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Cited by 3Thyroid Disorders and TreatmentsPotassium and Related DisordersThyroid and Parathyroid Surgery

Thyrotoxic Periodic Paralysis With Hypokalemia: A Case Study

Open access
Mebane, Nova B, Khan, Aisha, Bevinal, Manzoor, Davis, Erin·2023·Cureus
DOI 10.7759/cureus.40757PMC PMC10361783
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Abstract

Thyrotoxic periodic paralysis (TPP) is a rare life-threatening condition most commonly seen in individuals between the ages of 20-40 years. It is most prevalent in Hispanic and Asian populations. Here we present a case report of a young male patient admitted to our facility with an acute onset of paralysis. He was found to have new-onset hyperthyroidism and severe hypokalemia. TPP was exacerbated by the intake of a high-carbohydrate meal as well as a steroid injection within 24 hours of symptom onset.

AI snapshot

Written from the paper’s full text.

TL;DR

This case report describes a 25-year-old Hispanic/Caucasian man with thyrotoxic periodic paralysis presenting as acute paralysis, severe hypokalemia (1.9 mmol/L), and new hyperthyroidism after a high-carbohydrate meal and recent intra-articular corticosteroid injection. He improved with potassium repletion and was discharged on methimazole and propranolol, with symptoms controlled at 3-week follow-up after propranolol dose reduction.

Key findings

  • The patient had severe hypokalemia at 1.9 mmol/L (rr 3.6–5.2), TSH <0.01 (rr 0.42–5.47), elevated free T4 at 3.73 ng/dL (rr 0.59–1.17), and elevated TSH binding inhibitory immunoglobulin at 8.60 IU/L (rr 0.00–1.75).
  • TPP was attributed to undiagnosed hyperthyroidism plus known precipitants: a high-carbohydrate meal within five hours before symptom onset and an intraarticular corticosteroid injection less than 24 hours before onset.
  • The authors note TPP incidence is 2% in Asian populations and 0.1%–0.2% in North Americans, with a male-to-female difference of about 26:1 despite higher thyrotoxicosis incidence in females.
  • At 3-week follow-up, the patient denied anxiety, tremors, muscle weakness, unprovoked sweating, and heart palpitations, but reported lightheadedness after evening propranolol; propranolol was decreased to 10 mg daily.

Methods

  • Design: single case report with review of the literature.
  • Data: a 25-year-old male of Hispanic and Caucasian descent with no significant past medical history, presenting with acute onset paralysis; hospital labs, EKG, chest X-ray, CT head, thyroid ultrasound, telemedicine neurology recommendations, and 3-week follow-up are described.
  • Main analysis: descriptive case synthesis comparing TPP with familial hypokalemic periodic paralysis and discussing proposed mechanisms and precipitating factors.

Limitations

  • Stated in the paper: the authors could not obtain a thyroid-stimulating immunoglobulin assay, so they could not determine whether the patient had Graves’ disease associated with TPP.
  • Stated in the paper: genetic analysis would have provided significant information about a possible hereditary predisposition involving CACNA1S, SCN4A, and KCNJ18.
  • Stated in the paper: there are few published cases of glucocorticoid administration prior to TPP, so whether glucocorticoids may precipitate TPP requires further investigation; evident from the text: this is a single case with no control or comparison group, and follow-up was limited to three weeks.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.7759/cureus.40757

Cites

16 of 16 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 26 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    During hospital admission, the patient had an elevated TSH binding inhibitory immunoglobulin level of 8.60 IU/L.

    “Pertinent lab values during his hospital admission include elevated free thyroxine (T4) level at 3.73 ng/dL (rr 0.59-1.17), elevated TSH binding inhibitory immunoglobulin 8.60 IU/L (rr 0.00-1.75), glycated hemoglobin 5.6 (rr 4.5-6.2), urine glucose 1,000 mg/dL, urine ketones 5 mg/dL, and urine blood 2+.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Initial labs showed severe hypokalemia of 1.9 mmol/L.

    “Initial labs were remarkable for severe hypokalemia of 1.9 mmol/L (rr 3.6-5.2) and TSH less than 0.01 (rr 0.42-5.47).”
    Quote in the paperSubstantial claim
  • Findingown data

    Initial labs showed TSH less than 0.01.

    “Initial labs were remarkable for severe hypokalemia of 1.9 mmol/L (rr 3.6-5.2) and TSH less than 0.01 (rr 0.42-5.47).”
    Quote in the paperSubstantial claim
  • Findingown data

    Thyroid ultrasound showed heterogeneous vascular thyroid with no discrete mass or lesion.

    “A thyroid ultrasound showed heterogeneous vascular thyroid with no discrete mass or lesion (Figures 1a, 1b).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Physical exam was remarkable for paralysis of the patient's extremities.

    “Physical exam was remarkable for paralysis of his extremities.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 20
  • May combine two claims. 15

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingreasoning

    The patient was discharged once sufficient evaluation was finished and he was back to baseline in motor and sensory function.

    “However, due to the patient not having local residence, he was discharged once sufficient evaluation was finished and he was back to baseline in motor and sensory function.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The patient was a 25-year-old male of Hispanic and Caucasian descent with no significant past medical history who presented with acute onset of paralysis starting in bilateral lower extremities.

    “A 25-year-old male of Hispanic and Caucasian descent with no significant past medical history presented to our emergency department from an outlying facility for acute onset of paralysis starting in bilateral lower extremities.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The patient had specific features associated with TPP: being an adult male, laboratory values indicative of hyperthyroidism, having no immediate family history of paralysis, and being symptomatic for no more than six hours.

    “Our patient described in this study had specific features associated with TPP which included being an adult male, laboratory values indicative of hyperthyroidism, having no immediate family history of paralysis, and being symptomatic for no more than six hours.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    At three-week follow-up, the patient reported lightheadedness shortly after taking his second dose of propranolol in the evenings.

    “However, he did report lightheadedness shortly after taking his second dose of propranolol in the evenings.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    CT head without contrast showed no evidence of acute intracranial abnormality or hemorrhage.

    “Imaging reported junctional rhythm with 48 ventricular rates on EKG, no radiographic evidence of acute cardiopulmonary process on Chest X-ray one-view, and no evidence of acute intracranial abnormality or hemorrhage on computed tomography (CT) head without contrast.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    At the outlying facility, the patient's vital signs were normal.

    “At the outlying facility, vital signs were normal.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The patient received a recent intraarticular corticosteroid injection to the right knee less than 24 hours prior to the onset of his symptoms.

    “He reported receiving a recent intraarticular corticosteroid injection to the right knee less than 24 hours prior to the onset of his symptoms.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    During hospital admission, the patient had glycated hemoglobin 5.6, urine glucose 1,000 mg/dL, urine ketones 5 mg/dL, and urine blood 2+.

    “Pertinent lab values during his hospital admission include elevated free thyroxine (T4) level at 3.73 ng/dL (rr 0.59-1.17), elevated TSH binding inhibitory immunoglobulin 8.60 IU/L (rr 0.00-1.75), glycated hemoglobin 5.6 (rr 4.5-6.2), urine glucose 1,000 mg/dL, urine ketones 5 mg/dL, and urine blood 2+.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Imaging reported junctional rhythm with 48 ventricular rates on EKG.

    “Imaging reported junctional rhythm with 48 ventricular rates on EKG, no radiographic evidence of acute cardiopulmonary process on Chest X-ray one-view, and no evidence of acute intracranial abnormality or hemorrhage on computed tomography (CT) head without contrast.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    At the time of evaluation, the patient was asymptomatic due to intravenous correction of hypokalemia at the outlying facility.

    “At the time of our evaluation, the patient was asymptomatic due to intravenous correction of hypokalemia at the outlying facility.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Chest X-ray showed no radiographic evidence of acute cardiopulmonary process.

    “Imaging reported junctional rhythm with 48 ventricular rates on EKG, no radiographic evidence of acute cardiopulmonary process on Chest X-ray one-view, and no evidence of acute intracranial abnormality or hemorrhage on computed tomography (CT) head without contrast.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The patient's sensation was intact.

    “The sensation was intact.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The patient consumed a high carbohydrate meal within five hours prior to symptom onset.

    “He consumed a high carbohydrate meal within five hours prior to symptom onset.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Etiologies associated with TPP include Graves' disease, toxic multinodular goiter, toxic thyroid adenoma, TSH-secreting pituitary adenomas, painless thyroiditis, and levothyroxine use.

    “Etiologies associated with TPP include Graves' disease, toxic multinodular goiter, toxic thyroid adenoma, thyroid-stimulating hormone (TSH) secreting pituitary adenomas, painless thyroiditis, and in patients taking levothyroxine [4].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet. 2016, 388:906-18. 10.1016/S0140-6736(16)00278-6 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Thyrotoxic periodic paralysis (TPP) is a rare complication of thyrotoxicosis seen in young adults.

    “Thyrotoxic periodic paralysis (TPP) is a rare complication of thyrotoxicosis seen in young adults and is most prevalent in Asian and Hispanic populations [1].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Meseeha M, Parsamehr B, Kissell K, Attia M. Thyrotoxic periodic paralysis: a case study and review of the literature. J Community Hosp Intern Med Perspect. 2017, 7:103-6. 10.1080/20009666.2017.1316906 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Familial hypokalemic periodic paralysis (HKPP) is a rare autosomal dominant channelopathy with a defect in calcium channels resulting in muscle paralysis, but there is no hyperthyroidism in these individuals.

    “This is a rare autosomal dominant channelopathy with a defect in calcium channels resulting in muscle paralysis, but there is no hyperthyroidism in these individuals [5].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5] Abbas H, Kothari N, Bogra J. Hypokalemic periodic paralysis. Natl J Maxillofac Surg. 2012, 3:220-1. 10.4103/0975-5950.111391 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Thyroid-stimulating immunoglobulin (TSI) assay is 96% sensitive and 99% specific for Graves' disease.

    “Unfortunately, we were unable to obtain a thyroid-stimulating immunoglobulin (TSI) assay, which is 96% sensitive and 99% specific for Graves’ disease [7].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Patel M, Ladak K. Thyrotoxic periodic paralysis: a case report and literature review. Clin Med Res. 2021, 19:148-51. 10.3121/cmr.2021.1610 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    TPP is most prevalent in Asian and Hispanic populations.

    “Thyrotoxic periodic paralysis (TPP) is a rare complication of thyrotoxicosis seen in young adults and is most prevalent in Asian and Hispanic populations [1].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Meseeha M, Parsamehr B, Kissell K, Attia M. Thyrotoxic periodic paralysis: a case study and review of the literature. J Community Hosp Intern Med Perspect. 2017, 7:103-6. 10.1080/20009666.2017.1316906 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    TPP is more common in males than in females, about a 26:1 difference, despite the higher incidence of thyrotoxicosis in females.

    “Interestingly, it is more common in males than in females; about a 26:1 difference despite the higher incidence of thyrotoxicosis in females [1].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Meseeha M, Parsamehr B, Kissell K, Attia M. Thyrotoxic periodic paralysis: a case study and review of the literature. J Community Hosp Intern Med Perspect. 2017, 7:103-6. 10.1080/20009666.2017.1316906 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    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].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [13] Ahamed R, McCalley S, Sule AA. Steroids and thyrotoxicosis precipitate periodic paralysis. Cureus. 2018, 10:e2106. 10.7759/cureus.2106 source

      Not checked in the free run.

    • cites [14] Polamaung W, Kongkit J, Yimnoi P, Boonchaya-Anant P, Snabboon T. Thyrotoxic hypokalemic periodic paralysis triggered by dexamethasone administration. Acta Medica (Hradec Kralove). 2020, 63:91-3. 10.14712/18059694.2020.24 source

      Not checked in the free run.

    • cites [15] Mizokami T, Fukui T, Imoto H, Fujii H, Sato Y, Nunoi K, Okamura K. Onset of reversible flaccid quadriplegia during treatment of thyrotoxic crisis. Intern Med. 2015, 54:421-5. 10.2169/internalmedicine.54.2954 source

      Not checked in the free run.

    • cites [16] Affram KO, Reddy TL, Osei KM. A rare case of thyrotoxic periodic paralysis after epidural steroid injection: a case report and literature review. Am J Case Rep. 2018, 19:1453-8. 10.12659/AJCR.911270 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Familial HKPP tends to have an onset of paralysis less than age 16, greater than 24 hours of paralysis, a familial history of paralysis, and may present with hypomagnesemia and/or hypophosphatemia.

    “The latter tends to have an onset of paralysis less than age 16, have greater than 24 hours of paralysis, have a familial history of paralysis, and may present with hypomagnesemia and/or hypophosphatemia [6].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] Venance SL, Cannon SC, Fialho D, et al.. The primary periodic paralyses: diagnosis, pathogenesis and treatment. Brain. 2006, 129:8-17. 10.1093/brain/awh639 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Testosterone can increase the activity of the sodium/potassium (Na+/K+) pump resulting in hypokalemia.

    “It is theorized that testosterone can increase the activity of the sodium/potassium (Na+/K+) pump resulting in hypokalemia [2].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2] Patel H, Wilches LV, Guerrero J. Thyrotoxic periodic paralysis: diversity in America. J Emerg Med. 2014, 46:760-2. 10.1016/j.jemermed.2013.08.104 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The incidence of TPP is 2% in Asian populations and 0.1%-0.2% in North Americans.

    “The incidence is 2% in Asian populations and 0.1%-0.2% in North Americans.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Meseeha M, Parsamehr B, Kissell K, Attia M. Thyrotoxic periodic paralysis: a case study and review of the literature. J Community Hosp Intern Med Perspect. 2017, 7:103-6. 10.1080/20009666.2017.1316906 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Thyroid hormone increases sensitivity to catecholamines and sensitizes beta-2 adrenergic receptors, resulting in stimulation of Na+/K+ ATPase channels in the liver and skeletal muscle allowing potassium to move into cells.

    “Thyroid hormone increases sensitivity to catecholamines and sensitizes beta-2 adrenergic receptors. This results in the stimulation of Na+/K+ ATPase channels in the liver and skeletal muscle allowing for potassium to move into cells [9].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Ginsberg AM, Clutter WE, Shah SD, Cryer PE. Triiodothyronine-induced thyrotoxicosis increases mononuclear leukocyte beta-adrenergic receptor density in man. J Clin Invest. 1981, 67:1785-91. 10.1172/jci110218 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    TSH receptor binding inhibitory immunoglobulin assay (TBIAb) has an incidence of 70.9% in untreated Graves' disease, 53.1% in currently treated Graves' disease, and 19.2% in remission from Graves' disease.

    “However, we were able to obtain a TSH receptor binding inhibitory immunoglobulin assay (TBIAb) which has an incidence of 70.9% (untreated Graves’ disease), 53.1% (currently being treated for Graves’ disease), and 19.2% (in remission from Graves’ disease) [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Cho WY, Choi HH, Chun HJ, Ahn IM. Thyrotropin binding inhibiting antibody (TBIAb) in Graves' disease. Korean J Intern Med. 1988, 3:45-51. 10.3904/kjim.1988.3.1.45 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Up to 43.3% of patients with hypokalemic paralysis have a secondary cause, with the most common cause being a complication of thyrotoxicosis.

    “Up to 43.3% of patients with hypokalemic paralysis have a secondary cause with the most common cause being a complication of thyrotoxicosis [3].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] Maurya PK, Kalita J, Misra UK. Spectrum of hypokalaemic periodic paralysis in a tertiary care centre in India. Postgrad Med J. 2010, 86:692-5. 10.1136/pgmj.2010.104026 source

      Not checked in the free run.

26 of 26

  • The paper relies on this without support.

    Clinical features such as age greater than 16 years, duration less than 24 hours, and absence of family history are sufficient to distinguish TPP from familial HKPP without genetic testing.

    “We diagnosed this patient with TPP as opposed to familial HKPP.”

  • The paper relies on this without support.

    Hyperthyroidism can easily go undiagnosed in seemingly healthy young adults with irregular primary care follow up.

    “Many seemingly healthy young adults can have irregular primary care follow up and hyperthyroidism can easily go undiagnosed.”
2 of 2

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?

  • Corticosteroids stimulate hepatic gluconeogenesis and may upregulate insulin secretion, thereby further promoting intracellular potassium uptake.

    “Sahebi et al. [38] and Mebane et al. [42] reported that corticosteroids stimulate hepatic gluconeogenesis and may upregulate insulin secretion, thereby further promoting intracellular potassium uptake.”

    From Thyrotoxic Hypokalemic Periodic Paralysis: Pathophysiological Mechanisms (2025) · cites this paper as [42]

    The Discussion says corticosteroids raise extracellular glucose and stimulate insulin secretion, but its description of that pathway says potassium shifts from the intracellular to the extracellular space—the opposite of the claimed uptake. An earlier Discussion sentence says insulin shifts potassium into cells, so the paper is internally inconsistent on this point. It also does not specify hepatic gluconeogenesis. (LLM, conf=0.84)

    Checked by a reasoning model — may be wrong.

    Experimental — accuracy not yet measured

  • This pattern contrasts with FHPP, in which hypomagnesemia and hypophosphatemia are more commonly observed.

    “This pattern contrasts with FHPP, in which hypomagnesemia and hypophosphatemia are more commonly observed [42].”

    From Thyrotoxic Hypokalemic Periodic Paralysis: Pathophysiological Mechanisms (2025) · cites this paper as [42]

    The Discussion (page not available in our copy) says familial hypokalemic periodic paralysis may present with hypomagnesemia and/or hypophosphatemia, distinguishing it from the reported thyrotoxic case. It does not say these findings are more commonly observed in the familial condition or provide a frequency comparison. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • In individuals with uncontrolled hyperthyroidism, THPP can be triggered or exacerbated by any factor that promotes hypokalemia.

    “In individuals with uncontrolled hyperthyroidism, THPP can be triggered or exacerbated by any factor that promotes hypokalemia [42].”

    From Thyrotoxic Hypokalemic Periodic Paralysis: Pathophysiological Mechanisms (2025) · cites this paper as [42]

  • Corticosteroids enhance Na+/K+-ATPase activity both directly and indirectly by altering glucose metabolism.

    “Corticosteroids enhance Na+/K+-ATPase activity both directly and indirectly by altering glucose metabolism.”

    From Thyrotoxic Hypokalemic Periodic Paralysis: Pathophysiological Mechanisms (2025) · cites this paper as [42]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Potassium shift is described in opposite directions

    Minor

    The discussion first says insulin shifts potassium into cells, potentiating hypokalemia. It later says insulin secretion shifts potassium from inside cells to outside cells.

1 of 1

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Authors
Mebane, N. B., Khan, A., Bevinal, M., & Davis, E.
Corresponding author
Mebane, Nova B
ORCID
Venue
Cureus
Publisher
Springer Science and Business Media LLC
Published
2023-06-21
Volume
15
Issue
6
Pages
e40757-e40757
ISSN
2168-8184 (ISSN-L)
DOI
10.7759/cureus.40757
PMC
PMC10361783
OpenAlex
W4381548128
Semantic Scholar
a420942ce2c826478fb16ac1205ee14c774f574d
Cited by
3
References
16
Citations by year
2025: 1 · 2024: 2
FWCI
0.61
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Cureus (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Funders
HCA Healthcare
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 › Surgery › Thyroid and Parathyroid Surgery
Keywords
thyrotoxic periodic paralysis, hypokalemia, hyperthyroidism, high-carbohydrate meal, young male patient

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