Early to recognize and Early to recover: A case series on Thyrotoxic periodic paralysis

Thyrotoxic periodic paralysis (TPP) is a rare disease of muscle, presenting with sudden onset weakness of muscles with or without features of hyperthyroidism. The disease most commonly occurs in the Asian population representing about 1.9% of thyrotoxic patients. It involves a predominantly male population with no family history, with or without hypokalemia. Pathophysiology is still not clearly understood. We are describing, a case series of two different patients of TPP presented to our emergency department (ED). One patient presented with classical episodic weakness of both lower limbs specifically during the night times with spontaneous reversal of weakness early in the morning. Another patient presented with complete weakness of both lower limbs for the past 1 day. Both of them had a history of weight loss and intermittent palpitations. They were promptly diagnosed in the ED and successfully treated. We recommend evaluating thyroid function status in the emergency room with the aforementioned clinical features, as early recognition and correction of thyrotoxic state are the definitive treatment helping in a complete reversal of weakness. Potassium supplements, beta-blockers, and antithyroid medications are used in treating acute attacks and preventing recurrence

Thyrotoxic hypokalemic periodic paralysis due to Graves' disease in 2 adolescents

Thyrotoxic periodic paralysis (TPP) is a notable and potentially lethal complication of thyrotoxicosis, and Graves' disease is the most common cause of TPP. TPP is commonly reported in Asian males between 20–40 years of age, but it is rare in children and adolescents. We report 2 Korean adolescents (a 16-year-old male and a 14-year-old female) with episodes of TPP who were previously diagnosed with Graves' disease. These 2 patients presented with lower leg weakness in the morning after waking up. They were diagnosed with TPP-associated with thyrotoxicosis due to Graves' disease. After they were initially treated with potassium chloride and antithyroid drugs, muscle paralysis improved and an euthyroid state without muscle paralytic events was maintained during follow-up. Therefore, clinicians should consider TPP when patients have sudden paralysis and thyrotoxic symptoms such as goiter, tachycardia, and hypertension.

Unusual Case of Acute Flaccid Quadriparesis in South India.

Aim: We report an extremely unusual case of thyrotoxicosis presenting as recurrent acute flaccid quadriparesis in a south Indian male. This case is reported to disseminate knowledge about this rare presentation of thyrotoxicosis among medical professionals. Presentation of Case: This patient presented with sudden onset of symmetrical weakness of both upper and lower limb since early morning with unexplained hypokalemia. He had diffuse toxic goiter with subtle features of hyperthyroidism associated with flaccid quadriparesis. Laboratory investigation revealed marked hypokalemia and hyperthyroidism. He was clinically diagnosed to have hyperthyroidism presenting as thyrotoxic periodic paralysis. He improved with potassium supplementation, beta blocker & anti-thyroid agent. Discussion: Thyrotoxic periodic paralysis (TPP) may be the initial presentation of thyrotoxicosis in rare occasion. Proximal muscle weakness of lower limb is often the first symptom noted. Hypokalemia noted in TPP is the consequence of a rapid and massive shift of potassium from the extracellular into the intracellular compartment, mainly into the muscles. TPP is distinguished from other forms of periodic paralysis (especially hypokalemic periodic paralysis) with thyroid function tests. Failure to recognize this rare disorder may result in fatal cardiac arrhythmia which is a potential cause of mortality. Conclusion: Clinicians should be aware of this atypical presentation of thyrotoxicosis as it is lethal if not treated. Young people with unexplained hypokalemic paralysis even without apparent evidence of thyroid dysfunction should be subjected to thyroid function test to identify this rare disorder.

Thyrotoxic periodic paralysis: a short clinical review.

Thyrotoxic Periodic Paralysis (TPP) is a potentially lethal manifestation of hyperthyroidism which is characterized by hypokalemia and muscular weakness. It mainly affects Asian men in the age group of 20 to 40 years. Immediate supplementation with oral or intravenous potassium will help to not only abort the acute attack of paralysis but will also prevent serious and life threatening cardiac arrhythmias. Non selective beta blockers like propranolol can also be used to ameliorate and prevent subsequent paralytic attack. Acetazolamide has no role in the treatment of TPP.

Graves’ Disease and Periodic Paralysis / Journal of the ASEAN Federation of Endocrine Societies

@#Thyrotoxic periodic paralysis represents a rare neurological emergency of an endocrine disorder. It poses a diagnostic challenge to the clinicians, as it is an uncommon disorder and its clinical presentation is similar to the more common hypokalemic paralysis. Adding to the diagnostic dilemma is that most patients do not have prior history of thyroid disorder and only have subtle features of hyperthyroidism. Hence, the diagnosis can be easily missed without a high clinical index of suspicion. These patients usually present to the emergency department with acute flaccid paralysis and all physicians should be aware of this clinical entity. The disease can be life-threatening if early diagnosis and prompt therapy is not initiated. We report three interesting cases in which periodic paralysis was the initial manifestation of underlying Graves’ disease in two and occurred in the third case who was previously diagnosed with thyrotoxicosis due to non-adherence to drug therapy.

Parálisis periódica hipocalémica tirotóxica. Aporte del laboratorio en un nuevo desafío diagnóstico / Hypokalemic periodic paralysis thyrotoxic Contribution of the laboratory in a new diagnostic challenge

La parálisis periódica tirotóxica hipocalémica es una patología de muy baja frecuencia en la Argentina; no obstante, es muy importante tenerla en cuenta como urgencia, ya que puede ser fatal si el diagnóstico y el tratamiento correctos no son oportunos. El objetivo de esta investigación bibliográfica es destacar el aumento de la incidencia de una enfermedad potencialmente fatal y, a la vez, fácilmente reversible con el tratamiento adecuado y oportuno, en las Salas de Guardia de nuestro país, a fin de que se la tenga en cuenta en las sospechas diagnósticas de emergencia y el aporte que puede hacer el bioquímico desde un Servicio de Urgencia, para ayudar al diagnóstico en forma rápida y certera.(AU)

Hypokalemic thyrotoxic periodic paralysis is a disease of very low frequency in Argentina; however, it is very important to take it into account as an emergency, because it can be fatal without a timely diagnosis and treatment. The objective of this research is to highlight its increased incidence in the emergency rooms of our country (it is a potentially fatal disease, but at the same time it is easily reversible with a proper and timely treatment), in order to include it in the emergency diagnostic suspicion and the biochemist contribution in an emergency service to reach a quick and accurate diagnosis.(AU)

A case of thyrotoxic periodic paralysis as initial manifestation of Graves' disease in a 16-year-old Korean adolescent

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 beta-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.

A Case of Thyrotoxic Periodic Paralysis.

Hypokalemic periodic paralysis is an uncommon manifestation of thyrotoxicosis and the condition is most commonly reported in young Asian men. Patient often presents with acute onset symmetrical flaccid muscle paralysis and proximal limb muscles may be more severely involved compared to distal muscles. Thyroid swelling as well as features of thyrotoxicosis may not be overt. A very high index of suspicion is often required for the diagnosis of thyrotoxic periodic paralysis. Treatment of throtoxicosis prevents further episodes of paralysis. We report a case of thyrotoxic periodic paralysis in a young male.

A 32-year-old Man with Normokalemic Thyrotoxic Periodic Paralysis

Thyrotoxic Periodic Paralysis (TPP) is a rare and life threatening condition commonly occurring in young Asian males. It is characterized by acute paralytic attacks and hypokalemia in association with thyrotoxicosis. Serum potassium levels may be normal in rare cases of TPP. The diagnosis of normokalemic TPP may be overlooked and/or delayed in most cases. Here, we describe a 32-year-old Iranian man with normokalemic TPP misdiagnosed as somatization disorder with the correct diagnosis made one year after the onset of symptoms.

A Case of Thyrotoxic Periodic Paralysis in 17-Year-Old Adolescent / 대한소아신경학회지

Thyrotoxic periodic paralysis (TPP) is a rare disease of muscle paralysis associated with hypokalemia and thyrotoxicosis. Hypokalemic periodic paralysis can be caused by potassium channelopathy or thyroid dysfunction. Thyrotoxic hypokalemic periodic paralysis is far more common in Asian males aged between 20 to 40 years and rare in children and adolescents. Clinical symptoms with motor paralysis were recovered just after treatment of potassium, propranolol, and methimazole. However, thyroid function tests were not normalized until 3 month treatment of methimazole and propranolol. We report a 17-year-old patient diagnosed with Graves' disease with TPP. Thyroid function test should including in periodic paralysis patient's evaluation.

Etiology of Hypokalemic Paralysis in Korea: Data from a Single Center

Recognizing the underlying causes of hypokalemic paralysis seems to be essential for the appropriate management of affected patients and their prevention of recurrent attacks. There is, however, a paucity of documented reports on the etiology of hypokalemic paralysis in Korea. We retrospectively analyzed 34 patients with acute flaccid weakness due to hypokalaemia who were admitted during the 5-year study period in order to determine the spectrum of hypokalemic paralysis in Korea and to identify the differences in clinical parameters all across the causes of hypokalemic paralysis. We divided those 34 patients into 3 groups; the 1st group, idiopathic hypokalemic periodic paralysis (HPP), the 2nd, thyrotoxic periodic paralysis (TPP), and the 3rd group, secondary hypokalemic paralysis (HP) without TPP. Seven of the patients (20.6%) were diagnosed as idiopathic HPP considered the sporadic form, and 27 patients (79.4%) as secondary HP. Among the patients diagnosed as secondary HP, 16 patients (47.1%) had TPP. Patients of secondary hypokalemic paralysis without TPP required a longer recovery time compared with those who had either idiopathic HPP or TPP. This is due to the fact that patients of secondary HP had a significantly negative total body potassium balance, whereas idiopathic HPP and TPP were only associated with intracellular shift of potassium. Most of the TPP patients included in our study had overt thyrotoxicosis while 3 patients had subclinical thyrotoxicosis. This study shows that TPP is the most common cause of hypokalemic paralysis in Korea. And we suggest that doctors should consider the presence of TPP in patients of hypokalemic paralysis even if they clinically appear to be euthyroid state.

A Case of Thyrotoxic Periodic Paralysis Associated with Transient Thyrotoxicosis / 고신대학교의과대학학술지

Thyrotoxic periodic paralysis is an acute muscle weakness of the limbs associated with hypokalemia. It can occur with any form of thyrotoxicosis. Thyrotoxic periodic paralysis associated with transient thyrotoxicosis due to thyroiditis is very rare. We experienced a case of thyrotoxic periodic paralysis associated with transient thyrotoxicosis. A 39-yr-old man was referred to our hospital because of paralysis of upper and lower extremity. The laboratory results were hypokalemia and mild thyrotoxicosis. A thyroid scan with Tc-99m revealed decreased uptake in the thyroid area compatible with destructive thyroiditis. The paralytic attack did not recur after the patient recovered to euthyroid state.

Case of Thyrotoxic Periodic Paralysis Accompanied by Atrioventricular Block Associated with Hypokalemia and Hypophosphatemia

Thyrotoxic periodic paralysis (TPP) occurs in 2% of the asian patients with hyperthyroidism and is characterized by bilateral flaccid paralysis of the extremity, especially lower limbs. It is well-known that hypokalemia is usually accompanied by TPP. However, hypophosphatemia is usually mild and well neglected. Although paralysis is generally recovered without treatment, in some cases, patients with TPP may die due to cardiopulmonary complications, such as cardiac arrhythmia. Therefore, proper and rapid replacement of potassium is essential. But it should be acknowledged that replacement may cause a rebound. TPP is often unrecognized and over-treated in the emergency room due to its non-specific symptoms. This is why clinicians must be familiar with this disease and its diagnostic clues such as Echocardiography change and clinical features. This is a case report of a 29-year-old male presenting with TPP accompanied by hypokalemia, hypophosphatemia and second degree atrioventricular block, who showed rebound hyperkalemia and hyperphosphatemia after rapid replacement of electrolytes. EKG changed to the normal sinus rhythm in the end after the correction of the electrolytes.

Induced Life-Threatening Electrolyte Imbalance in Sub-clinical Hyperthyroidism -A case report-

Thyrotoxic periodic paralysis (TPP) is rare in white Caucasian but a few in Asian. A 36-year-old man presented with suddenly developed paraparesis was brought by ambulance. He got some medications and injection for the upper respiratory infection in the morning of admission day. On admission he revealed bilateral proximal muscle weakness without pain. He didn't have any specific medical history of himself and his family. The laboratory results on admission revealed severe hypokalemia (2.1 mM/l). Potassium replacement was immediately started and his symptom was gone. We found TSH was extremely decreased (<0.005 microIU/ml) but T3 and T4 were within normal level. We guess TPP was induced by some drugs to the patient with sub-clinical hyperthyroidism. Hyperthyroidism is not always clinically apparent and then may be easily missed. However just a single medication or injection that is usually prescribed can induce critical progressive hypokalemia.

A case of thyrotoxic periodic paralysis associated with rhabdomyolysis / 대한내과학회지

Hyperthyroidism has been associated with changes in muscle function such as thyrotoxic myopathy, thyrotoxic periodic paralysis and thyroid opthalomopathy, but rarely rhabdomyolysis. Usually serum creatinine kinase is either normal or low in hyperthyroidism. Only 3 reports described association between rhabdomyolysis and hyperthyroidism, no previous literatures have thyrotoxic periodic paralysis associated rhabdomyolysis. Patients with hypokalemic periodic paralysis sometimes elevated serum muscle protein during recovery from paralytic attack, but the mechanism was not well known. We report a patient who presented with clinical feature of thyrotoxic periodic paralysis and increasing serum CK, myoglobin during recovery from paralysis.

A Case of Thyrotoxic Periodic Paralysis Presenting as Ventricular Tachycardia / 대한내분비학회지

sociated with hyperthyroidism occurs in 2.0% of Graves disease and is characterized by myasthenia or bilateral flaccid paralysis of lower extremity, in some cases, it may be accompanied with cardiac arrhythmias which are mostly due to hypokalemia. The most common type of cardiac arrhythmias associated with hyperthyroidism is sinus tachycardia, 1015% of patients have atrial fibrillation. Rarely, ventricular tachycardia or ventricular fibrillation develop and lead to cardiac arrest in severe case. A 26-year-old man was admitted to the hospital because of weakness of lower extremity. The initial EKG showed ventricular tachycardia. The laboratory results were, TSH 0.08 microunit/mL, free T4 4.11 ng/mL, T3 2.88 ng/mL, serum K 1.9 mEq/L. He was diagnosed as ventricular tachycardia associated with hypokalemic thyrotoxic periodic paralysis. His symptoms improved during the treatment with propylthiouracil and potassium replacement. We report a case of thyrotoxic periodic paralysis presenting as ventricular tachycardia with brief review of literatures.

Clinical Aspects in Patients with Thyrotoxic Periodic Hypokalemic Paralysis / 영남의대학술지

BACKGROUND: Thyrotoxic periodic paralysis is an uncommon illness characterized by intermittent flaccid paralysis of skeletal muscle, usually accompanied by hypokalemia, in patient with hyperthyroidism. However. the pathophysiology of thyrotoxic periodic paralysis remains largely unexplained and controversial. This report describes the clnical and biochemical findings in 19 patients with thyrotoxic periodic paralysis who were examined at the Yeungnam University Medical Center (YUMC) during the past decade. METHODS: The medical records of 997 YUMC patients, seen between 1986 and 1996, with dignosis of hyperthyroidism were reviewed. Nineteen patients out of 997 hyperthyrodism patients were diagnosed, and examined by history, physical examination, serum electrolyte value, and thyroid function test during paralysis. On the basis of these results, compasons were made on age. sex, precipitating factors, timing, affected limbs, prognosis, serum potassium and serum phosphate and thyroid hormone levels. RESULTS: the prevalence of periodic paralysis in hyperthyroidism was 1.9 percent and the male to female prevalence ratio was 30:1 and in all patients, the development of perodic paralysis was correlated with hyperfuntional state of the throid gland. Eleven cases of periodic paralysis were associated with hypokalemia and their throid hormon levels were significantly more increased than those of the patients without hypokalemia. interestingly, our study shows the recurrence of paralysis after treatment. CONCLUSION: Although the precise pathophysiology of the disease is as yet undefined and controversial, it occurs primarily in Asians with an overwhelming male preponderance and prevalence of 2 percent in hyperthyrodism. The interactive roles of thyroid hormon. Na-K pump. and genetically inherited defect in the celluar membrance potential of the skeletal muscle can be speculated. Further investigation will be neede to firmly establish the mechanism of thyrotoxic periodic paraysis.

A Case of Thyrotoxic Hypokalemic Periodic Paralysis Presenting as Cardiac Arrest / 대한내분비학회지

Periodic paralysis associated with thyrotoxicosis is characterized by intermittent flaccid paralysis of the skeletal muscle. The paralysis usually involve the skeletal muscle of the limbs, especially lower extrimities. In general, sensory function is intact. Involvement of respiratory, ocular or bulbar muscles is very rare, but bulbar and respiratoy invelvement may prove fatal. It is very rare a case that has severe clinical manifestation such as cardiac arrest. We report a case of thyrotoxic hypokalemic periodic paralysis presenting as cardiac arrest.