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Thyrotoxic Periodic Paralysis

Thyrotoxic Hypokalemic Periodic Paralysis


Presentation

  • The case history and update of current knowledge of thyrotoxic periodic paralysis is presented.[ncbi.nlm.nih.gov]
  • It is important to consider the diagnosis of thyrotoxic periodic paralysis in patients presenting with acute onset of weakness. The report discusses the epidemiology, presentation, treatment, and complications of this condition.[ncbi.nlm.nih.gov]
  • We also review the clinical presentation, pathophysiology, biochemical features and management of TPP. All three patients were young Asian males, presenting with muscle weakness of sudden onset.[ncbi.nlm.nih.gov]
  • We present the case of a 15-year-old Asian-American male who presented to a tertiary-care pediatric emergency department complaining of generalized weakness and flaccid paralysis of his lower extremities.[ncbi.nlm.nih.gov]
  • Here we present the case of a 25-year-old man who presented to the emergency department (ED) with sudden onset weakness of bilateral upper and lower extremities.[ncbi.nlm.nih.gov]
Euthyroid
  • The PE tests were compared between the hyperthyroid and euthyroid states in five of the TPP and three of the Tw/oPP patients.[ncbi.nlm.nih.gov]
  • The subject with TPP had values for G(Na), I(Na), action potential threshold, I(Kir), and [Ca(2 )] that were similar to HOPP when T-toxic and to controls when euthyroid.[ncbi.nlm.nih.gov]
  • Before achieving the euthyroid status, the rate of recurrent attacks was as high as 62.2%, and peaked in the first 3 months after hoTPP was diagnosed.[ncbi.nlm.nih.gov]
  • We report a case of secondary hypokalemic PP due to thyrotoxicosis in which the decrease in the CMAP amplitude after exercise dramatically improved after treatment, when a euthyroid state was achieved.[ncbi.nlm.nih.gov]
  • Treatment with propranolol and methimazol was initiated and one year later he remains euthyroid and symptom free.[ncbi.nlm.nih.gov]
Noncompliance
  • In this case, a 43-year-old African American woman with thyrotoxic periodic paralysis had recurrent lower extremity myopathy and acute respiratory failure precipitated by noncompliance with treatment for Graves disease.[ncbi.nlm.nih.gov]
Hysteria
  • Clinicians should include this disease process in their differential diagnoses along with other paralyzing disorders such as Guillain-Barré, multiple sclerosis, transverse myelitis, tick paralysis, conversion disorder or hysteria.[westjem.com]
  • […] patients already exhibit signs of hyperthyroidism due to Graves’ disease (goiter and exophthalmia) or thyrotoxicosis symptoms at the time of the paralysis crisis, but often the thyroid alteration is not recognized at the time and may be confused with hysteria[intechopen.com]
  • Although patients can present with tetraparesis that resembles other conditions such as Gullain-Barré syndrome, transverse myelitis, and acute spinal cord compression or hysteria, bowel and bladder function are never affected.[doi.org]
Impulsivity
  • Hypokalemia leads to hyperpolarization of muscle cells, making the neuromuscular junction less responsive to normal nerve impulses and leading to decreased contractility of the muscles.It is not clear how the described genetic defects increase the Na[en.wikipedia.org]
  • Low potassium levels in the serum lead to hyperpolarization of skeletal muscle cells, making the neuromuscular junction less responsive to normal nerve impulses, which in turn decreases the contractility of the muscles [7] .[cureus.com]
  • Cardiovascular examination during this time showed apical impulse at left 6 th intercostal space 0.5 cm lateral to the mid-clavicular line with forceful ill-sustained character.[jnsbm.org]
Tremor
  • Or, there may be signs of hyperthyroidism, such as an enlarged thyroid changes in the eyes, tremor, hair and nail changes.[nlm.nih.gov]
  • Case 3 A 32-year-old male presented with acute onset flaccid paraparesis, tremors of both hands and palpitations. He had a history of transient proximal weakness 6 weeks back which recovered spontaneously.[ijem.in]
  • They include: Weight loss Palpitations Heat intolerance Increased appetite Agitation Insomnia Hand tremors A fast heart rate Excessive sweating The attack itself normally begins with muscle pain, cramps or muscle stiffness followed by weakness which begins[markvanderpump.co.uk]
  • Exercise-related attacks tend to occur during a period of rest immediately after exercise; exercise may therefore be recommended to abort an attack.There may be symptoms of thyroid overactivity, such as weight loss, a fast heart rate, tremor, and perspiration[en.wikipedia.org]
Flaccid Paralysis of the Lower Extremity
  • We herein report a 25-yr-old Korean man who suffered from flaccid paralysis of the lower extremities and numbness of hands. The patient was subsequently diagnosed as having TPP associated with transient thyrotoxicosis due to painless thyroiditis.[ncbi.nlm.nih.gov]
  • We present the case of a 15-year-old Asian-American male who presented to a tertiary-care pediatric emergency department complaining of generalized weakness and flaccid paralysis of his lower extremities.[ncbi.nlm.nih.gov]
Fine Tremor
  • He had tachycardia, fine tremors of both hands, and grade1 diffuse goiter. His serum potassium was 1.8 mmol/l, ESR 30 mm/h, TSH 0.03 μU/l, free T4:3.2 ng/dl, TPO antibody 117 IU/ml (nl 35), and there was decreased uptake (0.21%) on 99m Tc scan.[ijem.in]

Workup

  • The patient was admitted to the intensive care unit where further workup revealed thyrotoxicosis and the patient was subsequently diagnosed with TPP.[ncbi.nlm.nih.gov]
  • Therefore thyroid function tests are part of the diagnostic workup of hypokalemic periodic paralysis. Correction of thyroid function is essential to treatment. The pathophysiology is still controversial.[ncbi.nlm.nih.gov]
Potassium Decreased
  • Studies suggest that restoration of potassium levels leads to resolution of paralysis, with potassium decreasing the time to resolution from 13 hours to six hours. 5 However, the physiology of TTP suggests that patients are not truly deficient in potassium[westjem.com]
Right Bundle Branch Block
  • Our patient was found to have an extremely low serum potassium concentration, as well as an electrocardiogram that revealed a prolonged QT interval and right bundle branch block.[ncbi.nlm.nih.gov]
HLA-A2
  • The human leukocyte antigen (HLA) B46, DR9, and DQB1*0303 have been reported to be present at a higher prevalence among Hong Kong Chinese TPP patients, whereas HLA A2, Bw22, AW19, B17, and DRW8 are reported to be associated in Singapore Chinese and Japanese[doi.org]

Treatment

  • Treatment includes the supplementation of potassium, a nonselective beta-blocker, and ultimately treatment of the underlying hyperthyroidism.[ncbi.nlm.nih.gov]
  • This review summarizes the epidemiology, clinical manifestations, pathogenesis, diagnosis, and treatment of TPP.[ncbi.nlm.nih.gov]
  • This case report reviews the literature looking at pathophysiology, causes, and treatment recommendations for this rare complication of hyperthyroidism.[ncbi.nlm.nih.gov]
  • Its differentiation of more common forms of periodic paralysis is important because aggressive treatment can place the patient at risk for rebound hyperkalemia. Treatment of the underlying thyroid dysfunction cures the muscle symptoms.[ncbi.nlm.nih.gov]
  • The exercise test is a useful electrophysiologic means of monitoring the neuromuscular status of patients with thyrotoxic periodic paralysis prior to, and after treatment of the thyrotoxicosis.[ncbi.nlm.nih.gov]

Prognosis

  • The pathophysiology, associations, therapy and prognosis are discussed. It is important that clinicians recognise the condition as all forms of periodic paralysis are amenable to treatment, and progressive weakness can be prevented or even reversed.[ncbi.nlm.nih.gov]
  • OBJECTIVE: This review emphasizes the etiology, pathogenesis, management and prognosis of TPP and aims to highlight clinical awareness of early diagnosis and rapid initiation of treatment.[ncbi.nlm.nih.gov]
  • Family history Timing Intensity History of administration of certain drugs Clinical examination Differential Diagnosis Laboratory investigations Serum K CPK and serum myoglobin ECG EMG Nerve conduction studies Provocative Testing Muscle biopsy Treatment Prognosis[slideshare.net]
  • Severe prognosis in a large family with hypokalemic periodic paralysis. Muscle Nerve 27, 165–169 (2003). 88. Okihiro, M. M. & Nordyke, R. A. Hypokalemic periodic paralysis. Experimental precipitation with sodium liothyronine.[nature.com]
  • In the case of long-lasting interictal flaccid muscle weakness, imaging techniques can inform on the pathogenesis, potential therapy, and prognosis.[ncbi.nlm.nih.gov]

Etiology

  • The etiology of these abnormalities and the patient's symptoms was found to be undiagnosed and uncontrolled hyperthyroidism from Grave's disease, which resulted in this dramatic presentation of thyrotoxic hypokalemic paralysis.[ncbi.nlm.nih.gov]
  • The periodic paralysis has been associated with thyrotoxicosis from various etiologies. Although the incidence of the disorder is relatively higher among Asians, it has been reported in many other ethnic groups.[ncbi.nlm.nih.gov]
  • Thyrotoxic hypokalemic periodic paralysis (THypoKPP) is an uncommon disorder with an unknown etiology. We describe a family in which the proband presented with paralysis and thyrotoxicosis.[ncbi.nlm.nih.gov]
  • The authors discuss the epidemiology, etiology, clinical manifestations, and treatments of TPP.[ncbi.nlm.nih.gov]
  • OBJECTIVE: This review emphasizes the etiology, pathogenesis, management and prognosis of TPP and aims to highlight clinical awareness of early diagnosis and rapid initiation of treatment.[ncbi.nlm.nih.gov]

Epidemiology

  • The epidemiology, aetiology and pathogenesis of TPP are discussed. The case demonstrates that neurological examination and biochemical findings may be normal between episodes of paralysis.[ncbi.nlm.nih.gov]
  • The report discusses the epidemiology, presentation, treatment, and complications of this condition.[ncbi.nlm.nih.gov]
  • The authors discuss the epidemiology, etiology, clinical manifestations, and treatments of TPP.[ncbi.nlm.nih.gov]
  • This review summarizes the epidemiology, clinical manifestations, pathogenesis, diagnosis, and treatment of TPP.[ncbi.nlm.nih.gov]
  • This review summarizes the epidemiology, clinical manifestations, pathogenesis, diagnosis, and treatment of TPP. Lin SH Thyrotoxic periodic paralysis. Mayo Clin Proc. 2005 ; 80(1): 99 - 105.[oadoi.org]
Sex distribution
Age distribution

Pathophysiology

  • Here we report three cases of TPP in the Netherlands, and review the literature on clinical features, pathophysiological hypothesis and treatment.[ncbi.nlm.nih.gov]
  • This case report reviews the literature looking at pathophysiology, causes, and treatment recommendations for this rare complication of hyperthyroidism.[ncbi.nlm.nih.gov]
  • The pathophysiology, associations, therapy and prognosis are discussed. It is important that clinicians recognise the condition as all forms of periodic paralysis are amenable to treatment, and progressive weakness can be prevented or even reversed.[ncbi.nlm.nih.gov]
  • The literature on the use of propranolol in TPP is reviewed, and the known pathophysiology of TPP is discussed.[ncbi.nlm.nih.gov]
  • The underlying pathophysiology of thyrotoxic periodic paralysis (TPP) is still obscure.[ncbi.nlm.nih.gov]

Prevention

  • Immediate potassium supplementation prevents serious cardiopulmonary complications and may hasten the recovery of muscle weakness. Nonselective beta-adrenergic blockers can ameliorate and prevent recurrence of the paralytic attacks.[ncbi.nlm.nih.gov]
  • Treating hyperthyroidism will prevent attacks and may even reverse muscle weakness.[nlm.nih.gov]
  • It is important that clinicians recognise the condition as all forms of periodic paralysis are amenable to treatment, and progressive weakness can be prevented or even reversed.[ncbi.nlm.nih.gov]
  • Potassium supplementation, propranolol, and spironolactone may be helpful both in the acute state and in preventing attacks.[ncbi.nlm.nih.gov]
  • Immediate potassium supplementation prevents serious cardiopulmonary complications and may hasten the recovery of muscle weakness. Nonselective β-adrenergic blockers can ameliorate and prevent recurrence of the paralytic attacks.[doi.org]

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