Exploring the Intersection of Hypokalemic Periodic Paralysis and Thyrotoxic Periodic Paralysis: A Medical Case

Just as you would expect that I will bring up a medical case to you, well I didn't disappoint, at least not today. In our post today, I will be sharing a case based on the medical documentation I saw on the Canadian Medical Association Journal titled "Acute generalized weakness due to thyrotoxic periodic paralysis". I will be writing this post creating a medical story around it but before I continue, it is important to acknowledge the author of this synopsis Cheryl Barnabé, a Resident at the Department of Internal Medicine, University of Manitoba, Winnipeg, Canada. That said, let's begin.

It started when a young man in his early thirties went to bed at night, but could not get up from his bed the following day. He had no medical problems in the past, and so we could say that he has been healthy. He is known for having a cup of coffee at all times during his long time work hours and would not go to bed early until it is about 2:00 am in the morning.

One day, he was done with his work early enough and decided to have dinner. After his food, he was tired but wasn't showing any signs of being sick, so he just retired to bed. You would expect that it as a great sleep but when he woke up, he did to a terrible nightmare as he could not raise his arms and legs. He was paralyzed and he knew this because he couldn't feel any pains in his arms or legs so he panicked. He called for help and soon neighbors were able to help him call an ambulance.

At the emergency department, he was quickly attended to by the emergency doctor who first asked series of questions so as to know about his medical history. From what he said, it was the first time such was happening, he doesn't have a family history of such, and he doesn't take medications or recreational drugs. He confirmed that he wasn't having any chest pain, dizziness or shortness of breath. After examination, the doctor found out that he was tachycardic (increased heart rate), but had a normal blood pressure.

When the muscles were examined, it was visible that his proximal muscles were weak which gave his shoulders, elbows, hips, and Knees no strength at all but he was able to move his wrists and his sensation was intact. This means that he had an acute onset paralysis of his proximal muscles.

With this presentation, the next thing is to find a diagnosis for the presentation. In doing this, it can be a muscular disorder, nerve disorder which could affect the central nervous system or the peripheral nervous system, it can be problems between the muscles and neuromuscular junction, it can also be electrolyte abnormality. If we are talking about electrolyte abnormalities, it can be either an increase or decrease in magnesium, calcium, potassium, or phosphate.

To get a proper diagnosis, tests and screenings need to be done. This tests would include a bloodwork, along with an ECG which will help at the electrical activities of the heart, a CT scan to check the activities of the brain. When the result came back, his potassium level was very low at 1.6mEQ per Liter and that was a strong cause for his paralysis and such low potassium can lead to abnormal heart rhythm.

Thee first thing to do is to administer potassium both intravenously and orally, also magnesium which helps potassium to absorb was given as well. Potassium in the body is important in regulating fluid, as well as helping in muscle contraction which includes heartbeat, as well as sending signals down the nerves.

Potassium is usually embedded in the cells with little outside of the cells and are regulated by the kidney, and excess or too little of it can be fatal. The patient's potassium was rechecked but then it was still low (hypokalemia). So what could have been the cause?

Hypokalemia can be caused by not eating enough potassium, losing it either by diarrhea or vomiting, low magnesium in the body, or if the body is shifting potassium into the cells through the sodium potassium ATPase pump. With more bloodwork, it was identified that the patient had high level of thyroid hormone in his blood which means he had hyperthyroidism.

Overtime, his muscles began to work and it looked like he never had an issue before. This means that there was a potassium shift from the cell to the blood, but what could have caused this? There can be triggers such as medications, alkalosis, refeeding syndrome, adrenaline, head injury, heart attack, exercise, hypothermia, and hypokalemic periodic paralysis. The patient had hypokalemic periodic paralysis and it could be as a result of Thyrotoxic periodic paralysis. So while we thought the patient had hypokalemic periodic paralysis he also had Thyrotoxic periodic paralysis.

This intricate case revealed a dual diagnosis—hypokalemic periodic paralysis and Thyrotoxic periodic paralysis—attributed to Graves Disease, an immune disorder, the leading cause of hyperthyroidism. Treatment involved propranolol for tremor and increased heart rate, coupled with Methimazole to reduce excess thyroid hormone production. Through this medical journey, we witness the intricate interplay of factors shaping a diagnostic puzzle and the comprehensive care required to restore health.

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Read More

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^{https://www.cmaj.ca/content/172/4/471
https://www.niddk.nih.gov/health-information/endocrine-diseases/graves-disease
https://www.mountsinai.org/health-library/diseases-conditions/graves-disease
https://www.thyroid.org/graves-disease/
https://www.ncbi.nlm.nih.gov/books/NBK448195/
https://www.ncbi.nlm.nih.gov/books/NBK559178/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700163/
https://emedicine.medscape.com/article/1171678-overview?form=fpf
https://www.ncbi.nlm.nih.gov/books/NBK560670/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1426181/}

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^{Image Reference}

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^{https://nara.getarchive.net/media/marwan-ahmad-mohammed-lies-in-his-hospital-bed-at-the-2b1c6f
https://www.pickpik.com/doctor-patient-operation-surgery-hospital-vital-signs-91168}