INFORMATION SHEET FOR CANDIDATE:

Your next patient in the emergency department is a

28 year old Chinese business man, Mr. Chong, who
returned from a business trip to Singapore. His wife
noticed that he seemed to be staggering a bit when
she picked him up from the airport. He woke up at
about 3 am unable to move. She called the ambulance
and the patient was brought to the hospital.

YOUR TASKS ARE:

 To take a focused history
 Perform a physical examination
 Arrange appropriate investigations
 Explain the most likely diagnosis and
management to the patient
History:

Mr. Chong had been on a business trip through Malaysia and Singapore for the last 2
weeks and told his wife on the phone a couple of times that he felt quite tired and
lethargic and found it difficult to move around because of weak. He arrived by aeroplane
yesterday afternoon. When he walked through customs he was weak in his legs but
otherwise unremarkable. He went to bed at about 9 pm and woke up at 3 am and could
not move. He was fully conscious and had no pains or other symptoms.

On further questioning, the patient stated that he had several month's history of heat
intolerance, palpitations and sweaty palms and had lost 10 lbs in weight over past few
months.

Past Medical History: unremarkable

SHx: married business man, two children, non smoker, little alcohol

Family History: mother, 2 brothers and uncle have history of thyroid disease

Examination:

Pulse 63/min (sometimes irregular), BP 145/66 mmHg, afebrile, RR 18, SaO2 98% on
RA.

Chest & Abdominal systems: NAD

Thyroid: palpable goitre with bruit, no eye signs
Neurology: Glasgow Coma Scale: 15/15, no neck rigidity, power: upper limbs
3/5; lower limbs 2/5, reflexes: areflexic for deep tendon reflexes, down-going
plantars

Investigations: see below

DIAGNOSIS: Thyrotoxic periodic paralysis (TPP).

TEST RESULTS REFERENCE INTERVAL UNITS
sodium 143 135-145 mmol/L
potassium 1.4 3.5-5.1 mmol/L
urea 4.5 3.4-8.9 mmol/L
creatinine 0.06 0.06-0.13 mmol/L
glucose 6.1 mmol/L
protein 64 66-81 g/L
albumin 32 36-48 g/L
bilirubin 7 <15 umol/L
ALP 117 50-160 U/L
ALT 36 <58 U/L
calcium 2.25 2.20-2.62 mmol/L
posphate 0.40 0.82-1.40 mmol/L
CK 104 42-218 U/L
TSH <0.1 0.3-5 mU/L
T4 25 4.5 - 11.2 mcg/dL
Progress

The ECG showed 2o heart block and so he was transferred to CCU for monitoring. This
changed to sinus tachycardia 105/min after treatment. The low potassium was treated
with potassium supplements and the hyperthyroidism was treated initially with
carbimazole and propranolol. He made a rapid recovery of power and was discharged on
Day 4 with follow up in the Endocrine Outpatient Clinic.
 First reported case of periodic paralysis in 1727 -- initially dismissed as hysteria
 First association with thyrotoxicosis in 1902, reported from Germany
 Predominantly an oriental disease: but also in Hispanics, Blacks and American
Indians
 occurs in 1.8% Chinese thyrotoxic patients
 typical age: 20 - 40 years
 male predominance: 76:1 in Southern China

Precipitating factors:

 high carbohydrate loads

 strenuous exercise
 trauma, cold exposure, infection, emotional stress

Time of onset:

typically late evening or early morning

 3 am to 9 am: 40%
 9 pm to 12 midnight: 21.8% (current case history)

Clinical manifestations:

Neurologic
 lower limbs affected more severely than upper

Cardiac
 multiple types of cardiac arrhythmias
 occasionally life-threatening (current case history)

Pathophysiology
  Potassium shifts (into intracellular spaces!): does NOT reflect depletion of body
potassium stores
 danger of overcorrection
 increased Na,K ATPase activity
 increased sensitivity to beta-adrenergic stimulation
?explain effect of propranolol
 activity stimulated by androgens
 hyperinsulinaemia and impaired glucose tolerance

Genetics & Immunogenetics

 Rare to have family history

 conflicting results of studies
o Singapore & Thailand: HLA A2, Bw22, Aw19 and B17
o Caucasians: HLA DR3
o Hong Kong: HLA B46, DR9 and DQB1*0303

Certain similarities to Familial Hypokalaemic Periodic Paralysis

 both can be induced by insulin or carbohydrate
 both male dominance: 3:1 to 12:1 in FPP

Thyrotoxic PP Familial PP

Rarely familial Autosomal dominant

Asian Caucasian

onset: 20-39 early onset: <16

dependence on thyroid status thyroid hormones: no effect or alleviate

acetazolamide worsens acetazolamide prevents attacks

Clinical features:
Adult Asian young men

Sporadic
Recurrent acute paralysis with complete recovery
Limb > trunk involvement
Precipitated by heavy carbohydrate load, high-salt diet, alcohol, exertion
Family history of hyperthyroidism
Clinical features of hyperthyroidism
Hypokalemia
Normal acid-base balance
Low potassium/phosphate excretion rate