It is not so often that I get two really thoroughly interesting and challenging cases in the same shift – one I posted on two days ago HERE. This is the second one. Ultimately, they are related, although from their presentations, you would never have guessed (well maybe Dr House would of! – on an aside, I still have trouble with Hugh Laurie as House – I know him so well from my obsession with the Black Adder series from the BBC – starring Rowan Atkinson, that I have trouble imagining him as a grouchy and brilliant American doctor when he was so well known playing a hilarious upper-class English twit, hence the photo above, but I digress….) ! An Asian man in his 30′s came in at 3am with a complaint of “can’t walk” and “weakness” for several hours. Apparently he had received an injection in his cervical spine earlier the day before for a disc herniation – I imagine a nerve block for radicular pain. He had no medical problems except the disc, was on no meds, and had normal vitals. He said through a translator that he felt “great” after the injection but then about 6-8 hours later as he was getting ready for bed, he began to feel his arms were “tired”. He decided to go to bed but then when he awoke several hours later, he realised he could barely move his arms and now his legs as well. He had absolutely no pain or loss of sensation. He called out for help and woke his family up – who called 911. On exam he had normal cranial nerves and level of consciousness. He had very severe PROXIMAL extremity weakness (ie his deltoids, rhomboids, rotator cuff, lats, hip flexors and extensors) but only mild weakness in the distal arms and legs. Sensation, vibratory sense, and proprioception (your feeling of your position in space) were all completely normal. He was very slightly hyper-reflexic (increased reflexes) with mild clonus of the ankles. He had no urinary or bowel problems. He was anxious and it was a little hard to tell at times if he was really giving his full effort – and since this pattern of weakness does not fit any sort of spinal cord injury I know of (although it can occur with Myaesthenia Gravis), I was a little suspicious for secondary gain. Also considering that this doc that performed the injection is a well-known procedure-doing ,money-grubber. The doc is part of the whole personal injury lawyer/”expert witness doc”/over-reading neuroradiologist triangle in my county. They are a well known group of docs (mostly neurologists and physiatrists) who basically make a lot of their money getting referrals from personal injury lawyers . They then order MRI’s which are then grossly over-read by a scamming group of neuroradiologists as “disc herniations” or more often “cord compression” (when they are not really present). They then do injections for chronic pain to demonstrate how miserable the patient is in preparation for the lawsuit. They then testify as to how “disabled” or in how much “severe pain” the patient is in after the accident. Everyone is happy when the lawsuit is successfully pressed that the guy is officially “disabled” or wins a big settlement in the case. A definitely minority of their cases are legit – otherwise they could not just make a living doing just that. Anyway, I was a little suspicious but the guy really seemed to be telling the truth so I assumed the guy had some kind of cord injury from the injection – ie a slowly expanding haematoma. Ergo I had to work the phones to get the MRI tech to come in early (when they usually arrive about 7:30). The CT was normal and I waited for the routine labs to come back. Well, I was surprised when I saw his potassium was 2.1!!!!! He was on no meds, was otherwise healthy so I had virtually no suspicion it would be abnormal. What is had is called Periodic Hypokalaemic Paralysis, a rare, often inherited condition where one gets very low potassium and thus muscle paralysis. The attacks are often triggered by alcohol, large meals and other things and involve complex pathways in the body’s cellular functioning. 85% of cases occur in Asian males for some reason. Since he had just had the needle in the neck however, I could not fully discount the cord injury so I went ahead with the MRI. The tech came in at 6am and took him for the scan. Shortly thereafter, my relief came in and when I told her about the case she told me about a few cases of the paralysis she had seen – thus she had read up on it. Part of the work up was to exclude treatable causes which included hyperthyroidism. We added a TSH on and would you believe it but it was 0.05!! Super low. The guy had no complaints that even in retrospect seemed attributable to thyrotoxicosis. Although his hyper-reflexia was consistent with it. He was started on IV K+ while the MRI report came back as negative. Strangely his K+ dropped to 1.7 AFTER 100Meq of potassium so he was transferred to the ICU where I heard he is doing better and his weakness is almost completely resolved. Talk about your RED HERRINGS!!!!! The fact that he had that injection right before the problem started was completely coincidental.
So there you have it. Don’t underestimate the thyroid!