Thyrotoxic hypokalemic periodic paralysis triggered by dexamethasone administration
Open accessAbstract
Thyrotoxic hypokalemic periodic paralysis (THPP) is a disease characterized by recurrent episodes of muscle weakness due to intracellular potassium shifting in the presence of high levels of thyroid hormone. It occurs more commonly amongst young Asian men with underlying Graves’ disease. Attacks are commonly precipitated by ingestion of carbohydrate-rich meals or alcohols, stress or strenuous exercise. Herein, we describe an adult Thai man suffering from a hypokalemic periodic paralysis attack after receiving a dexamethasone injection. The diagnosis of Graves’ disease was confirmed by his thyroid function test and a presence of thyrotropin-receptor antibody. His weakness and hypokalemia responded well to potassium supplement and a non-selective beta blocker, while his thyrotoxicosis was initially controlled by an anti-thyroid medication and subsequently with a subtotal thyroidectomy. Clinicians should beware of this manifestation when administering steroids in the thyrotoxic patients, especially of Asian male descent.
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Written from the paper’s full text.
TL;DR
This case report describes a 36-year-old Thai man with Graves’ disease who developed thyrotoxic hypokalemic periodic paralysis after receiving a 5 mg dexamethasone injection. His weakness and hypokalemia resolved with oral potassium and non-selective beta blockade, and his thyrotoxicosis was later treated with methimazole and subtotal thyroidectomy.
Key findings
- A 36-year-old Thai man developed flaccid lower-extremity paralysis and proximal upper-extremity weakness (3/5 motor power) 5 hours after a 5 mg dexamethasone injection for right elbow tendinitis; laboratory results showed potassium 2.0 mEq/L, phosphate 2.0 mg/dL, and creatine kinase 300 U/L, with ECG sinus tachycardia, QTc 0.5 sec, and U wave.
- Graves’ disease was confirmed by FT4 1.97 ng/dL, TSH < 0.005 μU/mL, and positive thyrotropin-receptor antibody; muscle strength and serum potassium were fully restored within 12 hours after 100 mEq oral liquid potassium, with rebound hyperkalemia of 5.8 mEq/L.
- He received methimazole 15 mg/d and propranolol 40 mg/d; one month later subtotal thyroidectomy was performed uneventfully, and he remained euthyroid without paralysis during follow-up.
- The discussion notes THPP occurs mostly in young Asian men with Graves’ disease (male-to-female ratio 20–70:1), with an overall incidence of about 2% in Asian thyrotoxic patients versus 0.1–0.2% in North America, and about 10 reported cases of steroids precipitating THPP.
Methods
- Design: single case report with a review of literature.
- Data/sample: one 36-year-old Thai man presenting with acute weakness after dexamethasone injection; data include clinical examination, laboratory tests, ECG, thyroid function tests, thyrotropin-receptor antibody, treatment, and follow-up.
- Main analysis: descriptive narrative of the case and discussion of prior literature; no formal statistical analysis.
Limitations
- Not stated in the paper.
- Evident from the text: this is a single case report with no control or comparison group, so causality between dexamethasone and THPP is inferred from temporal association and cannot be established definitively.
- Evident from the text: the follow-up duration is not specified, limiting assessment of long-term recurrence or treatment outcomes.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
0 of 14 cited sources checked · 0 supported · 0 flagged
- Findingown data
Rebound hyperkalemia of 5.8 mEq/L was noted.
“Rebounded hyperkalemia, 5.8 mEq/L, was noted.”
Quote in the paperNot a substantial claim - Findingown data
Five hours before the weakness, the patient received a 5 mg dexamethasone injection prescribed by his general practitioner to control pain from right elbow tendinitis.
“Five hours prior, his general practitioner has prescribed him a 5 mg of dexamethasone injection to control his pain from right elbow tendinitis.”
Quote in the paperSubstantial claim - Findingown data
Serum phosphate was 2.0 mg/dL (hypophosphatemia).
“Laboratory results revealed hypokalemia (2.0 mEq/L, 3.5-4.5),hypophosphatemia (2.0 mg/dL, 2.5-4.5), and mildly elevated serum creatine kinase (300 U/L, ).”
Quote in the paperNot a substantial claim - Findingown data
Muscle strength and serum potassium were fully restored within 12 hours after administration of 100 mEq of oral liquid potassium.
“His muscle strength and serum potassium were fully restored within 12 hours after the administration of 100 mEq of oral liquid potassium.”
Quote in the paperNot a substantial claim - Findingown data
After receiving dexamethasone, the patient developed myalgia that progressed to paralysis predominantly in both legs.
“Thereafter, he developed myalgia which has progressed to paralysis predominantly in both of his legs.”
Quote in the paperSubstantial claim
- Findingown data
Serum potassium was 2.0 mEq/L (hypokalemia).
“Laboratory results revealed hypokalemia (2.0 mEq/L, 3.5-4.5),hypophosphatemia (2.0 mg/dL, 2.5-4.5), and mildly elevated serum creatine kinase (300 U/L, ).”
Quote in the paperSubstantial claim - Interpretationown data
In this report, the authors demonstrated an unusual complication of glucocorticoid usage in precipitating hypokalemic paralytic attack in a patient with thyrotoxicosis.
“In this report, we demonstrated an unusual complication of glucocorticoid usage in precipitating hypokalemic paralytic attack in a patient with thyrotoxicosis.”
Quote in the paperSubstantial claim- Rests on an assumption: Glucocorticoids may induce hypokalemia by directly increasing the Na+/K+-ATPase pool in skeletal muscle and by causing hyperinsulinemia.
- Rests on an assumption: Steroids can trigger muscle weakness by inducing myopathy and renal potassium loss owing to mineralocorticoid effects.
- Premisecitation
THPP occurs more commonly among young Asian men with underlying Graves' disease.
“It occurs more commonly amongst young Asian men with underlying Graves' disease.”
- Also stated in: § DISCUSSION · plain
“Most affected THPP patients are young Asian men (male-to-female ratio of 20-70 : 1) with underlying Graves' disease despite the female preponderance in hyperthyroidism (male-to-female ratio 1 : 4-10) (1-3).”
Quote in the paperNot a substantial claim0 of 3 sources checked - Also stated in: § DISCUSSION · plain
- Interpretationown data
The authors reported an unusual case of THPP precipitated by the use of a high-dose steroid.
“We reported an unusual case of THPP precipitated by the use of a high-dose steroid.”
Quote in the paperSubstantial claim- Rests on an assumption: Glucocorticoids may induce hypokalemia by directly increasing the Na+/K+-ATPase pool in skeletal muscle and by causing hyperinsulinemia.
- Rests on an assumption: Steroids can trigger muscle weakness by inducing myopathy and renal potassium loss owing to mineralocorticoid effects.
- Premisecitation
From the literature reviews, about 10 cases have been reported regarding steroids as a precipitating factor of THPP, ranging from low dose prednisolone to pulse methylprednisolone.
“From the literature reviews, about 10 cases have been reported regarding the steroids as a precipitating factor of THPP, ranging from low dose prednisolone to pulse methylprednisolone (7,8).”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [7] Ahamed, 2018, Cureus
Not checked in the free run.
- cites [8] Wongraoprasert, 2007, Intern Med source
Not checked in the free run.
- Interpretationown data
THPP can sometimes be the first manifestation of thyroid disorders, as described in this patient.
“THPP occurs only in the presence of thyrotoxicosis state and sometimes it can be the first manifestation of thyroid disorders as described in our patient.”
Quote in the paperNot a substantial claim
- Classified as probably not a substantial claim. 10
- May combine two claims. 12
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Findingown dataThe patient had noted about 4 kg weight loss and palpitations during the past 6 months.
“He was noted about 4 kg weight loss and palpitations during the past 6 months.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataGraves' disease was confirmed with FT4 1.97 ng/dL, TSH < 0.005 μU/mL, and a positive thyrotropin-receptor antibody.
“Graves' disease was confirmed with FT 4 1.97 ng/dL ( 0.8-1.8),TSH < 0.005 μU/mL (0.3-4.1), and a positive for thyrotropin-receptor antibody.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataThe patient was a 36-year-old Thai man who complained of acute weakness in both lower extremities.
“A 36-year-old Thai man complained of acute weakness in both the lower extremities.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Findingown dataSensory function and cranial nerves were spared.
“Sensory function and cranial nerves were spared.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataAn electrocardiogram showed sinus tachycardia, a prolonged QTc interval of 0.5 sec, and the presence of U wave.
“An electrocardiogram showed sinus tachycardia, a prolonged QTc interval of 0.5 sec and the presence of U wave.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataSerum creatine kinase was mildly elevated at 300 U/L.
“Laboratory results revealed hypokalemia (2.0 mEq/L, 3.5-4.5),hypophosphatemia (2.0 mg/dL, 2.5-4.5), and mildly elevated serum creatine kinase (300 U/L, ).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataOne month later, subtotal thyroidectomy was performed uneventfully, and the patient was in euthyroid state and did not experience paralysis during the follow-up period.
“One month later, subtotal thyroidectomy was performed uneventfully, and the patient was in euthyroid state and did not experience paralysis during the follow-up period.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Findingown dataThe patient denied history of alcohol use or family history of weakness.
“He denied history of alcohol use or a family history of weakness.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataNeurological examination revealed flaccid paralysis and decreased deep tendon reflexes in both lower extremities, with weakness of 3/5 motor power also involving the proximal part of the upper extremities.
“Neurological examination revealed flaccid paralysis and decreased deep tendon reflexes in both the lower extremities.His weakness of 3/5 motor power also involved in proximal part of the upper extremities.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationSensation is typically intact while deep tendon reflexes are markedly decreased or absent in THPP.
“Sensation is typically intact while deep tendon reflexes are markedly decreased or absent (1,2).”
Quote in the paperNot a substantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationTHPP attacks are commonly precipitated by ingestion of carbohydrate-rich meals or alcohol, stress, or strenuous exercise.
“Attacks are commonly precipitated by ingestion of carbohydrate-rich meals or alcohols, stress or strenuous exercise.”
- Also stated in: § INTRODUCTION · plain
“Episodes of attacks can be precipitated by an ingestion of high carbohydrate meal or alcohol, stress or strenuous exercise (1,3).”
Quote in the paperNot a substantial claim0 of 2 sources checked- Also stated in: § INTRODUCTION · plain
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationGlucocorticoids are currently used in various conditions of Graves' disease including ophthalmopathy due to its anti-inflammatory action, and also in thyroid storm due to its blocking on thyroid hormone peripheral conversion.
“Glucocorticoids are currently used in various conditions of Graves' disease including ophthalmopathy due to its anti-inflammatory action; and also in thyroid storm due to its blocking on thyroid hormone peripheral conversion (4).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [4] Ross, 2016, Thyroid source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationThe overall incidence of THPP in Asian thyrotoxic patients is about 2% compared with 0.1-0.2% in North America.
“The overall incidence of THPP in Asian thyrotoxic patients is about 2% comparing with 0.1-0.2% in North America (3).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [3] Maciel, 2011, Nat Rev Endocrinol source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationOther electrolyte abnormalities that have also been described in THPP are hypophosphatemia and hypomagnesemia.
“Other electrolyte abnormalities that have also been described are hypophosphatemia and hypomagnesemia (5).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [5] Chang, 2013, Eur J Endocrinol source
Not checked in the free run.
Classified as probably not a substantial claim.
PremisecitationThyrotoxic hypokalemic periodic paralysis (THPP) is characterized by recurrent episodes of muscle weakness and hypokalemia due to intracellular potassium shifting in the presence of high thyroid hormone.
“Thyrotoxic hypokalemic periodic paralysis (THPP) is a disease characterized by recurrent episodes of muscle weakness due to intracellular potassium shifting in the presence of high levels of thyroid hormone.”
- Also stated in: § INTRODUCTION · plain
“Thyrotoxic hypokalemic periodic paralysis (THPP) is characterized by recurrent episodes of muscle weakness and hypokalemia from intracellular potassium shifting (1,2).”
Quote in the paperSubstantial claim0 of 2 sources checked- Also stated in: § INTRODUCTION · plain
The paper relies on this without support.
Hypokalemia from intracellular shifting in THPP is related to increased sodium-potassium adenosine triphosphatase (Na+/K+-ATPase) pump activity in skeletal muscle from direct stimulation by thyroid hormone, catecholamines, androgens, and insulin.
“Hypokalemia from an intracellular shifting is related to an increase in sodium-potassium adenosine triphosphatase (Na + /K + -ATPase) pump activity in the skeletal muscle from a direct stimulation by thyroid hormone, catecholamines, androgens and insulin.”
The paper relies on this without support.
Glucocorticoids may induce hypokalemia by directly increasing the Na+/K+-ATPase pool in skeletal muscle and by causing hyperinsulinemia.
“Glucocorticoids may induce hypokalemia by directly increasing the Na + /K + -ATPase pool in skeletal muscle and also by causing hyperinsulinemia.”
The paper relies on this without support.
Steroids can trigger muscle weakness by inducing myopathy and renal potassium loss owing to mineralocorticoid effects.
“Moreover, steroids can also trigger muscle weakness by inducing myopathy and renal potassium loss owing to its mineralocorticoid effects.”
The paper relies on this without support.
THPP occurs only in the presence of thyrotoxicosis state.
“THPP occurs only in the presence of thyrotoxicosis state and sometimes it can be the first manifestation of thyroid disorders as described in our patient.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
There are few published cases of glucocorticoid administration prior to TPP.
“There are few published cases of glucocorticoid administration prior to TPP, thus the possibility that glucocorticoids may precipitate TPP requires further investigation.”
From Thyrotoxic Periodic Paralysis With Hypokalemia: A Case Study (2023) · cites this paper as [14]
From the current review of the literature, there are at least 13 cases of TPP associated with glucocorticoid use.
“From the current review of the literature, there are at least 13 cases of TPP associated with glucocorticoid use [13-16].”
From Thyrotoxic Periodic Paralysis With Hypokalemia: A Case Study (2023) · cites this paper as [14]
Cites
1 retracted
Thyrotoxic Periodic Paralysis: Clinical Challenges
Vijayakumar, A., Ashwath, G., & Thimmappa, D. (2014) · Journal of Thyroid Research · doi:10.1155/2014/649502 · Cited by 88 · cited 4× · see citing works
“Potassium administration during the attacks should be in oral form dividing into small doses with the maximal daily dose of 90 mEq (2).”
BackgroundInfluentialRetractedRoss, D. S., Burch, H. B., Cooper, D. S., Greenlee, M. C., Laurberg, P., Maia, A. L., Rivkees, S. A., Samuels, M., Sosa, J. A., Stan, M. N., et al. (2016) · Thyroid® · doi:10.1089/thy.2016.0229 · Cited by 2,938 · see citing works
Thyrotoxic Periodic Paralysis: A Diagnostic Challenge
Kung, A. W. C. (2006) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2006-0356 · Cited by 371 · see citing works
Chang, C.-C., Cheng, C.-J., Sung, C.-C., Chiueh, T.-S., Lee, C.-H., Chau, T., & Lin, S.-H. (2013) · European Journal of Endocrinology · doi:10.1530/eje-13-0381 · Cited by 114 · see citing works
Novel etiopathophysiological aspects of thyrotoxic periodic paralysis
Maciel, R. M. B., Lindsey, S. C., & Dias da Silva, M. R. (2011) · Nature Reviews Endocrinology · doi:10.1038/nrendo.2011.58 · Cited by 86 · see citing works
Thyrotoxic Periodic Paralysis Induced by Pulse Methylprednisolone
Wongraoprasert, S., Buranasupkajorn, P., Sridama, V., & Snabboon, T. (2007) · Internal Medicine · doi:10.2169/internalmedicine.46.0044 · Cited by 37 · see citing works
Self-citationDoes thyrotoxic periodic paralysis have a genetic predisposition? A case report
Rasheed, E., Seheult, J. N., Gibney, J., & Boran, G. P. (2018) · Annals of Clinical Biochemistry International Journal of Laboratory Medicine · doi:10.1177/0004563218785395 · Cited by 16 · see citing works
Flagged first, then by citations
Research works printed but not linked: 1
- Ahamed, 2018, Cureus, 10, e2106
Cited by
Sorted by citations
Wanas, A. M., Giacuzzo, C., Ghazi-Nouri, S., & Tan, L. T. (2025) · Orbit · doi:10.1080/01676830.2023.2296553 · Cited by 6 · see citing works
“…in some instances, the diagnosis of Graves’ disease was made in the course of investigation for HPP following steroid therapy, where patients were not previously known to be thyrotoxic, 30,31 thus highlighting the role of hyperthyroidism in heightening the tendency for steroid-induced HPP.”
Murashita, M., Wada, N., Baba, S., Sugawara, H., Miyoshi, A., & Obara, S. (2022) · Endocrinology Diabetes and Metabolism Case Reports · doi:10.1530/edm-22-0236 · Cited by 5 · see citing works
Gendron, A.-A., Marquis, A., Mongeon, C., Statie, A., Bouchard, A., & Khazaka, M. (2022) · The Canadian Journal of Hospital Pharmacy · doi:10.4212/cjhp.3145 · Cited by 3 · see citing works
Thyrotoxic Periodic Paralysis With Hypokalemia: A Case Study
Mebane, N. B., Khan, A., Bevinal, M., & Davis, E. (2023) · Cureus · doi:10.7759/cureus.40757 · Cited by 3 · see citing works
“From the current review of the literature, there are at least 13 cases of TPP associated with glucocorticoid use [13-16].”
BackgroundGlucocorticoid-induced Thyrotoxic Periodic Paralysis Following Lumbar Nerve Root Block
Uda, S., Shimizu, H., & Nishioka, H. (2025) · Internal Medicine · doi:10.2169/internalmedicine.5987-25 · Cited by 1 · see citing works
Thyrotoxic hypokalemic periodic paralysis and COVID-19 infection
Chinangkulpiwat, S., Tantiprawan, J., Amornvit, J., Bunchaya-Anant, P., & Snabboon, T. (2022) · Journal of Family Medicine and Primary Care · doi:10.4103/jfmpc.jfmpc_475_22 · Cited by 1 · see citing works
“[8] Potassium administration during the attacks should be in the oral form divided into small doses with a maximal daily dose of 90 mEq to shorten the weakness period and prevent a possible fatal arrhythmia.[9] Non‐selective β‐blockers should be used to treat hyperthyroidism and hypokalemia and prevent paralytic attac…”
BackgroundSelf-citationIsshak, R., Orhun, N., Rajab, I. M., Shober, D., & Michael, P. (2025) · AACE Endocrinology and Diabetes · doi:10.1016/j.aed.2025.02.005 · Cited by 1 · see citing works
Contreras-García, C., Salgado-Gómez, E., & Ochoa-Magdaleno, J. (2023) · Revista Mexicana de Endocrinología Metabolismo y Nutrición · doi:10.24875/rme.23000014
Parálisis periódica hipocalémica como debut de enfermedad de Graves: caso clínico
Cardona, A. H., Peñaranda-Parada, E. A., Ausecha, D. R. S., & Sánchez-Mejía, J. (2024) · Revista Colombiana de Endocrinología Diabetes & Metabolismo · doi:10.53853/encr.11.2.864
- Authors
- Polamaung, W., Kongkit, J., Yimnoi, P., Boonchaya-Anant, P., & Snabboon, T.
- Affiliations
- Prapokklao Hospital (TH)
- Chulalongkorn University (TH)
- Thai Red Cross Society (TH)
- Corresponding author
- Polamaung, Waraporn
- Kongkit, Jaruwan
- Yimnoi, Parichat
- Snabboon, Thiti
- ORCID
- Snabboon, Thiti
- Venue
- Acta Medica (Hradec Kralove, Czech Republic)
- Published
- 2020
- Volume
- 63
- Issue
- 2
- Pages
- 91-93
- ISSN
- 1211-4286 (ISSN-L)
- 1805-9694
- OpenAlex
- W3047817278
- Semantic Scholar
- 4eb57a6d4340ae905b1ba04c517dd9b8d8e8a75a
- Cited by
- 9
- References
- 7
- Citations by year
- 2025: 2 · 2024: 2 · 2023: 2 · 2022: 3
- FWCI
- 0.95
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- Locations
- Acta Medica (Hradec Kralove Czech Republic) (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Greater South Information System
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Potassium and Related Disorders
- Health Sciences › Medicine › Pathology and Forensic Medicine › Ophthalmology and Eye Disorders
- Keywords
- thyrotoxic hypokalemic periodic paralysis, dexamethasone, Graves' disease, thyrotoxicosis, hypokalemia, TSH receptor antibodies, potassium supplementation, beta-blockers, subtotal thyroidectomy, Asian men
- MeSH terms
- Adult, Anti-Inflammatory Agents, Dexamethasone, Graves Disease, Humans, Hypokalemia, Male, Paralysis, Muscle Weakness, Lower Extremity
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