Thyrotoxic hypokalemic periodic paralysis (THPP) is a disease characterized by recurrent episodes of muscle weakness due to intracellular potassium shifting in the presence of high levels of thyroid hormone. It occurs more commonly amongst young Asian men with underlying Graves’ disease. Attacks are commonly precipitated by ingestion of carbohydrate-rich meals or alcohols, stress or strenuous exercise. Herein, we describe an adult Thai man suffering from a hypokalemic periodic paralysis attack after receiving a dexamethasone injection. The diagnosis of Graves’ disease was confirmed by his thyroid function test and a presence of thyrotropin-receptor antibody. His weakness and hypokalemia responded well to potassium supplement and a non-selective beta blocker, while his thyrotoxicosis was initially controlled by an anti-thyroid medication and subsequently with a subtotal thyroidectomy. Clinicians should beware of this manifestation when administering steroids in the thyrotoxic patients, especially of Asian male descent.
Calcium alkali syndrome (CAS), a relatively unusual etiology of hypercalcemia, is characterized by a classical triad of hypercalcemia, azotemia, and metabolic alkalosis. This condition has been described in patients who have taken an excess dose of calcium with an alkali or with a volume-depletion status. To diagnose CAS it requires a high index of suspicion and a detailed history of medication/supplement intake specifically for calcium-containing drugs and a history of all possible ingested alkali. We reported a case of post-surgical hypoparathyroidism whom later on was presented with hypercalcemic crisis due to CAS. The proposed mechanism of CAS and management are also included.
Obesity in women of childbearing age is linked to lower fertility rates due to chronic oligoovulation and anovulation. Effective weight loss treatment such as bariatric surgery can improve fertility potential. However, pregnancy during the first 12 months after bariatric surgery should be avoided due to an active catabolic state and may increase the potential risk of fetal growth restriction. Here, we report a case with an immediate return of fertility function following a bariatric surgery with favorable outcomes. A 30‐year‐old woman with obesity, history of polycystic ovarian syndrome and infertility become pregnant within 2‐month period following bariatric surgery. She first recognized her pregnancy at the gestational age of 8 weeks. Micronutrient laboratory results at baseline were normal except for low 25‐OH vitamin D level of 18.7 ng/dL. She continued to lose her weight during the first trimester but was able to gain some weight during the second and third trimesters. Close fetal ultrasonography monitoring was done during each trimester. The fetal ultrasonography showed an appropriate fetal weight, a normal Doppler study and no abnormality detected in the fetus. Finally, at 36 weeks of gestation, a 2380‐g female baby was delivered successfully.
Background: Functioning paraganglioma is a rare catecholamine-producing tumor that arises in the sympathetic nervous system. It usually presents with sustained or paroxysmal hypertension accompanied by episodes of its classic triad of headache, palpitation, and diaphoresis. However, a wide range of signs and symptoms may be present. We report an unusual manifestation as acute myocardial infarction, which accidentally diagnosed by the trigger response from metoclopramide injection. Case presentation A 66-year-old woman with medical history of well-control hypertension, dyslipidemia and type 2 diabetes mellitus for 8 years presented with typical angina pain for 1 hour. She denied history of chest pain or triad symptoms of pheochromocytoma/paraganglioma (PCC/PGL). Her physical examination was unremarkable except severe hypertension, 206/89 mmHg, and occasional sinus tachycardia. Acute inferior wall myocardial infarction was proposed by an electrocardiogram study, acute ST elevation in lead II, III and aVF, and highly elevated cardiac enzymes. Echocardiogram and coronary angiography showed preserved left ventricle function (LV ejection fraction 70%) without regional wall motion abnormality. No evidence of coronary artery disease was found. During the catheterization, the cardiologist raised the possibility of the presence of PCC/PGL from her fluctuating blood pressure, 73/42 to 206/113 mmHg, after 10-mg metoclopramide injection to control her vomiting. Computer tomography of the abdomen showed a lobulated heterogeneous enhancing left para-aortic mass with internal necrosis, 6.1x4.9x4.1 cm in size, abutting left anterolateral aortic wall and encasing celiac trunk, superior mesenteric artery, and left renal arterial wall. Her hormonal study showed 24-hour urine fractionated metanephrine/normetanephrine levels of 2,924 nmol (<1,777 nmol)/4,328 nmoL(< 3,279 nmol), respectively, and plasma free metanephrine/normetanephrine levels of 93.66 pg/mL (0-96.6 pg/mL)/233.61 pg/mL (0-163.05 pg/mL). She underwent surgical tumor removal with uneventful outcome and the pathology confirmed the diagnosis of functioning PGL. During 2-years follow-up, the patient remained asymptomatic and her hormonal and functioning imaging study showed no recurrence. The genetic testing for PCC/PGL panel was negative. Conclusion: We present an unusual manifestation of PCC/PGL as acute coronary syndrome. The clinician should remind this tumor as the differential diagnosis, especially in a patient with negative coronary angiogram.
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