Patient-Centered Focused Review|Articles in Press

Recurrent hypokalemic paralysis in hypothyroidism

Published:February 06, 2023DOI:


      Hypothyroidism, a commonly encountered thyroid disorder, usually manifests with readily recognizable typical features. However, an unusual presentation of a classic thyroid disorder may hinder accurate diagnosis in certain instances. One such rare initial presentation of hypothyroidism is recurrent hypokalemic paralysis, and existing reports in the literature are sparse. It has been more commonly reported in thyrotoxicosis. We report the case details and clinical outcomes of two middle-aged individuals (a 34-year-old male and a 37-year-old female) with recurrent episodes of hypokalemic paralysis. Their clinical examination revealed pure motor hyporeflexia quadriparesis with hypotonia and diminished deep tendon reflexes without any autonomic dysfunction. They had no significant previous medical history. Biochemical findings revealed hypokalemia in both cases (1.4 and 1.9 mEq/L, respectively) with elevated levels of thyroid‑stimulating hormone and thyroid‑related antibodies in both individuals, thus, confirming the diagnosis of autoimmune hypothyroidism. Immediate treatment with intravenous and oral potassium correction helped in the recovery. Thyroxine supplementation was considered a follow-up treatment, and for a one-year follow-up period there were no complaints of limb weakness reported in both individual.

      Key Indexing Terms

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of the Medical Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ahlawat SK
        • Sachdev A.
        Hypokalaemic paralysis.
        Postgrad Med J. 1999; 75: 193-197
        • Bandhakavi M.
        Periodic paralysis as an unusual presentation of autoimmune hypothyroidism with goiter.
        Clin Pediatr (Phila). 2009; 48: 677-678
        • Singh TK
        • Sangme N
        • Singh LN
        • et al.
        Hypokalemic periodic paralysis associated with hypothyroidism.
        Indian J Phy Med Rehab. 2012; 23: 79-81
        • Kayal AK
        • Goswami M
        • Das M
        • et al.
        Clinical and biochemical spectrum of hypokalemic paralysis in North: East India.
        Ann Indian Acad Neurol. 2013; 16: 211-217
        • Sinha U
        • Sengupta N
        • Sinharay K
        • et al.
        Recurrent hypokalemic paralysis: An atypical presentation of hypothyroidism.
        Indian J Endocrinol Metab. 2013; 17: 174-176
        • Chauhan P
        • Naxane A.
        Hypothyroidism with recurrent hypokalemic paralysis.
        Int J Sci Re. 2017; 6: 2131-2132
        • Mohapatra BN
        • Lenka SK
        • Acharya M
        • et al.
        Clinical and aetiological spectrum of hypokalemic flaccid paralysis in Western Odisha.
        J Assoc Physicians India. 2016; 64: 52-58
        • Sharma CM
        • Kumawat BL
        • Garg AK
        • et al.
        Etiological and biochemical profile of hypokalemic paralysis in North‑West India.
        Int J Sci Res. 2017; 6: 203‑206
        • Saluja M
        • Swami Y
        • Chittora S
        • et al.
        Hypokalaemic periodic paralysis: rare presentation of hypothyroidism.
        JIACM. 2017; 18: 306-307
        • Aggarwal A
        • Wadhwa R
        • Pande A
        • et al.
        Hypokalemic periodic paralysis and spectrum of thyroid disorders: analysis of 7 cases from Northern India.
        Indian J Endocrinol Metab. 2019; 23: 168-170
        • Rahmawati PL
        • Arimbawa IK
        • Laksmidewi AAAP.
        Profile of patients with hypokalemic periodic paralysis.
        Int J Med Rev Case Rep. 2021; 5: 26-32
        • Nayak R.
        Practical approach to the patient with acute neuromuscular weakness.
        World J Clin Cases. 2017; 5: 270-279
        • Maramattom BV
        • Wijdicks EF.
        Acute neuromuscular weakness in the intensive care unit.
        Crit Care Med. 2006; 34: 2835-2841
        • Dinkar A
        • Singh J.
        Dengue infection in North India: An experience of a tertiary care center from 2012 to 2017.
        Tzu Chi Med J. 2019; 32: 36-40
        • Singh J
        • Singh A
        • Dinkar A
        • et al.
        A rare presentation of dengue fever: acute motor quadriparesis due to hypokalemia.
        Int J Res Med Sci. 2014; 2: 1732-1734
        • Singh J
        • Kumar N
        • Dinkar A.
        Demographic, clinical, investigational characteristics of COVID-19 related Guillain-Barré syndrome with differences from typical and another virus-related Guillain-Barré syndrome.
        Infect Disord Drug Targets. 2022;
        • Compston A.
        Aids to the investigation of peripheral nerve injuries. Medical Research Council: Nerve Injuries Research Committee. His Majesty's Stationery Office: 1942; pp. 48 (iii) and 74 figures and 7 diagrams; with aids to the examination of the peripheral nervous system. By Michael O'Brien for the Guarantors of Brain. Saunders Elsevier: 2010; pp. [8]64 and 94 Figures.
        Brain. 2010; 133: 2838-2844
        • Kumar P
        • Mukherji A
        • Roy A.
        Prevalence of hypothyroidism in the population of West Bokaro coal mine area, Jharkhand: a Hospital-Based Observational Study.
        Cureus. 2022 Sep 3; 14: e28733
        • Gutch M
        • Kumar S
        • Bhattacharjee A
        • et al.
        Unusual manifestations associated with primary hypothyroidism: experience from A Tertiary Care Health Center.
        J ASEAN Fed Endocr Soc. 2017; 32: 60-67
        • Singh J
        • Dinkar A
        • Kumar N
        • et al.
        Recurrent nausea and vomiting with weight loss associated with hypothyroidism: Fact or Myth.
        Endocr Metab Immune Disord Drug Targets. 2022;
        • Kanemaru Y
        • Aizawa K
        • Kagami T
        • et al.
        A case of hypokalemic myopathy associated with transient hypothyroidism.
        Endocrinol Jpn. 1984; 31: 809-814
        • Kinoshita I
        • Usa T
        • Satoh A
        • et al.
        A case of hypothyroidism associated with hypokalemic periodic paralysis.
        Rinsho Shinkeigaku. 1990; 30: 100-102
        • Chaudhary SP
        • Gupta K
        • Guta RK
        • et al.
        Hypokalemic paralysis during management of hypothyroidism.
        Indian Pediatr. 2000; 37: 1261-1263
        • Baaj M
        • Safi S
        • Hassikou H
        • et al.
        Hypokalemic paralysis revealing Sjögren's syndrome associated with autoimmune thyroiditis.
        Nephrol Ther. 2010; 6: 52-56
        • Maurya PK
        • Kalita J
        • Misra UK.
        Spectrum of hypokalaemic periodic paralysis in a tertiary care centre in India.
        Postgrad Med J. 2010; 86: 692-695
        • Basak RC
        • Sharkawi KM
        • Rahman MM
        • et al.
        Distal renal tubular acidosis, hypokalemic paralysis, nephrocalcinosis, primary hypothyroidism, growth retardation, osteomalacia and osteoporosis leading to pathological fracture: a case report.
        Oman Med J. 2011; 26: 271-274
        • Koul PA
        • Wahid A.
        Distal renal tubular acidosis, and hypokalemic paralysis in a patient with hypothyroidism.
        Saudi J Kidney Dis Transpl. 2011; 22: 1014-1016
        • Arambewela MH
        • Sumanathilaka MR
        • Pathirana KD
        • et al.
        A possible association of hypokalaemic periodic paralysis, autoimmune thyroiditis and neuromyotonia.
        Ceylon Med J. 2013; 58: 175-176
        • Naveen L
        • Malkarnekar S.
        Adult-onset distal renal tubular acidosis with hypokalemic quadriparesis in a patient with autoimmune hypothyroidism.
        J Integr Nephrol Androl. 2014; 1: 82-84
        • Agarwal A
        • Kumar P
        • Gupta N.
        Pediatric Sjogren syndrome with distal renal tubular acidosis and autoimmune hypothyroidism: an uncommon association.
        CEN Case Rep. 2015; 4: 200-205
        • Hongmei Z
        • Weiwei Z
        • Li Xiaoyong
        • et al.
        Approach of the patient with hypokalemia caused Hashimoto's thyroiditis with primary Sjogren's syndrome by and renal tubular acidosis.
        Chin J Endocrinol Metab. 2016; 32: 349-352
        • Kadeeja N
        • Senthilnathan N
        • Viswanathan S
        • et al.
        Sporadic hypothyroidism-related hypokalemic paralysis: diagnosis in a resource-poor setting.
        J Family Med Prim Care. 2017; 6: 862-864
        • Velarde-Mejía Y
        • Gamboa-Cárdenas R
        • Ugarte-Gil M
        • et al.
        Hypokalemic paralysis: a hidden card of several autoimmune diseases.
        Clin Med Insights Arthritis Musculoskelet Disord. 2017; 10: 1-4
        • Guerra-Hernández NE
        • Ordaz-López KV
        • Vargas-Poussou R
        • et al.
        Distal renal tubular acidosis in two children with acquired hypothyroidism.
        Nefrologia (Engl Ed). 2018; 38: 655-659
        • Meregildo-Rodríguez ED
        • Case Failoc-Rojas VE.
        Report: Recurrent hypokalemic periodic paralysis associated with distal renal tubular acidosis (type 1) and hypothyroidism secondary to Hashimoto's thyroiditis.
        F1000Res. 2018; 7: 1154
        • Lin N
        • Wang J
        • Liao W
        • et al.
        Hypothyroid myopathy with periodic paralysis as the main symptom: a case report and literature review.
        Ann Palliat Med. 2020; 9: 3698-3704
      1. Goretti L, Edijanto SP. Hypokalemic periodic paralysis and renal tubular acidosis in patient with hypothyroidism. Indian J Foren Med Toxicol. 202;15(3):3431-35.

        • Permatasari CA
        • Zahraini H
        • Marpaung FR
        Aryati. Hypokalemic periodic paralysis and renal tubular acidosis in a patient with hypothyroid and autoimmune disease.
        Ann Med Surg (Lond). 2022 Feb 22; 75103389
        • Achakzai H
        • Khan S
        • Amin QK
        • Ahmed N
        • Anwar S.
        Hypokalemic periodic paralysis: an atypical presentation of non-autoimmune hypothyroidism with distal renal tubular acidosis.
        Cureus. 2022; 14 (Apr 11): e24046
        • Lin SH
        • Lin YF
        • Halperin ML
        Hypokalaemia, and paralysis.
        QJM. 2001; 94: 133-139
        • Rao N
        • John M
        • Thomas N
        • et al.
        Aetiological, clinical, and metabolic profile of hypokalaemic periodic paralysis in adults: a single-centre experience.
        Natl Med J India. 2006; 19: 246-249
        • Aminoff MJ.
        Neurologic causes of weakness and paralysis.
        in: Jameson J Fauci AS Kasper DL Hauser SL Longo DL Loscalzo J Harrison's Principles of Internal Medicine, 20e. McGraw Hill, 2018: 135-138 (20Accessed Apr 25 2022)