PaJR Case Reports: 40F With Recurrent Hypokalemic Paralysis Diagnosed With Sjogrens

Tuesday, February 18, 2025

40F With Recurrent Hypokalemic Paralysis Diagnosed With Sjogrens

01-02-2023

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.

Vignatha

roll no: 55

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case:

40yr female came with chief complaints of

Weakness of both upper and lower limbs since 4 hours

History of present illness:

Patient was apparently asymptomatic hours ago then she is unable to get up from bed and walk properly. She has h/o 2 episodes of vomiting which are non bilious, non projectile, filled with food particles.

H/o similar complaints in the past

1st episode -3to 4 yrs back bad left lower limb weakness and was diagnosed to have hypokalemia for which potassium correction was done

2nd episode: in Nov 2021 had h/o both upper and lower limbs weakness , Loss of consciousness for 2 days , loss of speech (for 4 days) , 1 unit PRBC was transfused and was diagnosed as hypokalemia.

3rd episode : in may 2022 she had same complaints and was admitted for 3 days.

Not a k/c/o HTN, DM,CVA, CAD, EPILEPSY ,TB,ASTHMA.

Personal history:

Diet: mixed

Appetite:normal

Sleep: adequate

Bowel and bladder movements: regular

Addictions:none

Sequence of events:

She got married in 1999 and had her first child in 2002. H/O abortion in 2001.

Due to some issues she worked as a nurse at local hospital for 6 months.

Later her husband passed away in 2009 and in 2010 she got married again. Since then until 2019 she was alright with out any health problems.

1st episode in 2019

2nd episode in 2021

3rd episode in 2022

General examination:

Pt is conscious, coherent and cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema

Vitals at admission:

Bp:100/60mmhg

Pr:90bpm

Rr:16cpm

Cvs:s1, s2 present

RS: BAE + , clear

CNS: HMF +

P/A : soft , non tender

Bowel sounds:sluggish

Investigations

Chest x ray

X ray B/L wrist

Serum electrolytes

Sodium:142

Potassium: 1.8

Chloride:108

Calcium ionized:1.35

Serum calcium:9.8

Serum creatinine:1.3

Blood urea:29

RBS:101

LFT:

Total bilirubin:0.60

Direct bilirubin:0.19

SGOT:11

SGPT:23

ALP:579

Total proteins: 4.8

Albumin: 2.95

A/G:1.59

Diagnosis:

Recurrent hypokalemic paralysis secondary to distal RTA and probable sjogrens

Treatment

IV fluids 1 NS and 1 RL @ 75ml/hr

Inj KCL 3 ampules (60mEq) in 500ml NS over 3 hours

Syrup potklor 15ml po/TID

Inj zofer 4mg IV/SOS

TAB PREGABA M 75mg po/hs

ECG 12th hourly

Investigations on 1/2/23

Urinary calcium:3.0

Spot urine sodium:60

Spot urinary potassium:12.0

Usg on 1/2/23

TIRADS 3 lesion in left lobe

TIRADS 4 and 1 lesion in right lobe

Parotitis of left side

Serum electrolytes on 2/2/23

Sodium:140

Potassium:3.8

Chloride:101

Calcium ionized:1.07

Thyroid profile on 1/2/23

T3:0.78

T4: 9.64

TSH:1.52

24 hr urinary electrolytes :

24 hr urinary potassium:55.6 (normal range:25-125)

24hr urinary sodium:552 (normal range:40-220)

24hr urine volume:4,600ml

X ray pelvis

Gait

15-02-2025

PPM 1 - Morning OPD data capture of a patient being reviewed after 2 years:

This was her gait in today's OPD 👇

https://youtu.be/jmoiU_dT0C4?feature=shared

Her previous EHR case report along with the previous gait video (providing an estimate of the change in her gait) is linked in the above description box and will share more data for @CR to prepare this fascinating landmark EHR case report that was extensively engaged with by our UGs and PGs in 2023 around this time! @PPM2 @PPM4 @PPM5

Two years around this time she presented with paralysis of all four limbs and while such a presentation is commonly thought to be Guillain Barre @PPM3, the K+ of 1.8 was an indicator to a hypokalemic muscle paralysis and she improved with iv potassium, and although the ABG wasn't mentioned in the initial informal EMR here: https://vignatha45.blogspot.com/2023/02/40-year-female-with-hypokalemia.html?m=1

she was also found to have metabolic acidosis with a normal anion gap that was thought to be distal RTA perhaps due to severe hypokalemia.

She also had severe cutaneous xerosis two years back as also captured in the OPD after 2 years today.

Also had dry eyes and hence a lingual biopsy was taken that was consistent with Sjogrens syn as mentioned in the previous EMR case report link.

Subsequently in NIMs they did a bone scan (not sure why) and found uptakes that suggested multiple fractures and put her on injection tirzepetide lifelong! @PPM2

PPM 2 - Hope no muscle wasting and winging here. Can try TRAWL (Trapezius weakness wings laterally) and SWIM (Serratus weakness wings medially)

It is way too excessive and sometimes heavily research driven institutes can lose track of patient centered outcomes.

The idea could have been that she may have mixed RTA and thus Vitamin D deficiency and perhaps will have Secondary Hyperparathyroidism and Osteoporosis!

I don't even know what to make of that scan tbh.

PPM 1 - 👍

PPM 1 - None noted

Another note from June 2023

An ABG is visible here along with an MRI report suggesting multiple fractures.

PPM 2 - Interesting that the wrist is involved - the consultants here have told me that distal radius osteoporosis is very sensitive and specific for Primary Hyperparathyroidism

Was a PTH done and Urine Ca Cr ever done sir?

So, was the risedronate stopped?

PPM 1 - 👍

Can ask her advocate in the PaJR group.

👆 there's a urinary calcium mentioned here altogether not sure how useful that is

Will need to fish out her EMR summary from two years back.

19-02-2025

PPM 1 -

Update:

OPD now (bedside or chair side):

Fixing her benchside issues of drug administration by working out how to optimise the usage of her new pen and vial provided by the CM fund free of cost.