Acute Flaccid Tetraparesis after COVID-19 Infection: Think of the Thyroid

Abstract

A previously well 32-year-old Chinese male presented with acute bilateral upper and lower limb paralysis upon waking, ten days after the onset of COVID-19 infection. Examination revealed areflexia over all four limbs, associated with reduced muscle strength, but no sensory or cranial nerve deficit. Initial concern was Guillain-Barre syndrome given the acute flaccid paralysis following COVID-19 infection. However, investigations revealed severe hypokalaemia (1.7 mmol/L) and primary hyperthyroidism. He was treated for thyrotoxic periodic paralysis (TPP) with β-blockers, antithyroid medications, and intravenous potassium chloride (KCl). Despite frequent monitoring of potassium, rebound hyperkalaemia occurred with prompt resolution of paralysis.

Thyrotoxic Periodic Paralysis in the Post-COVID Era: A Case Report with Literature Review

“…Rarely, COVID-19 infection or vaccination can precipitate TPP, and thus far, there have only been six case reports in the literature globally, as outlined in Table 2 [5,[7][8][9][10][11]. While the time from COVID-19 infection or vaccination to TPP seems to range from 0-22 days, one case report has described TPP occurring 90 days after COVID-19 infection [5].…”

“…While the time from COVID-19 infection or vaccination to TPP seems to range from 0-22 days, one case report has described TPP occurring 90 days after COVID-19 infection [5]. The underlying etiology of thyroid disease leading to COVID-19-induced TPP is often Graves' disease or thyroiditis (subacute or painless) [7][8][9]11]. Most patients require a combination of potassium replacement, β-blocker therapy, and anti-thyroid medication for the treatment of TPP and maintenance of euthyroidism [5,8,10]; one patient required a 6-week course of prednisolone for subacute thyroiditis [9] and another presented in extremis needing advanced cardiac life support for thyroid storm and pulseless ventricular tachycardia [7].…”

“…The underlying etiology of thyroid disease leading to COVID-19-induced TPP is often Graves' disease or thyroiditis (subacute or painless) [7][8][9]11]. Most patients require a combination of potassium replacement, β-blocker therapy, and anti-thyroid medication for the treatment of TPP and maintenance of euthyroidism [5,8,10]; one patient required a 6-week course of prednisolone for subacute thyroiditis [9] and another presented in extremis needing advanced cardiac life support for thyroid storm and pulseless ventricular tachycardia [7]. Of note, all reported cases thus far have been male patients; our case report is unique in that our patient is the first female with post-COVID-19 TPP.…”

“…First, COVID-19 can potentially worsen thyrotoxicosis in patients with pre-existing thyroid disease, precipitating TPP [4,7]. Additionally, COVID-19 may initiate inflammatory cascades that can lead to the development of thyrotoxicosis in patients who are previously euthyroid, which subsequently manifests as TPP [5,[8][9][10][11]. While the effects of COVID-19 on the thyroid have been previously delineated in the literature, post-COVID-19 TPP represents a novel phenomenon with only six case reports that have been published worldwide [5,[7][8][9][10][11].…”

“…Additionally, COVID-19 may initiate inflammatory cascades that can lead to the development of thyrotoxicosis in patients who are previously euthyroid, which subsequently manifests as TPP [5,[8][9][10][11]. While the effects of COVID-19 on the thyroid have been previously delineated in the literature, post-COVID-19 TPP represents a novel phenomenon with only six case reports that have been published worldwide [5,[7][8][9][10][11]. Notably, all cases thus far have been restricted to male patients, and no cases have been described in North America.…”