Clinicopathology Conference

1
Clinicopathology Conference

• January 14, 1999
• Dr. Patrick Ober
• Dr. Jamie Gitter

2
21 Year Old Male with Recurrent

• Lower Extremity Paralysis

3
August 15, 1998

• Healthy 21 year old white male
• Presented to local ED with upper and lower
  extremity weakness and vomiting.
• Reported similar episodes of weakness over past 3
  months without seeking help.
• Previous episodes lasted less than an hour.
• Often associated with vomiting.
• No prior neurological history.

4
August 15, 1998

• In the ED, neuro exam revealed 3/5 proximal and
  distal motor strength.
• Rest of exam was unremarkable.
• Potassium was 1.7 meq/L.
• Patient was treated with 40 meq KCl and Diamox
  250 mg bid.
• Symptoms improved.
• Patient discharged for outpatient care.

5
September 14, 1998

• Patient presented to urgent care clinic.
• Reported muscle twitching and lower extremity
  tremors.
• Denied severe weakness.
• Recently developed a pruritic rash on the arms.
• Exam showed a papular rash on the arms, otherwise
  unremarkable.

6
September 14, 1998

• Potassium noted to be 4.1 meq/L.
• KCl 20 meq per day was prescribed.
• Diamox was discontinued.
• Follow up in two weeks was arranged.

7
September 25, 1998

• Patient presented to ED unable to walk.
• Exam showed hypertension (169/82) and diffuse
  weakness, otherwise normal.
• Potassium was 2.5 meq/L.
• Urinary potassium was 15.2.
• Treated with 100 meq KCl orally.
• Repeat potassium was 4.9 meq/L.

8
September 25, 1998

• Neurological symptoms resolved.
• Given diagnosis by ED staff of periodic
  paralysis.
• Prescription for 40 meq KCl was given.
• Follow up was arranged at outside clinic.

9
November 16, 1998

• Patient missed his clinic appointment

10
November 26, 1998

• Presented to the same ED with complaints of
  diffuse weakness and sore arms.
• Symptoms occurred after alcohol ingestion.
• Exam showed marked, generalized weakness, pain,
  and lower extremity hyperreflexia.
• Potassium was 2.4 meq/L.
• Other labs 7.4/36/105/22 on 2L NC, CK 642,
  CBC was normal.

11
November 26, 1998

• Given 60 meq KCl orally in the ED.
• Symptoms resolved.
• ED staff concurred with previous diagnosis of
  periodic paralysis from hypokalemia.
• In addition to his daily potassium pill patient
  encouraged to scarf bananas and swill orange
  juice.
• One week follow up was arranged.

12
November 29, 1998

• Mother concerned.
• ED staff perplexed.
• Dr. Gitter called to demystify the situation.

13
December 8, 1998

• Patient and mother presented to Dr. Gitter.
• Old records from ED visits unavailable.
• History from patients perspective reviewed.
• Since last ED visit, episodes of weakness have
  continued.
• Associated symptoms included recent fall,
  diarrhea, and muscle cramps.

14
December 8, 1998

• A more thorough history was obtained.
• Medications KCl 20 meq per day
• Social Hx Recent employment as a waiter
  (currently unable to work) 1 ppd tobacco
  enthusiast Rare ETOH
• Family Hx Mom with uterine cancer Dad
  with hypertension

15
December 8, 1998

• Exam showed a BP 138/82, pulse 80s, no
  thyromegaly, 5/5 strength, down-going toes, but
  diminished reflexes in lower extremities.
• The following tests were obtained Basic
  metabolic profile, Mg2 Urinalysis with Na and
  K Thyroid panel

16
December 9, 1998

• TSH found to be 0.04 (0.4 - 5.5)
• FTI was 5.4 (0.7 - 2.2)
• T3 was 287 (62 - 194)
• T4 was 20.2 (5.5 - 11.8)
• Potassium 4.7 meq/L with BMP normal
• Urine potassium 160 and sodium 109.

17
December 10, 1998

• Discussed with Dr. Ober, then family
• Diagnosis of Thyrotoxic Periodic Paralysis was
  made.
• Propranolol 20 mg PO tid was prescribed.
• Follow up was continued.

18
December 14, 1998

• Patient returned to clinic for follow up.
• Reported significant improvement with the
  propranolol.
• Further history revealed heat intolerance.
• Exam was unremarkable.
• Began discussion of therapy for hyperthyroidism.

19
December 22, 1998

• Patient continues to do well.
• Family pleased with Dr. Gitters care.
• Thyroid uptake scan was consistent with Graves
  Disease.
• Patient declined RAI ablation.
• PTU initiated.
• Frequent follow up was arranged to monitor
  symptoms.