Euthyroid Thyrotoxic Periodic Paralysis

Abstract

Thyrotoxic periodic paralysis (TPP) is a dramatic complication of thyrotoxicosis usually seen in young men with untreated Graves' disease. We report the case of a 29-year-old active duty man with TPP attacks atypical in that they occurred during and after resolution of the hyperthyroidism. Our literature review revealed only two previously reported cases of TPP concurrent with euthyroidism. Risk factors for TPP include the postprandial state after carbohydrate-rich meals and the post-exertional state. At least a 2-week "window of vulnerability" for TPP appears to exist after initiation of antithyroid therapy. Hyperthyroid active duty males are especially at risk of TPP, and require physical profiling at the time of diagnosis and for a limited period after they become euthyroid, to minimize the occurrence of this complication.

Thyrotoxic Hypokalemic Periodic Paralysis: Report of Four Cases in Black American Males1

“…Forty percent of the Asian-American TPP case reports were from Hawaii, probably reflecting the large Japanese population in that state. White, Hispanic, and American Indian patients with TPP have appeared in the literature as case reports or included in small series of patients (1)(2)(3)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23).…”

“…Diffuse hyporeflexia was present. Admission lab data: sodium 143 mmol/L (normal range 136-147), potassium 1.4 mmol/L (3.5-5), chloride 104 mmol/L (98-105), bicarbonate 30.5 mmol/L (23-30), glucose 160 mg/dL (60-100), BUN 15 mg/dL (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23), creatinine 0.8 mg/dL (0.4-1.5), calcium 9.5 mg/dL (8.7-10.2), phosphorus 3.6 mg/dL (2.5-4.9), magnesium 2.1 mg/dL (1.8-2.4), and CPK of 5560 U/L, which was 100% MM fraction (normal 50-180). Admission EKG showed sinus tachycardia, prominent U waves, and poor R wave progression with ST elevation in VI-V3 consistent with anterior myocardial infarction.…”

“…Initial physical exam: BP 130/58, pulse 146/min, respirations 44/min, and temperature 37.5°C; thyroid was soft and diffusely enlarged, approximately 50 g, without nodules; lungs had bibasilar crackles; heart was tachycardie without murmurs, gallops, or rubs; neurologic exam was normal except for profound muscle weakness in all extremities but reflexes were normal. Admission lab data: sodium 144 mmol/L (135-145), potassium 2.3 mmol/L (3.6-5.0), chloride 103 mmol/L (101-111), bicarbonate 26 mmol/L (26-31), glucose 139 mg/dL (65-110), BUN 14 mg/dL (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21), creatinine 0.7 mg/dL (0.7-1.5) calcium 9.6 mg/dL ( Admission EKG showed atrial flutter with 2:1 conduction that converted to sinus tachycardia with improvement of hypokalemia. He was admitted to a telemetry ward and treated with intravenous potassium phosphate and magnesium sulfate.…”

“…Initial physical exam: BP 146/64, pulse 101/min, respirations 24/min, temperature 37.3°C; thyroid was diffusely enlarged, approximately 30 g; lungs were clear to auscultation; heart was tachycardie without murmur; neurologic exam was abnormal with no motor strength in lower extremities and very slight strength in upper extremities with hyporeflexia. Initial lab data were sodium 142 mmol/L (137-145), potassium 2.1 mmol/L (3.6-5), chloride 108 mmol/L (98-107), bicarbonate 12 mmol/L (22-31), glucose 255 mg/dL (75-110), BUN 9 mg/dL (9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21), creatinine 0.9 mg/dL (0.7-1.4), calcium 9.9 mg/dL (8.4-10.2), phosphorus 0.8 mg/dL (2.4-4.4), magnesium 2.0 mg/dL (1.7-2.2), and CPK 141 U/L (55-170). Admission EKG revealed a wide QRS with a right bundle branch block pattern at a rate of 100 bpm.…”

“…In the United States, most patients with TTP are men of Asian descent, with relatively few reported cases in other ethnic groups including Whites, African-Americans, Hispanics, and American Indians (1)(2)(3)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23). We report four cases of TPP in AfricanAmerican males diagnosed in our institution over a 13-year period (1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988)(1989)(1990)(1991)(1992)(1993).…”