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!
Whoa.
Doc, thank you. You guys really save the day when it comes right down to it.
I know the drug seekers can get you down, but that right there is why you do what you do.
I hope I never need such a brilliant intervention, and due to my age (22) I probably wont for some time. But I hope if the day comes I do need someone like you there for me you will be.
You said the attacks are triggered by “alcohol, large meals and other things” – maybe the injection was a trigger. I’ve seen one similar case: Asian male in his 20’s, couldn’t get out of bed, medics were quite dismissive on arrival, but his K+ was 1.8. He perked right up after a potassium infusion.
Great blog, interesting case!!
(and the kick in the behind that I needed. hashimoto and fed up, so I was postponing getting the bloodwork done but it’s been almost 8 months…So, oops, I know I should know better (3rd year med student))
Cushing’s patients deal with hypokalemia all the time. Some more than others. I’ve experienced it to the point of not being able to move one time, and my cortisol level was very high. By chance, did he have a steriod injection? (I also have very low TSH…but that’s secondary to pituitary surgery…still hypothyroid with that low value.)
He might have – although I think his injection was more of a nerve block with Bupivicaine or something similar.
Speaking of Dr. House… On last night’s episode, I noticed there was no anesthesiologist present during surgery, and that the patient wasn’t intubated, although she was under full sedation (and subsequently went into respiratory arrest and was saved by a cric from a doctor who rushed in at the last minute without scrubbing or wearing gloves, no less). Does that really happen (not the parenthetic part), or is it another creative liberty taken by tv?
I also notice this hospital has no (or few) nurses, nor does Seattle Grace, the alleged hospital in Gray’s Anatomy.
That is the sort of thing that is so ridiculous about medical dramas on TV. Most of that stuff is completely unrealistic. I mean, technically the medical problems are accurate but the daily flow of how things happen is pure drama. Reality would be too boring! I get the most drama in the ER but even at our worst, we are almost never as exciting as a “slow” episode of “ER”.
I had a similar case last year…the guy was in his 30’s, healthy, had taken steroids for some days…one morning he woke up and wasn’t able to walk with proximal paralysis of arms,too…there was areflexya so we thought of Guillain Barré. Serum K was 1.7 indeed! And it was an hyperthiroidism (Graves’disease). He only had tachycardia (HR about 130) and mild repolarization abnormalities on EKG. He was treated in neurology department and he dramatically improved about 10 minutes (I’m not joking) after iv potassium was started.
I find your story of periodic paralysis very intriguing. But I find your initial suspicion of secondary gain with this patient very disturbing.
The medical profession has become so tainted with the attitude that “everyone is out to make a buck” that it often hinders good medical care and social justice. This attitude has resulted in a noticeable lack of compassion in our physicians today.
It is a known fact that in the past, patients with periodic paralysis were sometimes placed in insane asylums due to limitations of the medical technology at that time. Now that we know that periodic paralysis can arise from a genetic abnormality with tests to indicate as such, these patients are now recognized having a real medical condition.
So despite the fact that a patient may present with symptoms that do not show on an MRI or blood work, does not necessarily suggest that the patient is not suffering from something real. It may very well be that the limits of our current medical technology cannot yet detect it. So your opinion that the majority of physicians and patients involved in the personal injury cases seemingly are there to “scam” the system, may be debased.
The primary motive of the majority of persons involved in personal injury claims is not “to make a buck”. The motives are to get better, to obtain the financial resources to do so, and to provide a level of social justice that is fair and reasonable. It is the inefficient and complicated legal system that blackens these genuine motives, not the patient who suffers.
Our present medical system runs on the “money game” and so does our justice system. If we could change the former, then the latter would not have as much influence. But I do not see many physicians crying out for change. I see them instead in fear about their own financial outcomes. I hear their complaints and fears of the legal system, but I do not see them making any efforts on changing their own profession to make medical care more affordable and accessible.
Your ER story had a good ending since you found significant blood results to make a diagnosis of periodic paralysis. But the next time you may not be so lucky. It is then that I hope you catch yourself placing initial suspicion on a patient’s motive, and instead, reflect on your level of compassion, as much as your level of medical skills.
B. McClain
http://www.cpab.info
Geez, you get slammed on that “lack of compassion” thing no matter what you write. Kudos.
Well, B McClain, the thing is that I was perplexed at first because of the timing of the onset with the injection into the C-spine. That seemed like the obvious cause at first. However, the pattern of weakness did not make anatomical sense – hence my suspicions. Also, couple that with the notoriety of the doc who did the injection and my warning lights went off. However, the important thing is that just because you suspect foul play, you can’t immediately jump to conclusions. Look a little deeper. You might find something. However, I have seen many people who fake weakness – ever heard of the Hoover sign????? Look it up, it is a good test to catch some fakers.
This is not hypokalemic periodic paralysis. This condition is inherited and usually manifested at younger age and is not associated with hyperthyroid.
The correct diagnosis in this patient should be thyrotoxic periodic paralysis(TPP). The pathophysiology of these two conditions are totally difference. There are some feature that can distinguish these two conditions which can be found in this review article(J Clin Endocrinol Metab, July 2006, 91(7):2490-2495.) For example, TPP usually affect male, age 20-40 yo, usually sporadic, etc. It is quite common for TPP patients to present with paralysis without any history of thyrotoxic symptom. Some researchs found that the prevalence of this condition is rising in the western population.
I guess technically you are correct Thaidoc since we found the hypokalaemia was caused by the thyroid. The true PHP is genetic and of uncertain aetiology. However, I wonder how many cases of “PHP” are never fully worked up and the K+ is just replaced – they usually get better and are discharged.
[...] M.D.s and J.D.s in cahoots: when neuroradiologists over-read MRIs in search of “disc herniations” and “cord compression” [ER Stories] [...]
Better reading than the “Case Records of the Massachusetts General Hospital” in the NEJM!
I love Dr. House and i always watch this TV series after my day job.*-~