne Heydorn
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Dyrehavevej 29, DK-3400, Hillerød, Denmark.
| | - Birgitte Bertelsen
- Center for Genomic Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Pia Eiken
- Department of Endocrinology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Peter Lommer Kristensen
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Dyrehavevej 29, DK-3400, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Sun L, Han B, Wang Y, Zhu W, Jiang J, Zou A, Chi B, Mao L, Ji Y, Wang Q, Tang L. A New Scoring System for Predicting Ventricular Arrhythmia Risk in Patients with Acute Myocardial Infarction. Clin Interv Aging 2023; 18:283-292. [PMID: 36851975 PMCID: PMC9961152 DOI: 10.2147/cia.s395121] [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: 10/27/2022] [Accepted: 02/13/2023] [Indexed: 02/22/2023] Open
Abstract
Objective In this study, a risk score for ventricular arrhythmias (VA) were evaluated for predicting the risk of ventricular arrhythmia (VA) of acute myocardial infarction (AMI) patients. Methods Patients with AMI were divided into two sets according to whether VA occurred during hospitalization. Another cohort was enrolled for external validation. The area under the curve (AUC) of receiver operating characteristic (ROC) was calculated to evaluate the accuracy of the model. Results A total of 1493 eligible patients with AMI were enrolled as the training set, of whom 70 (4.7%) developed VA during hospitalization. In-hospital mortality was significantly higher in the VA set than in the non-VA set (31.4% vs 2.7%, P=0.001). The independent predictors of VA in patients with AMI including Killip grade ≥3, STEMI patients, LVEF <50%, frequent premature ventricular beats, serum potassium <3.5 mmol/L, type 2 diabetes, and creatinine level. The AUC of the model for predicting VT/VF in the training set was 0.815 (95% CI: 0.763-0.866). A total of 1149 cases were enrolled from Xuzhou Center Hospital as the external validation set. The AUC of the model in the external validation set for predicting VT/VF was 0.755 (95% CI: 0.687-0.823). Calibration curves indicated a good consistency between the predicted and the observed probabilities of VA in both sets. Conclusion We have established a clinical prediction risk score for predicting the occurrence of VA in AMI patients. The prediction score is easy to use, performs well and can be used to guide clinical practice.
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Affiliation(s)
- Ling Sun
- Department of Cardiology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, People's Republic of China
| | - Bing Han
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou Clinical School of Nanjing Medical University, Xuzhou, Jiangsu, 221009, People's Republic of China
| | - Yu Wang
- Department of Cardiology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, People's Republic of China
| | - Wenwu Zhu
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou Clinical School of Nanjing Medical University, Xuzhou, Jiangsu, 221009, People's Republic of China
| | - Jianguang Jiang
- Department of Cardiology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, People's Republic of China
| | - Ailin Zou
- Department of Cardiology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, People's Republic of China
| | - Boyu Chi
- Department of Cardiology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, People's Republic of China.,Dalian Medical University, Dalian, Liaoning, 116000, People's Republic of China
| | - Lipeng Mao
- Department of Cardiology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, People's Republic of China.,Dalian Medical University, Dalian, Liaoning, 116000, People's Republic of China
| | - Yuan Ji
- Department of Cardiology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, People's Republic of China
| | - Qingjie Wang
- Department of Cardiology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, People's Republic of China
| | - Liming Tang
- Department of Gastrointestinal Disease, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, 213003, People's Republic of China
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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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Mahon-Daly F, Liegeois C, Carter JP. Thyrotoxic periodic paralysis (TPP): assessment in the emergency department. BMJ Case Rep 2022; 15:e245830. [PMID: 35217552 PMCID: PMC8883208 DOI: 10.1136/bcr-2021-245830] [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] [Accepted: 12/31/2021] [Indexed: 11/03/2022] Open
Abstract
A male patient aged in his early twenties presented to the emergency department (ED) with quadriparesis. He was ordinarily fit and well and had exercised and eaten a carbohydrate rich meal the evening before. His point-of-care venous blood sample on arrival to the ED showed hypokalaemia of 1.6 mmol/L. (normal range=3.5-5.0 mmol/L). He was put on a cardiac monitor and started on an intravenous infusion of potassium chloride. With the benefit of hindsight, his male sex, particular features in his history and his initial ECG all pointed to a differential diagnosis of thyrotoxic periodic paralysis (TPP), although a differential diagnosis of a first attack of familial hypokalaemic paralysis was considered. As urgent thyroid function tests were sent promptly, there was minimal delay in reaching a diagnosis of TPP and promptly starting propranolol as a safe and more effective means of reversing TPP, followed by definitive treatment with carbimazole.
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Affiliation(s)
| | - Claire Liegeois
- Emergency Department, Imperial College Healthcare NHS Trust, London, UK
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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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