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Hypothyroid Myopathy with Periodic Paralysis As the Main Symptom: a Case Report and Literature Review

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Hypothyroid Myopathy with Periodic Paralysis As the Main Symptom: a Case Report and Literature Review 3704 Case Report Hypothyroid myopathy with periodic paralysis as the main symptom: a case report and literature review Ning Lin, Jiajun Wang, Wuping Liao, Ying Wen Department of Chinese Medicine, Guangdong Second Provincial General Hospital, Guangzhou, China Correspondence to: Ning Lin. Department of Chinese Medicine, Guangdong Second Provincial General Hospital, Guangzhou 510317, China. Email: [email protected]. Abstract: Hypothyroid myopathy is a skeletal muscle disease caused by hypothyroidism. However, patients with hypothyroidism are often misdiagnosed as polymyositis if they do not have a clear history of thyroid gland or obvious hypometabolic symptoms, but with myasthenia and myalgia as the main symptoms or the first symptoms. Moreover, hypothyroid myopathy with periodic paralysis as the first symptom is rare in clinic. In this study, we summarized the clinical data of 1 case of hypothyroid myopathy with periodic paralysis as the first symptom in our clinical diagnosis and treatment. A 27-year-old male patient with recurrent periodic paralysis was found with hypothyroidism during a most recent attack of myasthenia and was diagnosed with hypothyroid myopathy, which was relieved after oral administration of levothyroxine. We also found 13 similar cases reported internationally, and summarized their clinical characteristics, diagnosis, and treatment methods to provide reference for the clinical diagnosis and treatment of such cases. In general, periodic paralysis may be the main symptom or even the first symptom of hypothyroid myopathy, which is easy to be confused with renal tubular acidosis (RTA) or other autoimmune diseases. The diagnosis is mainly based on the detection of thyroid function and thyroid autoantibodies. Timely supplement of thyroxine and correction of electrolyte disorders are the key to treatment. Keywords: Hypothyroid myopathy; periodic paralysis; diagnosis; case report Submitted Jul 17, 2020. Accepted for publication Sep 04, 2020. doi: 10.21037/apm-20-1578 View this article at: http://dx.doi.org/10.21037/apm-20-1578 Introduction potassium shift (3). Hypothyroid myopathy (HM) is a skeletal muscle disease caused by hypothyroidism. About Periodic paralysis is a type of myopathy related to potassium 30% to 80% of patients with hypothyroidism develop ion (K+) metabolism, which is clinically characterized by myopathy whose symptoms include myasthenia, muscle recurrent myasthenia with changes in serum potassium ion spasm after exercise, myalgia, and muscle stiffness (4). The levels (1). Hypokalemic periodic paralysis (HOPP) is the symptoms of HM are usually mild, but tend to become most common type of periodic paralysis, with an incidence more pronounced in untreated severe hypothyroidism (5). of about 1 in 100,000, and is more common in Asian men. The skeletal muscle damage caused by hypothyroid HOPP can be divided into two types: primary (familial or myopathy is due to Glucosaminoglycan deposition in idiopathic) HOPP and secondary (acquired) HOPP (2). type II fast muscle fibers and type I slow muscle fibers, Primary HOPP is caused by the intracellular shift of K+ weakened contractility of actin-myosin unit, decreased due to potassium channel gene mutations. Secondary myosin ATPase activity and slowed ATP turnover (6). HOPP is caused by a variety of etiologies; one of the most The literature about neuromuscular complications common causes is thyrotoxicosis, which is characterized by in hypothyroidism is mostly based on retrospective increased activity of the sodium-potassium pump caused analysis. In addition, the risk of hypothyroidism is higher by excessive thyroid hormones, leading to intracellular in patients with myotonic dystrophy (7). Therefore, © Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2020;9(5):3698-3704 | http://dx.doi.org/10.21037/apm-20-1578 Annals of Palliative Medicine, Vol 9, No 5 September 2020 3699 the true prevalence of neuromuscular complications aspartate and oral administration of potassium chloride during hypothyroidism is not easy to determine and solution. On September 22, the serum potassium was may be underestimated. So, it is not difficult to diagnose 2.98 mmol/L, and intravenous and oral potassium hypothyroid myopathy if the patients have a clear history supplement was continued. On the night of September 22, of hypothyroidism (primary hypothyroidism, secondary the serum potassium was 3.64 mmol/L, and the patient hypopituitarism hypothyroidism, autoimmune thyroiditis, still felt weakness of the lower limbs, and so was admitted post-thyroidectomy status, antithyroid drug prescription, with periodic paralysis. The patient was previously etc.), or muscle lesions diagnosed according to the typical healthy and denied any history of hypertension, thyroid clinical symptoms of hypothyroidism (low basal metabolism dysfunction, or other diseases. His vital signs were normal: syndrome, myxedema face, cardiovascular system, digestive body temperature, 36.2 ; pulse, 72/min; blood pressure system changes, etc.) (8). However, it is easy to misdiagnose 120/84, mmHg. The patient had no obvious thyroid ℃ hypothyroidism patients if they have no clear history enlargement, and no obvious abnormalities in the heart, of thyroid disease or no significant hypometabolism lung, or abdomen. His muscle strength and upper limb symptoms, but do have myasthenia and myalgia as the main muscle tension were generally normal, and he exhibited symptoms or the first symptom (9). The condition most no obvious muscle atrophy or hypertrophy of the lower commonly confused with hypothyroid myopathy in clinic limbs, and no muscle tenderness. The muscle strength was is polymyositis (10). However, hypothyroid myopathy with grade 4, muscle tension decreased, and knee reflex and periodic paralysis as the first symptom is rare in clinic, and Achilles tendon reflex had weakened. Laboratory results is mostly only known through case reports. This study during hospitalization, including blood biochemistry, urine summarized the clinical data of 1 case of hypothyroid biochemistry, and blood gas analysis, are shown in Table 1. myopathy with periodic paralysis as the first symptom in our Blood cortisol, aldosterone, and other examinations showed clinical diagnosis and treatment. In the study, we also found no abnormality. Electrocardiogram (ECG) revealed sinus 13 similar cases reported internationally, and summarized rhythm and ST segment elevation. Chest X-ray showed no their clinical characteristics, diagnosis, and treatment obvious abnormality. Abdominal color Doppler ultrasound methods to provide reference for the clinical diagnosis and showed fatty liver, with both kidneys and urinary bladder treatment of such cases. We present the following article in showing no obvious abnormality. Electromyography (EMG) accordance with the CARE reporting checklist (available at showed no definite neurogenic or myogenic injury. The http://dx.doi.org/10.21037/apm-20-1578). patient was diagnosed with HOPP, and continued oral and intravenous potassium supplement. Serum potassium on multiple retests was generally normal, while creatine kinase Case presentation (CK) on multiple retests was elevated (Table 1). After 5 days, The patient was a 27-year-old male from Tianmen City, the subjective symptoms of the patient had improved with Hubei Province, and was admitted on September 23, normal serum potassium. He refused further diagnosis and 2017. Beginning 8 years prior, the patient had lower limb treatment due to personal reasons and was discharged. weakness and difficulty in walking. The examination in On July 31, 2018, the patient again experienced weakness another hospital found low serum potassium, so the patient with pain in the lower limbs after exertion. Outpatient was a given potassium supplement for treatment with the blood biochemistry and thyroid function detection are symptoms being relieved after rest. On September 21, shown in Table 1. Liver enzymes were elevated: alanine 2017, after exerting himself, the patient relapsed with lower aminotransferase (ALT), 81 U/L (reference value 0–50 U/L); limbs weakness and difficulty in walking but without loss of aspartate transaminase (AST), 67 U/L (reference value energy, fear of cold, lethargy, poor appetite, constipation, 0–50 U/L). Twelve items of anti-ENA antibody were weight gain, or other symptoms. Consequently, the patient all negative. Thyroid color Doppler ultrasound showed visited our emergency department for treatment. The diffused thyroid enlargement and abundant blood supply. examination results were as follows: serum potassium, EMG revealed no clear neurogenic or myogenic injury. 3.2 mmol/L; muscle enzyme, serum free triiodothyronine According to these indicators, the patient was diagnosed (FT3), free thyroxine (FT4), and thyroid stimulating with autoimmune thyroiditis complicated with hypothyroid hormone (TSH) were normal. The symptoms were not myopathy, and was given levothyroxine sodium tablets 25 μg, significantly relieved after intravenous drip of potassium 1 tablet/day orally. After 4 weeks, the patient indicated by © Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2020;9(5):3698-3704 | http://dx.doi.org/10.21037/apm-20-1578 3700 Lin et al. A case of hypothyroid myopathy with periodic paralysis Table 1 Laboratory results in the patient with hypothyroid myopathy with hypokalemic periodic paralysis as the first symptom Na+ K+ CL− CK Urine K+ Urine AnGap TSH FT4 aTPO Date Blood PH (mmol/L) (mmol/L) (mmol/L) (U/L) (mmol/24 h) PH (mmol/L) (uIU/L) (pmol/L) (U/mL) 2017-9-21 142 3.2 96 164 5.4 15.08 2017-9-22 141 2.98 100 2017-9-23 137 4.27 98.2 619 8 7.3 20 2017-9-27 142 3.8 103.7 977 83.2 2018-7-31 142 3.67 100.4 10.58 13.58 85.59 Reference value 137–147 3.5–5.3 99.0–110.0 26–218 5.0–8.0 7.35–7.45 8–16 0.35–5.5 11–23 0–60 CK, creatine kinase; TSH, thyroid stimulating hormone; FT4, free thyroxine. Table 2 Clinical data of 5 previously healthy cases of hypothyroid myopathy with periodic paralysis as the first symptom Age TPOAb Others Case Gender K+ CK FT4 TSH (year) (IU/mL) 1. China (11) Female 36 3.37 mmol/L 380 U/L 0.32 μg/dL 288.8 IU/mL >1,000 EMG: multiple peripheral nerve lesion 2.
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