Hypokalemic Periodic Paralysis and Spectrum of Thyroid Disorders: Analysis of 7 Cases from Northern India

Intravenous methylprednisolone-induced hypokalaemic periodic paralysis in a thyrotoxic patient: a case report and literature review

Hypokalaemic periodic paralysis (HPP) is an uncommon complication of corticosteroid therapy, which may also be seen in thyrotoxicosis. It was mostly described in the Asian population, and it is rare in other ethnic groups. We present the case of a poorly controlled thyrotoxic Caucasian male with thyroid eye disease (TED) who suffered an acute quadriplegic episode caused by severe hypokalaemia and was admitted to the intensive care unit (ITU) within 24 hours of initiating intravenous methylprednisolone (IVMP) infusion. Once his potassium blood levels were repleted, he completely recovered from the episode. Although HPP is rare in the Caucasian population, it can be precipitated in thyrotoxic patients by systemic steroids. Caution should be exercised when administering IVMP in poorly controlled thyrotoxic patients, and we suggest monitoring the potassium levels at regular intervals with ECG monitoring for at least 24 hours in at-risk individuals.

Graves' Disease With Initial Presentation of Thyrotoxic Periodic Paralysis

Graves' disease is a common cause of hyperthyroidism. However, thyrotoxic periodic paralysis (TPP) is a rare complication of Graves' disease and is characterized by episodes of muscle weakness and hypokalemia in the setting of thyrotoxicosis. Episodic weakness and paralysis can be the first manifestation of Graves' disease with TPP despite lacking classic symptoms of hyperthyroidism and can be precipitated by risk factors such as a high carbohydrate diet and strenuous exercise. Although TPP is reversible with correction of hypokalemia and thyrotoxicosis, its uncommon presentation can lead to delay in diagnosis and treatment. Here, we describe a case of a 24-year-old Thai male who presented with proximal muscle weakness that progressed to frequent falls and inability to ambulate over the course of three days. He was found to have severe hypokalemia and diagnosed with TPP from underlying Graves' disease. He was treated with cautious replacement of potassium, a beta blocker, and methimazole to reverse thyrotoxicosis. He regained his ability to ambulate, and his weakness resolved after hypokalemia was corrected. He did not have a reoccurrence of muscle weakness the following 12 months after discharge by continuing treatment with methimazole. The varied clinical manifestations of TPP can make diagnosis challenging, but early recognition and treatment can prevent severe complications of this potentially life-threatening condition.

Recurrent hypokalemic paralysis in hypothyroidism

Hypothyroidism, a commonly encountered thyroid disorder, usually manifests with readily recognizable typical features. However, an unusual presentation of a classic thyroid disorder may hinder accurate diagnosis in certain instances. One such rare initial presentation of hypothyroidism is recurrent hypokalemic paralysis, and existing reports in the literature are sparse. It has been more commonly reported in thyrotoxicosis. We report the case details and clinical outcomes of two middle-aged individuals (a 34-year-old male and a 37-year-old female) with recurrent episodes of hypokalemic paralysis. Their clinical examination revealed pure motor hyporeflexia quadriparesis with hypotonia and diminished deep tendon reflexes without any autonomic dysfunction. They had no significant previous medical history. Biochemical findings revealed hypokalemia in both cases (1.4 and 1.9 mEq/L, respectively) with elevated levels of thyroid‑stimulating hormone and thyroid‑related antibodies in both individuals, thus, confirming the diagnosis of autoimmune hypothyroidism. Immediate treatment with intravenous and oral potassium correction helped in the recovery. Thyroxine supplementation was considered a follow-up treatment, and for a one-year follow-up period there were no complaints of limb weakness reported in both individual.

Subclinical hyperthyroidism presenting with hypokalemic periodic paralysis in the emergency department

Subclinical hyperthyroidism (SH) is a condition in which blood levels of Thyroxine (T4) and Triiodothyronine (T3) are normal in the presence of low levels of thyroid-stimulating hormone (TSH). Patients with SH have either no symptoms or mild nonspecific symptoms. Hypokalemic periodic paralysis (HPP) is one of the rare presentations of overt hyperthyroidism; however, only a few cases are reported to date to occur with SH. This case report presents a case of a young Asian male who was admitted to the emergency department (ED) with paralysis of the lower extremities that progressed to the upper extremities and neck muscles in 2 days. Clinically, he was euthyroid; however, his thyroid profile revealed normal levels of T3 and T4 with undetectable TSH levels. This case report aims to add to the limited literature on SH that presents with HPP in the ED.

Hypokalemic Paraparesis Progressing to Quadriparesis in a Case of Intradural Spinal Tumor

Introduction

This study aims to present a case of spinal intradural tumor with paraparesis referred for surgery, which later progressed to quadriparesis and subsequently found to have hypokalemia due to primary hyperaldosteronism causing a clinical dilemma.

Case Report

A 46-year-old male was referred for surgery from peripheral center with a diagnosis of an intradural tumor at L1. The patient presented to us with paraparesis, which progressed to quadriparesis. On evaluation, the patient was found to have low serum potassium levels of 1.6 mmol/L with hypertension. The plasma aldosterone-renin was elevated which was suggestive of primary hyperaldosteronism. Further, investigations in the form of CT abdomen suggested the presence of a right adrenal adenoma. The patient was diagnosed with hypokalemia-induced quadriparesis and treated conservatively with potassium supplementation and later spironolactone. The patient recovered completely in 72 h and was able to walk independently before discharge.

Conclusion

Spinal tumor may not always be the cause for patient's paraparesis; non-spinal factors such as hypokalemia should be kept in mind. The presence of intradural spinal tumor with hypokalemia may cause decision dilemma regarding treatment and interdisciplinary approach is recommended to facilitate the treatment.