|Year : 2016 | Volume
| Issue : 1 | Page : 21-24
Hypokalemic paralysis in febrile thrombocytopenic patients: A case series
Satish P Nirhale, Piyush Ostwal, Prajwal Rao, Pravin Naphade
Department of Neurology, Dr. DY Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
|Date of Web Publication||29-Feb-2016|
Dr. Piyush Ostwal
601, N4, Nakshatram, Premlok Park, Chinchwad, Pune - 411 033, Maharashtra
Source of Support: None, Conflict of Interest: None
Hypokalemic paralysis in association with febrile thrombocytopenia, especially dengue fever, has been gaining recognition in recent years in India. Till now there have been no reports from western India of this entity. We present here seven cases of hypokalemic paralysis with febrile thrombocytopenia. Two of our cases were dengue-positive. Remarkably, all of our patients were young males 27-40 years of age. All the patients presented with history of fever and quadriparesis, and on investigation had thrombocytopenia with hypokalemia. All the patients responded well to intravenous potassium correction, with complete recovery of motor power. We emphasize that hypokalemic paralysis should be an important consideration in a febrile thrombocytopenic patient presenting with acute quadriparesis.
Keywords: Dengue, fever with thrombocytopenia, hypokalemic paralysis, quadriparesis
|How to cite this article:|
Nirhale SP, Ostwal P, Rao P, Naphade P. Hypokalemic paralysis in febrile thrombocytopenic patients: A case series. Sifa Med J 2016;3:21-4
|How to cite this URL:|
Nirhale SP, Ostwal P, Rao P, Naphade P. Hypokalemic paralysis in febrile thrombocytopenic patients: A case series. Sifa Med J [serial online] 2016 [cited 2021 Jun 19];3:21-4. Available from: https://www.imjsu.org/text.asp?2016/3/1/21/177692
| Introduction|| |
Fever with low platelet counts, commonly referred to as febrile thrombocytopenia, is a fairly common clinical presentation encountered by physicians in a tropical country such as India. The common causes of this presentation are infections such as dengue and malaria. In the last few years a few case reports and case series, mostly from North India, have been published reporting hypokalemic paralysis along with dengue fever. ,,,, Over the same period we also witnessed similar cases with and without dengue serology positivity in the western part of India, where patients developed hypokalemic paralysis during courses of febrile thrombocytopenia. We report here a series of these cases, describing their clinical and biochemical parameters and their response to treatment. To our knowledge such cases have not been reported from western India till now.
| Case Reports|| |
A 30-year-old man presented with history of fever, with body ache of 3 days' duration and weakness of all four limbs of 1 day's duration. On examination, power in the upper limbs was Medical Research Council scale (MRC) 0/5 proximally and MRC 3/5 distally. In the lower limbs, power was MRC 0/5 in all the muscle groups. The deep tendon reflexes in the upper limbs were normal and in the lower limbs they were brisk. On the day of admission he had a fever spike of 100°F. The laboratory investigations showed serum potassium 2.3 mEq/L at admission. His platelet count was 88,000/cu mm, and serology for dengue [immunoglobulin M (IgM), immunoglobulin G (IgG)] was negative. He received intravenous potassium supplementation. With the correction of serum potassium, he showed improvement in motor power over 2 days. Supportive treatment was given for febrile thrombocytopenia, and the patient recovered completely over 7 days.
A 40-year-old man presented with history of fever for 2 days, associated with pain in legs. He had developed weakness in all four limbs 12 h before the admission. His body temperature was 101°F. On examination, power in the upper limbs was MRC 3/5 proximally and MRC 4/5 distally. In the lower limbs the power was MRC 2/5 proximally and MRC 3/5 distally. The deep tendon reflexes were absent in the upper limbs and sluggish in the lower limbs. His serum potassium level was 2.5 mEq/L. Dengue serology was positive for IgG and negative for IgM. He was treated with intravenous potassium supplementation, with which he started improving within 8 h; over the next 3 days he recovered completely.
A 28-year-old man presented with history of fever, with chills associated with backache of 2 days' duration and weakness of all four limbs of 1 day's duration. Power in the upper limbs was MRC 2/5 proximally and MRC 3/5 distally. Power in the lower limbs was MRC 1/5 proximally and MRC 2/5 distally. The deep tendon reflexes were normally elicitable in all four limbs. The patient's serum potassium level was 2.2 mEq/L on the day of admission. His platelet count showed fall from 174,000/cu mm on day 1 to 91,000/cu mm by day 3. He was given intravenous potassium in drip for 2 days. With the correction in serum potassium, his power started improving within 5 h and he became normal within 4 days. His thyroid function tests were normal. During his hospital stay he had spikes of fever in the range of 99-100°F.
A 27-year-old man presented with history of fever for 4 days, skin rash for 3 days, calf pain for 2 days, and weakness of all four limbs of 2 days' duration. Power in the upper limbs proximally was MRC 3/5 and distally was MRC 4/5. In the lower limbs the proximal muscles had power of MRC 2/5 and the distal muscles had power of MRC 4/5. The deep tendon reflexes were absent in the upper limbs and were normally elicitable in the lower limbs. He did not have fever after admission. His serum potassium level was 2.4 mEq/L. His platelet counts declined from 122,000 on day 1 to 86,000 on day 3. The serology for dengue was IgM-positive and IgG-negative. As per the World Health Organization 2009 dengue classification, this case was categorized as nonsevere dengue without warning sign. The patient improved with intravenous potassium correction. The power in all his four limbs was much better by 6 h and had improved completely by day 3.
A 36-year-old man presented with history of fever, body ache, joint pain, and weakness of all the four limbs of 1 day's duration. There was no history of skin rash. Power in the upper limbs was 5/5. In the lower limbs, power was MRC 3/5 proximally and was MRC 4/5 distally. The deep tendon reflexes were normally elicitable in all four limbs. The serum potassium level was 2.9 mEq/L. Serology for dengue was negative. Rapid malaria test was negative. The platelet count at admission was 112,000/cu mm. The thyroid function test was normal. With potassium supplementation the patient started improving after 3 h, and completely recovered by 36 h. Fever also subsided after 2 days of admission.
A 36-year-old man presented with fever of 3 days' duration and weakness of all four limbs of 2 days' duration. On admission, a fever spike of 99°F was recorded. On examination, the power in all four limbs was MRC 0/5. The deep tendon reflexes in the upper limbs were absent and in the lower limbs were normally elicitable. The serum potassium level was 1.9 mEq/L. The serology for dengue was negative. The rapid malaria test was negative. Thyroid function test showed slightly higher levels of thyroxine (T4) with normal levels of triiodothyronine (T3) and thyroid-stimulating hormone (TSH). The patient's platelet count was 116,000/cu mm. He was started on intravenous potassium, and started recovering within 2 h, achieving complete recovery by 48 h.
A 38-year-old man presented with fever with skin rash of 3 days' duration. He had developed weakness in both lower limbs 1 day earlier. On examination, power in his upper limbs was MRC 5/5 and in his lower limbs was MRC 3/5. All the reflexes were normally elicitable, except for sluggish knee jerks. The patient also had subconjunctival hemorrhage. The serum potassium level was 3.0 mEq/L. The platelet count at admission was 99,000/cu mm and it fell to 20,000/cu mm on day 2. Serology for dengue showed positivity for IgM, IgG, and nonstructural protein 1 (NS1) antigen. He was classified as nonsevere dengue without warning signs. His arterial blood gases showed mild metabolic acidosis (pH 7.32, bicarbonate 16 mEq/L). For hypokalemia he was started on potassium drip, and he started recovering after 6 h. The serum potassium level at the onset was not very low, but with the clinical profile and rapid improvement with potassium correction, we do not think that there was any other cause of weakness. Fever also settled after 2 days of hospital stay, with the highest temperature recorded being 100°F.
| Discussion|| |
Hypokalemic paralysis can be due to a primary disorder inherited in an autosomal dominant manner, or it can be due to secondary causes of hypokalemia such as renal tubular acidosis, thyrotoxic periodic paralysis, primary hyperaldosteronism, Gitelman syndrome, barium poisoning, and diarrhea.  In an Indian study where 29 patients of hypokalemic paralysis were analyzed, almost half of them were found to have secondary causes of hypokalemia. 
Here we describe a series of seven cases from western India with febrile thrombocytopenia who also developed hypokalemic paralysis [Table 1]. All patients were middle-aged males 27-40 years of age. All had fever a few days (1-3 days) prior to paralysis. All had low total leukocyte count (2200-3900/cu mm) and low platelet count (20,000-116,000/cu mm). Only two had rash, and those same patients were dengue serology-positive. None of the patients had sensory symptoms. Bowel or bladder involvement was not seen in any of the patients. There was no past history of hypokalemia and paralysis. There was no family history of hypokalemic periodic paralysis. There was no history of either heavy physical exertion followed by rest, prior heavy-carbohydrate meal, or diarrhea. All cases responded to intravenous potassium replacement. Serum creatine kinase levels were not obtained. A differential of myositis in such a setting was considered, but low serum potassium levels, absence of significant muscle tenderness, and good improvement after potassium supplementation favors the diagnosis of hypokalemic paralysis. Additionally, mild to moderate elevation of creatine kinase has been reported in hypokalemic paralysis.
In the last few years hypokalemic paralysis in association with febrile illness has been described from India in scattered case reports and a few case series. The earliest report was from Chandigarh in 2008, where dengue infection as a novel cause of hypokalemic paralysis was introduced.  Later there was a report from Lucknow describing three cases of dengue infection with acute pure motor quadriparesis due to hypokalemia.  Gutch et al. reported another case of hypokalemic quadriparesis with dengue fever and thrombocytopenia.  In a retrospective analysis of 29 cases of hypokalemic paralysis from North India it was found that 4 patients had dengue fever.  One case of dengue fever with hypokalemic paralysis with no other cause found on investigation has been reported from Bangalore as well.  One case has been reported from New Delhi.  Ten patients with dengue with hypokalemic paralysis were seen during an epidemic in Delhi.  The median age of presentation for dengue-associated hypokalemic paralysis has been reported to be 29 years.  The association of quadriparesis with severe hypokalemia after an acute attack of chikungunya fever has also been described.  Hypokalemic paralysis in 6 of our 7 patients developed during the defervescence phase of fever rather than at the peak of fever, which has also been observed in previous reports. Patients started improving within a few hours and completely recovered over 1-4 days in our case series, which is in accordance with previous reports.  The risk of etiological differential diagnosis for hypokalemic paralysis is wide, and in case of recurrent episodes a more extensive evaluation is warranted.
Hypokalemia has been reported in a significant number of cases of infectious diseases, particularly dengue fever.  A number of mechanisms have been proposed for the development of hypokalemia during infections. Potassium can either be redistributed into the cells or be lost into the urine because of renal tubular dysfunction. Catecholamine release in response to stress and increased insulin secretion may drive potassium into the cells, resulting in a fall in serum levels. One or more of these mechanisms may be responsible in a given case. 
| Conclusion|| |
Febrile thrombocytopenias are very common in India, and their newly recognized association with hypokalemic paralysis will help clinicians achieve better management of patients. The detailed evaluation of underlying pathogenesis may help in the timely recognition and prevention of hypokalemic paralysis in the future.
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Conflicts of interest
There are no conflicts of interest.
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