1/ Res report with our fellow Dr. Michelle Rengarajan this week featured a cool case with a lot of ✨pearls✨
28 year old man presents with acute quadriplegia.
What's on your ddx?
2/ BMP drawn and showed K of 1.3!
Your intern year prepared you for this aggressive K repletion moment.
His K improved quickly and weakness resolved! Pt's TSH of <0.01 makes the diagnosis of
*drum roll*
✴thyrotoxic period paralysis (TPP)!✴
3/ We are not done! What's causing the hyperthyroidism?
Review the axis to find 4 mechanisms:
1️⃣Autonomous hormone production by the thyroid (Graves vs. Toxic Nodule)
2️⃣Exogenous
3️⃣Release of preformed hormone
4️⃣Hypothalamic/pituitary stimulation of production
4/ We will focus on the top 3 since they cause a low TSH like our Pt. How do we find the etiology?
The T3/T4 ratio can be a helpful initial clue!
Which one of the following conditions often has a T3/T4 ratio greater than 20?
🤔🤔🤔🤔🤔🤔
5/ ANS: Graves!
The ratio is one hint, other key diagnostics include:
☢radioactive iodine scan
🧪TSI & TBII
Check out this great table for a refresher on how to distinguish the different causes of ⬆️ thyroid levels.
6/ TSI comes back ➕
You diagnose this Pt with Graves Dz!
Treatment options?
💊 methimazole (or PTU)
☢ radioactive iodine ablation***
🔪 thyroidectomy
*** ☢ suboptimal here. There is a risk of worsening hyperthyroidism in 1st 6mo ➡️ precipitate periodic paralysis
7/ take home messages:
🏠 hypokalemia periodic paralysis can be a presentation of hyperthyroidism!
🏠 4 key mechanisms for thyrotoxicosis
🏠 T3/T4 >20 , +ve TSI and diffuse uptake on RAIU are hallmarks of Graves dz
🏠 3 Tx options for Graves> Meds, RAI, surgery!
8/ Learn more by reviewing a CPC on a similar case!
nejm.org/doi/full/10.10…
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