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Thyrotoxic Periodic Paralysis: An Endocrine Cause of Paraparesis

This case report describes a 36-year-old man who presented with progressive leg weakness due to hypokalemia caused by thyrotoxic periodic paralysis. Thyrotoxic periodic paralysis is a form of periodic paralysis seen in hyperthyroid patients, and is more common in males of Asian descent. The patient's hyperthyroidism was due to previously treated Graves' disease. Intravenous potassium replacement resolved his weakness. He was started on beta-blockers and antithyroid medication to prevent further episodes by treating his hyperthyroidism. Thyrotoxic periodic paralysis should be considered as a cause of weakness in hypokalemic patients with hyperthyroidism.

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50 views2 pages

Thyrotoxic Periodic Paralysis: An Endocrine Cause of Paraparesis

This case report describes a 36-year-old man who presented with progressive leg weakness due to hypokalemia caused by thyrotoxic periodic paralysis. Thyrotoxic periodic paralysis is a form of periodic paralysis seen in hyperthyroid patients, and is more common in males of Asian descent. The patient's hyperthyroidism was due to previously treated Graves' disease. Intravenous potassium replacement resolved his weakness. He was started on beta-blockers and antithyroid medication to prevent further episodes by treating his hyperthyroidism. Thyrotoxic periodic paralysis should be considered as a cause of weakness in hypokalemic patients with hyperthyroidism.

Uploaded by

Rina Erlina
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© © All Rights Reserved
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CASE REPORT

Thyrotoxic Periodic Paralysis: An Endocrine Cause of Paraparesis


Atif Munir

ABSTRACT
Periodic paralysis is a muscle disorder that belongs to the family of diseases called channelopathies, manifested by
episodes of painless muscle weakness. Periodic paralysis is classified as hypokalemic when episodes occur in
association with low potassium levels. Most cases are hereditary. Acquired cases have been described in association with
hyperthyroidism. Diagnosis is made on clinical and biochemical grounds. Patients may be markedly hypokalemic during
the episode and respond well to potassium supplementation. Episodes can be prevented by achieving a euthyroid state.
This report describes a young gentleman presenting with thyrotoxic hypokalemic paraparesis. The condition needs to be
considered in the differential diagnosis of neuromuscular weakness in the context of hypokalemia by the treating
physicians.

Key Words: Graves disease. Thyrotoxicosis. Periodic paralysis. Paraparesis endocrine cause. Hypokalemia.

INTRODUCTION Other electrolytes including calcium, magnesium and


Thyrotoxic periodic paralysis is a sporadic form of phosphate were normal. Creatine kinase levels were
periodic paralysis which can occur in association with not elevated. Electrocardiogram did not show any
thyrotoxicosis, hence it should be differentiated from hypokalemic changes or arrhythmias. Thyroid function
familial causes which have an autosomal dominant tests checked in view of history of Graves disease
inheritance. The condition is more common in males,1 revealed hyperthyroidism, with TSH < 0.05 mlU/L, free
and the incidence is highest in Asian population. It T4 at 43.9 pmol/L, and free T3 at 18.4 pmol/L. In
manifests as episodes of neuromuscular weakness retrospect, the patient gave a 2 months history of
which can be precipitated by heavy exercise or thyrotoxic symptoms.
carbohydrate rich meal. Potassium was replaced intravenously with cardiac
This report describes the uncommon condition. monitoring and patient made a swift recovery. He was
mobilising independently after 12 hours of being
CASE REPORT admitted to hospital and was reviewed by neurology and
A fit and well gentleman of Asian origin aged 36 years endocrine team. Propranolol and propylthiouracil were
presented to the medical admission unit with a few days commenced to treat his hyperthyroidism and prevent
history of progressive painless leg weakness making further episodes of periodic paralysis with a clinical
him bedbound over the last one day. He was known to diagnosis of thyrotoxic periodic paralysis. He remains
have Graves disease which was treated medically euthyroid on treatment with no further episodes of
about 5 years ago and had been in remission. There was paralysis.
no history of any other neuromuscular symptoms,
preceding illness, backache or incontinence. There was DISCUSSION
no family history of a similar presentation. Clinical In contrast to other forms of thyroid disease, which are
examination showed paraparesis with power of 1/5 in more common in females, thyrotoxic periodic paralysis
the proximal and 2/5 in the distal muscles of both legs. is commoner in males.1 Thyroid hormone increases
Reflexes and sensations were intact, coordination and tissue responsiveness to beta-adrenergic stimulation,
gait could not be assessed due to severe weakness. which increases sodium-potassium ATPase activity in
Neurological examination of arms and cranial nerves the skeletal muscle membrane. This tends to drive
was normal and there were no signs of respiratory potassium into cells, perhaps leading to hyper-
compromise. Clinically, patient appeared euthyroid. polarization of the muscle membrane and relative
Routine biochemistry results were within the reference inexcitability of the muscle fibers.2 In this way, excess
range apart from marked hypokalemia (2.5 mmol/L). thyroid hormone may predispose to paralytic episodes
by increasing the susceptibility to the hypokalemic action
Department of Diabetes and Endocrinology, University Hospital of epinephrine or insulin.
of North Tees, UK.
Patients by definition, have attacks in the hyperthyroid
Correspondence: Dr. Atif Munir, 7-Burghley Drive, Ingleby state. During an acute attack, it must be distinguished
Barwick, Stockton On Tees, TS175GN, UK. from other common causes of acute quadriparesis, such
E-mail: [email protected]
as myasthenic crisis, Guillain-Barré syndrome, acute
Received: June 18, 2012; Accepted: February 15, 2013. myelopathy and botulism.

Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (Special Supplement 2): S99-S100 S99
Atif Munir

Attacks of weakness occur with generalized weakness The finding of hypokalemia in a patient presenting with
and preserved consciousness. Thyrotoxic symptoms neuromuscular paralysis should alert the clinician to the
usually precede the onset of paralysis. Attacks vary in diagnosis of periodic paralysis, in which the possibility of
frequency and duration. Intervals of weeks to months thyrotoxicosis must always be evaluated.
are common.3 Duration of symptoms can range from
minutes to days. Attacks can be precipitated by events REFERENCES
that are associated with an increased release of 1. Hsieh MJ, Lyu RK, Chang WN, Chang KH, Chen CM, Chang
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S100 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (Special Supplement 2): S99-S100

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