Code pseudo stroke – a case of hypokalaemic periodic paralysis mimicking stroke

Abstract

We present a case of thyrotoxic periodic paralysis (TPP) presenting with stroke symptoms as a harbinger of Grave’s disease. A 61-year-old female presented with symptoms of abdominal pain and fatigue two weeks prior to admission and reported acute diarrhoea and unintentional weight loss. Investigation revealed thyrotoxicosis with undetectable thyroid stimulating hormone (TSH), elevated free T4 and elevated thyroid stimulating immunoglobulin (TSI). On the third day of admission, while undergoing physical therapy, code stroke was called on account of the onset of right-side predominant acute flaccid paralysis of upper and lower extremities, right-side facial droop, dysarthria and hyporeflexia bilaterally. The patient was alert and fully oriented with stable vitals with no increased labour in breathing at room air. An emergent head and neck CT, angiography, and magnetic resonance imaging (MRI) were negative. Serum potassium was 2.7 mmol/l, requiring prompt replacement. The patient’s paralysis and dysarthria improved over the following three days with a complete reversal of symptoms following the correction of serum potassium. Thyrotoxic periodic paralysis can occur in association with any of the causes of hyperthyroidism. It is due to a significant intracellular shift of potassium, subsequently manifesting clinically with hypokalaemia and muscle paralysis.

Keywords

• hypokalemic periodic paralysis
• thyrotoxic periodic paralysis
• thyrotoxicosis
• pseudostroke
• stroke mimics