Category: Thyroid

Type: e-Poster

Monitor: 9

9 - A CASE OF HYPOKALEMIC PERIODIC PARALYSIS ON A HISPANIC MALE PRESENTING WITH LOWER EXTREMITIES PARALYSIS AND SUBTLE SIGNS & SYMPTOMS OF THYROTOXICOSIS

Saturday, Apr 27
10:30 AM – 11:00 AM

Objective :

Thyrotoxic periodic paralysis(TPP) is a rare complication of hyperthyroidism, characterized by the abrupt onset of hypokalemia along with severe limb weakness. In North America, its estimated to occur in 0.1–0.2% of thyrotoxic patients. 


Methods : Case studies


Results :

An 18-year-old Hispanic male with a history of Graves’ disease presented to the emergency department(ER) with acute onset bilateral lower extremity weakness that developed a few hours after the ingestion of a high carbohydrate meal. Associated symptoms included palpitations and nausea. The patient denied prior similar episodes and reported feeling well otherwise. He had been diagnosed with hyperthyroidism due to Graves’ disease two years prior to presentation; he had been treated with methimazole for one year but discontinue the medication and lost his follow up with his endocrinologist. Upon presentation, his vital signs were significant for hypertension(150/80 mmHg), tachycardia(HR 120/min), and tachypnea(RR 25/min). He did not have exophthalmos or lid lag. The thyroid gland was diffusely enlarged, without tenderness or nodules. His neurological exam was significant for severe bilateral lower extremity weakness, more proximal than distal, and numbness. Laboratory workup was significant for hypokalemia(2.6 M/UL), suppressed TSH(7.77 ng/dL). Burch-Wartofsky score upon presentation was 45, consistent with the impending storm. Thyroid ultrasound demonstrated an enlarged thyroid gland with the increased vascular flow without nodules. Upon arrival to the ER 80mEq of potassium chloride was given per the hospital electrolyte replacement protocol. The patient was started on propylthiouracil, propranolol, and dexamethasone. Serum potassium was closely monitored. The patient developed mild hyperkalemia(5.2 M/UL) that resolved shortly after, once potassium replacement was held as the diagnosis of TPP was considered. Upon resolution of thyrotoxic state, he was discharged on methimazole and propranolol, serum potassium remained normal. 


Discussion :

Patients with TPP can present with subtle symptoms of thyrotoxicosis and prominent neurologic symptoms. Hypokalemia results from the shift of potassium into the intracellular space due to the effect of excess thyroid hormone on the Na-K ATPase channel. Treatment of hyperthyroidism helps normalize potassium levels at the extracellular space. Aggressive potassium replacement is thus not recommended as it can result in rebound hyperkalemia. 


Conclusion : TTP is one of the endocrinologic emergency that clinicians need to keep in mind. The main purpose of this abstract is to highlight and make clinicians to be aware of TTP diagnosis and treatment in Hispanic patients.

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Subhanudh Thavaraputta

Resident
Department of Internal Medicine, Texas Tech University Health Sciences Center
Lubbock, Texas

The second-year Internal Medicine resident at Texas Tech University Health Sciences Center.

Myrian NOELLA.. Vinan-Vega

Resident
Department of Internal Medicine, Texas Tech University Health Sciences Center

First-year Internal Medicine resident at Department of Internal Medicine, Texas Tech University Health Sciences Center

Drew Payne

Assistant Professor
Department of Internal Medicine, Texas Tech University Health Sciences Center

Assistant Professor at the Department of Internal Medicine, Texas Tech University Health Sciences Center

Ebtesam Islam

Assistant Professor
Division of Pulmonary/Critical Care, Department of Internal Medicine, Texas Tech University Health Sciences Center

Pulmonary/Critical Care Assistant Professor at the Department of Internal Medicine, Texas Tech University Health Sciences Center

Ana Marcella Rivas

Assistant Professor
Division of Endocrinology, Department of Internal Medicine, Texas Tech University Health Sciences Center

Assistant Professor of Division of Endocrinology at the Department of Internal Medicine, Texas Tech University Health Sciences Center