A 10-year analysis of thyrotoxic periodic paralysis in 135 patients: focus on symptomatology and precipitants

BackgroundA comprehensive analysis has not been performed on patients with thyrotoxic periodic paralysis (TPP) characterized by acute hypokalemia and paralysis in the setting of thyrotoxicosis.PurposeThe aim of this study was to analyze the detailed symptomatology of thyrotoxicosis and precipitating factors for the attack in a large cohort of TPP patients.Patients and methodsA prospective observational study enrolled patients with TPP consecutively over 10 years at an academic medical center. Clinical features, including signs/symptoms of thyrotoxicosis and precipitating factors, were analyzed. The Wayne's index was used to assess the severity of thyrotoxicosis at presentation. Patients who agreed to receive an oral glucose-loading test after recovery were evaluated.ResultsAmong the 135 TPP patients (male:female, 130:5), 70% of paralytic attacks occurred in the morning, especially during the seasons of summer and fall. Two-thirds of patients did not have a known family or personal history of hyperthyroidism. Only 17% of TPP patients manifested overt signs/symptoms of thyrotoxicosis (Wayne's index >19). A clear precipitating factor, such as high carbohydrate load, acute upper respiratory tract infection, strenuous exercise, high-salt diet, or the use of steroids or bronchodilators, was identified in only 34% of TPP patients. A glucose load to stimulate insulin secretion induced acute hypokalemia (K+2.47±0.6 mmol/l) with reparalysis in only 18% (10/55) of TPP patients.ConclusionsMost TPP patients have only subtle clinical signs/symptoms of thyrotoxicosis and only a small fraction has clear precipitating factors. In addition to the effects of hyperinsulinemia, other insulin-independent mechanisms may participate in the pathogenesis of TPP.

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Thyrotoxic Periodic Paralysis—A Misleading Challenge in the Emergency Department

Diagnostics ◽

10.3390/diagnostics10050316 ◽

2020 ◽

Vol 10 (5) ◽

pp. 316 ◽

Cited By ~ 1

Author(s):

Stefana Bilha ◽

Ovidiu Mitu ◽

Laura Teodoriu ◽

Cristian Haba ◽

Cristina Preda

Keyword(s):

Clinical Signs ◽

Initial Therapy ◽

Periodic Paralysis ◽

The Other ◽

Motor Deficit ◽

Antithyroid Drugs ◽

Thyrotoxic Periodic Paralysis ◽

First Case ◽

Life Threatening ◽

Antithyroid Agents

Despite its’ life-threatening potential due to cardiac severe dysrhythmia in the context of severe hypokalemia, thyrotoxic periodic paralysis (TPP) often goes unrecognized. Although classically confined to young Asian men, it can occur irrespective of age, sex, and race. We report a short series of three cases of TPP as first presentation of Graves’ disease in a young Caucasian male and in two Caucasian elderly and middle-aged women, respectively. The first patient developed malignant ventricular arrhythmias due to severe hypokalemia and was defibrillated, with recovery after prompt potassium correction and administration of antithyroid agents and propranolol. The other two cases developed persistent hypokalemia despite adequate potassium chloride (KCl) repletion, with slow recovery of motor deficit and serum potassium normalization up to day 5. In the first case, long-term euthyroid state was achieved via total thyroidectomy due to the presence of a suspicious nodule that proved to be malignant. In the other two cases, medical treatment was the choice of therapy for thyrotoxicosis. None experienced recurrent TPP. Thyroid hormone evaluation is mandatory in the presence of hypokalemic paralysis, even in the absence of clinical signs of thyrotoxicosis. If TPP is confirmed, initial therapy should comprise antithyroid drugs and propranolol, besides hypokalemia correction.

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Clinical Predictors for Laboratory-Confirmed Influenza Infections: Exploring Case Definitions for Influenza-Like Illness

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2014.64 ◽

2015 ◽

Vol 36 (3) ◽

pp. 241-248 ◽

Cited By ~ 19

Author(s):

Shital C. Shah ◽

Dino P. Rumoro ◽

Marilyn M. Hallock ◽

Gordon M. Trenholme ◽

Gillian S. Gibbs ◽

...

Keyword(s):

Influenza A ◽

Medical Center ◽

Academic Medical Center ◽

Clinical Signs ◽

Case Definition ◽

Chief Complaint ◽

Nasopharyngeal Swab ◽

Clinical Predictors ◽

Case Definitions ◽

Influenza Like Illness

OBJECTIVETo identify clinical signs and symptoms (ie, “terms”) that accurately predict laboratory-confirmed influenza cases and thereafter generate and evaluate various influenza-like illness (ILI) case definitions for detecting influenza. A secondary objective explored whether surveillance of data beyond the chief complaint improves the accuracy of predicting influenza.DESIGNRetrospective, cross-sectional study.SETTINGLarge urban academic medical center hospital.PARTICIPANTSA total of 1,581 emergency department (ED) patients who received a nasopharyngeal swab followed by rRT-PCR testing between August 30, 2009, and January 2, 2010, and between November 28, 2010, and March 26, 2011.METHODSAn electronic surveillance system (GUARDIAN) scanned the entire electronic medical record (EMR) and identified cases containing 29 clinical terms relevant to influenza. Analyses were conducted using logistic regressions, diagnostic odds ratio (DOR), sensitivity, and specificity.RESULTSThe best predictive model for identifying influenza for all ages consisted of cough (DOR=5.87), fever (DOR=4.49), rhinorrhea (DOR=1.98), and myalgias (DOR=1.44). The 3 best case definitions that included combinations of some or all of these 4 symptoms had comparable performance (ie, sensitivity=89%–92% and specificity=38%–44%). For children <5 years of age, the addition of rhinorrhea to the fever and cough case definition achieved a better balance between sensitivity (85%) and specificity (47%). For the fever and cough ILI case definition, using the entire EMR, GUARDIAN identified 37.1% more influenza cases than it did using only the chief complaint data.CONCLUSIONSA simplified case definition of fever and cough may be suitable for implementation for all ages, while inclusion of rhinorrhea may further improve influenza detection for the 0–4-year-old age group. Finally, ILI surveillance based on the entire EMR is recommended.Infect Control Hosp Epidemiol 2015;00(0): 1–8

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Neoplastic causes of nonacute facial paralysis: A review of 221 cases

Ear Nose & Throat Journal ◽

10.1177/014556131609500916 ◽

2016 ◽

Vol 95 (9) ◽

pp. 390-396 ◽

Cited By ~ 7

Author(s):

John P. Leonetti ◽

Sam J. Marzo ◽

Douglas A. Anderson ◽

Joshua M. Sappington

Keyword(s):

Facial Nerve ◽

Facial Paralysis ◽

Medical Center ◽

Demographic Data ◽

Academic Medical Center ◽

Tertiary Care ◽

Clinical Signs ◽

Surgical Approaches ◽

Facial Weakness ◽

Gradual Onset

We conducted a retrospective review to assess the clinical presentation of patients with tumor-related nonacute complete peripheral facial weakness or an incomplete partial facial paresis and to provide an algorithm for the evaluation and management of these patients. Our study population was made up of 221 patients—131 females and 90 males, aged 14 to 79 years (mean: 49.7)—who had been referred to the Facial Nerve Disorders Clinic at our tertiary care academic medical center over a 23–year period with a documented neoplastic cause of facial paralysis. In addition to demographic data, we compiled information on clinical signs and symptoms, radiologic and pathologic findings, and surgical approaches. All patients exhibited gradual-onset facial weakness or facial twitching. Imaging identified an extratemporal tumor in 128 patients (58%), an infratemporal lesion in 55 patients (25%), and an intradural mass in 38 (17%). Almost all of the extratemporal tumors (99%) were malignant, while 91 % of the infratemporal and intradural tumors were benign. A transtemporal surgical approach was used in the 93 infratemporal and intradural tumor resections, while the 128 extratemporal lesions required a parotidectomy with partial temporal bone dissection. The vast majority of patients (97%) underwent facial reanimation. We conclude that gradual-onset facial paralysis or twitching may occur as a result of a neoplastic invasion of the facial nerve along its course from the cerebellopontine angle to the parotid gland. We caution readers to beware of a diagnosis of “atypical Bell's palsy.”

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Impaired Insulin Action Is Associated With Increased Glucagon Concentrations in Nondiabetic Humans

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2017-01197 ◽

2017 ◽

Vol 103 (1) ◽

pp. 314-319 ◽

Cited By ~ 11

Author(s):

Anu Sharma ◽

Ron T Varghese ◽

Meera Shah ◽

Chiara Dalla Man ◽

Claudio Cobelli ◽

...

Keyword(s):

Glucose Tolerance ◽

Insulin Action ◽

Cell Function ◽

Medical Center ◽

Academic Medical Center ◽

Glucagon Secretion ◽

Tolerance Test ◽

Oral Glucose ◽

Cross Sectional ◽

Cell Dysfunction

Abstract Context Abnormal glucagon concentrations contribute to hyperglycemia, but the mechanisms of α-cell dysfunction in prediabetes are unclear. Objective We sought to determine the relative contributions of insulin secretion and action to α-cell dysfunction in nondiabetic participants across the spectrum of glucose tolerance. Design This was a cross-sectional study. A subset of participants (n = 120) was studied in the presence and absence of free fatty acid (FFA) elevation, achieved by infusion of Intralipid (Baxter Healthcare, Deerfield, IL) plus heparin, to cause insulin resistance. Setting An inpatient clinical research unit at an academic medical center. Participants A total of 310 nondiabetic persons participated in this study. Interventions Participants underwent a seven-sample oral glucose tolerance test. Subsequently, 120 participants were studied on two occasions. On one day, infusion of Intralipid plus heparin raised FFA. On the other day, participants received glycerol as a control. Main Outcome Measure(s) We examined the relationship of glucagon concentration with indices of insulin action after adjusting for the effects of age, sex, and weight. Subsequently, we sought to determine whether an acute decrease in insulin action, produced by FFA elevation, altered glucagon concentrations in nondiabetic participants. Results Fasting glucagon concentrations correlated positively with fasting insulin and C-peptide concentrations and inversely with insulin action. Fasting glucagon was not associated with any index of β-cell function in response to an oral challenge. As expected, FFA elevation decreased insulin action and also raised glucagon concentrations. Conclusions In nondiabetic participants, glucagon secretion was altered by changes in insulin action.

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Hyperglycemia Alters Tumor Necrosis Factor-α Release from Mononuclear Cells in Women with Polycystic Ovary Syndrome

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2005-0694 ◽

2005 ◽

Vol 90 (9) ◽

pp. 5336-5342 ◽

Cited By ~ 59

Author(s):

Frank González ◽

Judi Minium ◽

Neal S. Rote ◽

John P. Kirwan

Keyword(s):

Polycystic Ovary Syndrome ◽

Mononuclear Cells ◽

Polycystic Ovary ◽

Medical Center ◽

Academic Medical Center ◽

Reproductive Age ◽

Controlled Study ◽

Oral Glucose ◽

Ovary Syndrome ◽

Glucose Ingestion

Abstract Context: Women with polycystic ovary syndrome (PCOS) are often insulin resistant and have chronic low-level inflammation. Objective: The purpose of this study was to determine the effects of hyperglycemia on lipopolysaccharide (LPS)-stimulated TNFα release from mononuclear cells (MNC) in PCOS. Design: The study was designed as a prospective controlled study. Setting: The study was carried out at an academic medical center. Patients: Sixteen reproductive age women with PCOS (eight lean, eight obese) and 14 age-matched controls (eight lean, six obese) participated in the study. Main Outcome Measures: Insulin sensitivity (IS) was derived from a 2-h 75-g oral glucose tolerance test (ISOGTT). Percentage of truncal fat was determined by dual-energy absorptiometry. TNFα release was measured from MNC cultured in the presence of LPS from blood samples drawn fasting and 2 h after glucose ingestion. Results: ISOGTT was lower in women with PCOS compared with controls (3.9 ± 0.4 vs. 6.3 ± 1.0; P < 0.03) and was negatively correlated with percentage of truncal fat (r = 0.56; P < 0.002). Truncal fat was greater in lean women with PCOS compared with lean controls (29.8 ± 2.6 vs. 23.8 ± 2.5%; P < 0.04). The TNFα response was different between obese and lean controls (−96.9 ± 21.2 vs. 24.4 ± 21.6 pg/ml; P < 0.03) and obese and lean women with PCOS (−94.1 ± 34.5 vs. 30.4 ± 17.6 pg/ml; P < 0.002). Fasting plasma C-reactive protein was elevated (P < 0.003) in obese PCOS and obese controls compared with lean controls. Conclusion: An increase in abdominal adiposity and increased TNFα release from MNC after hyperglycemia may contribute to insulin resistance in lean PCOS patients. In contrast, obese PCOS patients have more profound chronic inflammation, and thus may have LPS tolerance that protects them from relatively mild excursions in blood glucose.

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Validation of a Community Acquired Pneumonia Score to Improve Empiric Antibiotic Selection at an Academic Medical Center

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.01482-20 ◽

2020 ◽

Author(s):

Meredith B. Oliver ◽

Karen Fong ◽

Laura Certain ◽

Emily S. Spivak ◽

Tristan T. Timbrook

Keyword(s):

Risk Factors ◽

Prediction Models ◽

Medical Center ◽

Academic Medical Center ◽

Clinical Signs ◽

Community Acquired Pneumonia ◽

Drug Resistant ◽

Clinical Prediction ◽

Local Risk ◽

Prior Infection

The 2019 American Thoracic Society and the Infectious Diseases Society of America Community-Acquired Pneumonia (CAP) Guidelines recommend drug resistant pathogens (DRP) be empirically covered if locally validated risk factors are present. This retrospective case-control validation study evaluated the performance of the Drug-Resistance in Pneumonia (DRIP) clinical prediction score. Two hundred 17 adult patients with ICD-10 pneumonia diagnosis, positive confirmed microbiologic data, and clinical signs and symptoms were included. A DRIP score of ≥ 4 was used to assess model performance. Logistic regression was used to select for significant predictors and create a modified DRIP score, which was evaluated to define clinical application. The DRIP score predicted pneumonia due to a DRP with a sensitivity of 67% and specificity of 73%. The AUROC curve was 0.76 (95% CI, 0.69-0.82). From regression analysis, prior infection with a DRP and antibiotics in the last 60 days, yielding score of 2 and 1 points respectively, remained local risk factors in predicting drug-resistant pneumonia. Sensitivity (47%) and specificity (94%) were maximized at a threshold of ≥ 2 in the modified DRIP model. Therefore, prior infection with a DRP remained the only clinically relevant predictor for drug-resistant pneumonia. The original DRIP score demonstrates a decreased performance in our patient population and behaves similar to other clinical prediction models. Empiric CAP therapy without anti-MRSA and anti-pseudomonal coverage should be considered for non-critically ill patients without a drug resistant pathogen infection in the past year. Our data support the necessity of local validation to authenticate clinical risk predictors for drug-resistant pneumonia.

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