A Rare Case of Thyrotoxic Periodic Paralysis in a Patient With Concomitant Methimazole-Induced Agranulocytosis
Background/Objective: Thyrotoxic periodic paralysis (TPP) is a rare condition causing weakness of the lower extremities associated with significant hypokalemia. Likewise, agranulocytosis due to methimazole use is a rare occurrence. We present the first documented case of concomitant TPP and agranulo...
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Elsevier
2025-01-01
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| author | Kevin S. Wei, MD Alexandra N. Lim, MD Sophie M. Cannon, MD |
| author_facet | Kevin S. Wei, MD Alexandra N. Lim, MD Sophie M. Cannon, MD |
| author_sort | Kevin S. Wei, MD |
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| description | Background/Objective: Thyrotoxic periodic paralysis (TPP) is a rare condition causing weakness of the lower extremities associated with significant hypokalemia. Likewise, agranulocytosis due to methimazole use is a rare occurrence. We present the first documented case of concomitant TPP and agranulocytosis from methimazole use. Case Report: A 48-year-old woman presented with sore throat, fevers, odynophagia, and sudden-onset bilateral leg weakness. Methimazole had been started 10 weeks prior for a new diagnosis of Graves’ disease. On admission, the patient was febrile, tachycardic, thyrotoxic, and neutropenic. She also experienced near-paralysis of the lower extremities. She was diagnosed with TPP and treated with beta blockade. She was admitted to the intensive care unit and started on broad-spectrum antibiotics, lithium, and propranolol for treatment of septic shock and hyperthyroidism, respectively. Given persistent hypokalemia despite 2 days of therapy, she was also diagnosed with refeeding syndrome. Discussion: TPP is a rare entity, though it should be considered on the differential for any thyrotoxic patient presenting with sudden weakness. If the associated hypokalemia does not begin to normalize within 48 h of beta blockade, other etiologies should be investigated. Lastly, alternative treatments such as lithium may be used to control hyperthyroidism in patients with methimazole-induced agranulocytosis. Conclusion: While methimazole-induced agranulocytosis and thyrotoxic periodic paralysis are independently rare diagnoses, the combination of the 2 is exceedingly rare, and our case represents the first documented case in the literature reflecting a patient suffering from both syndromes. |
| format | Article |
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| institution | Kabale University |
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| language | English |
| publishDate | 2025-01-01 |
| publisher | Elsevier |
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| series | AACE Clinical Case Reports |
| spelling | doaj-art-3f9386453cf949e79cee438b784e43472025-01-15T04:11:46ZengElsevierAACE Clinical Case Reports2376-06052025-01-011116669A Rare Case of Thyrotoxic Periodic Paralysis in a Patient With Concomitant Methimazole-Induced AgranulocytosisKevin S. Wei, MD0Alexandra N. Lim, MD1Sophie M. Cannon, MD2Department of Internal Medicine, Keck School of Medicine at USC, Los Angeles, California; Address correspondence to Dr Kevin S. Wei, Department of Internal Medicine, Keck School of Medicine at USC, 2020 Zonal Ave, Los Angeles, CA 90033.Department of Internal Medicine, Keck School of Medicine at USC, Los Angeles, CaliforniaDivision of Endocrinology, Diabetes and Metabolism, UCLA Health, Los Angeles, CaliforniaBackground/Objective: Thyrotoxic periodic paralysis (TPP) is a rare condition causing weakness of the lower extremities associated with significant hypokalemia. Likewise, agranulocytosis due to methimazole use is a rare occurrence. We present the first documented case of concomitant TPP and agranulocytosis from methimazole use. Case Report: A 48-year-old woman presented with sore throat, fevers, odynophagia, and sudden-onset bilateral leg weakness. Methimazole had been started 10 weeks prior for a new diagnosis of Graves’ disease. On admission, the patient was febrile, tachycardic, thyrotoxic, and neutropenic. She also experienced near-paralysis of the lower extremities. She was diagnosed with TPP and treated with beta blockade. She was admitted to the intensive care unit and started on broad-spectrum antibiotics, lithium, and propranolol for treatment of septic shock and hyperthyroidism, respectively. Given persistent hypokalemia despite 2 days of therapy, she was also diagnosed with refeeding syndrome. Discussion: TPP is a rare entity, though it should be considered on the differential for any thyrotoxic patient presenting with sudden weakness. If the associated hypokalemia does not begin to normalize within 48 h of beta blockade, other etiologies should be investigated. Lastly, alternative treatments such as lithium may be used to control hyperthyroidism in patients with methimazole-induced agranulocytosis. Conclusion: While methimazole-induced agranulocytosis and thyrotoxic periodic paralysis are independently rare diagnoses, the combination of the 2 is exceedingly rare, and our case represents the first documented case in the literature reflecting a patient suffering from both syndromes.http://www.sciencedirect.com/science/article/pii/S2376060524001184thyrotoxic periodic paralysismethimazoleagranulocytosisthyrotoxicosis |
| spellingShingle | Kevin S. Wei, MD Alexandra N. Lim, MD Sophie M. Cannon, MD A Rare Case of Thyrotoxic Periodic Paralysis in a Patient With Concomitant Methimazole-Induced Agranulocytosis AACE Clinical Case Reports thyrotoxic periodic paralysis methimazole agranulocytosis thyrotoxicosis |
| title | A Rare Case of Thyrotoxic Periodic Paralysis in a Patient With Concomitant Methimazole-Induced Agranulocytosis |
| title_full | A Rare Case of Thyrotoxic Periodic Paralysis in a Patient With Concomitant Methimazole-Induced Agranulocytosis |
| title_fullStr | A Rare Case of Thyrotoxic Periodic Paralysis in a Patient With Concomitant Methimazole-Induced Agranulocytosis |
| title_full_unstemmed | A Rare Case of Thyrotoxic Periodic Paralysis in a Patient With Concomitant Methimazole-Induced Agranulocytosis |
| title_short | A Rare Case of Thyrotoxic Periodic Paralysis in a Patient With Concomitant Methimazole-Induced Agranulocytosis |
| title_sort | rare case of thyrotoxic periodic paralysis in a patient with concomitant methimazole induced agranulocytosis |
| topic | thyrotoxic periodic paralysis methimazole agranulocytosis thyrotoxicosis |
| url | http://www.sciencedirect.com/science/article/pii/S2376060524001184 |
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