Hypokalaemic Paralysis in Plasmodium vivax Malaria
Hypokalaemic Paralysis in Plasmodium vivax Malaria
A 26-year-old male presented at the hospital with complaints of high grade intermittent fever, with chills, for two days and the sudden onset of progressive weakness for a day. The fever was not accompanied by vomiting, diarrhoea or any other systemic complaints. The patient had been treated by a local doctor after his complete blood count screen had revealed Plasmodium vivax malaria (trophozoites in blood smear) with thrombocytopenia (platelets 56,000/mm). He had been given cefixime 200mg po bid and artesunate 200mg po od for a day. The next day, he had suddenly developed gradually progressive lower limb weakness leading to an inability to stand up and walk. He denied any history of recent vaccinations, use of diuretics, any trauma or seizures. There was neither any history of a similar weakness in his past nor any family history of it. The patient denied any history of alcohol, tobacco or recreational drug use. A driver by occupation, he lived in an urban area. He denied any prior history of malaria.
On physical examination, his pulse was 74/min, regular; his blood pressure was 124/70 mm Hg and his abdominal examination revealed mild splenomegaly. His cardiac examination was unremarkable. The neurological examination showed bilateral lower limb flaccid paralysis (grade I power) with knee and ankle reflexes absent, with absent bilateral plantar reflexes. In the lower limbs, the muscle tone was reduced without any muscle tenderness. Lower limb sensations were intact. The power was 5/5 in upper limbs with no sensory deficit. The cranial nerves examination was normal. The patient was admitted to the hospital and his blood samples were sent for urgent tests for serum electrolytes. The results revealed a potassium value of 1.47 mEq/L. The ECG, correspondingly, showed flattened T waves and the presence of U waves.
Intravenous potassium chloride was given for correcting the potassium level and, since it was a life-threatening hypokalaemia (<1.5 mEq/L), at a relatively rapid rate of 30 mEqs/hr. Repeat serum chemistry after three hours showed a potassium value of 2.67 mEq/L. There was some improvement in clinical signs of weakness and ECG. The rate of correction was subsequently slowed down to 20mEqs/hr. After a total infusion of 150 mEqs potassium IV, electrolyte tests repeated after 8 hours, showed a potassium value of 5.25 mEq/L. Potassium supplementation was then stopped. The correlation of the potassium value with the neurological examination and ECG is given in Table 1, also indicating the moments when potassium supplementation was carried out. The patient did not have any complaints after 8 hours of hospitalization. The repeat electrolytes tests done on the subsequent days revealed potassium in the normal range. The correlation of the potassium value with the lower limb neurological examination findings over the course of hospitalization is given in Figure 1.
(Enlarge Image)
Figure 1.
Correlation of the potassium value with the lower limb neurological examination findings over the course of hospitalization.
Arterial blood gas, serum magnesium, serum calcium, blood sugar and renal function were within normal limits. The liver function tests showed mild indirect bilirubinemia. His urine test results were within the normal range. The patient also tested negative for dengue, leptospirosis and HIV. Total T4 was mildly elevated; however, TSH and Total T3 were normal. The summary of the blood investigations is given in Table 2.
The patient received artesunate 120mg IV 12 hourly on day 1 followed by od dose for two days, ceftriaxone 1gm IV 12 hourly for three days and doxycycline 100mg po bid for five days. Injectibles were stopped on day 4 and he was put on artemether/lumefantrine 80/480mg po bid for three days; and to prevent a relapse, primaquine 7.5mg po bid was added for fourteen days after testing for glucose-6-phosphate dehydrogenase deficiency.
The patient was discharged home on day 5. He returned for a follow-up consultation two weeks later. He did not have any complaints, including fever, during that intervening period.
Case Presentation
A 26-year-old male presented at the hospital with complaints of high grade intermittent fever, with chills, for two days and the sudden onset of progressive weakness for a day. The fever was not accompanied by vomiting, diarrhoea or any other systemic complaints. The patient had been treated by a local doctor after his complete blood count screen had revealed Plasmodium vivax malaria (trophozoites in blood smear) with thrombocytopenia (platelets 56,000/mm). He had been given cefixime 200mg po bid and artesunate 200mg po od for a day. The next day, he had suddenly developed gradually progressive lower limb weakness leading to an inability to stand up and walk. He denied any history of recent vaccinations, use of diuretics, any trauma or seizures. There was neither any history of a similar weakness in his past nor any family history of it. The patient denied any history of alcohol, tobacco or recreational drug use. A driver by occupation, he lived in an urban area. He denied any prior history of malaria.
On physical examination, his pulse was 74/min, regular; his blood pressure was 124/70 mm Hg and his abdominal examination revealed mild splenomegaly. His cardiac examination was unremarkable. The neurological examination showed bilateral lower limb flaccid paralysis (grade I power) with knee and ankle reflexes absent, with absent bilateral plantar reflexes. In the lower limbs, the muscle tone was reduced without any muscle tenderness. Lower limb sensations were intact. The power was 5/5 in upper limbs with no sensory deficit. The cranial nerves examination was normal. The patient was admitted to the hospital and his blood samples were sent for urgent tests for serum electrolytes. The results revealed a potassium value of 1.47 mEq/L. The ECG, correspondingly, showed flattened T waves and the presence of U waves.
Intravenous potassium chloride was given for correcting the potassium level and, since it was a life-threatening hypokalaemia (<1.5 mEq/L), at a relatively rapid rate of 30 mEqs/hr. Repeat serum chemistry after three hours showed a potassium value of 2.67 mEq/L. There was some improvement in clinical signs of weakness and ECG. The rate of correction was subsequently slowed down to 20mEqs/hr. After a total infusion of 150 mEqs potassium IV, electrolyte tests repeated after 8 hours, showed a potassium value of 5.25 mEq/L. Potassium supplementation was then stopped. The correlation of the potassium value with the neurological examination and ECG is given in Table 1, also indicating the moments when potassium supplementation was carried out. The patient did not have any complaints after 8 hours of hospitalization. The repeat electrolytes tests done on the subsequent days revealed potassium in the normal range. The correlation of the potassium value with the lower limb neurological examination findings over the course of hospitalization is given in Figure 1.
(Enlarge Image)
Figure 1.
Correlation of the potassium value with the lower limb neurological examination findings over the course of hospitalization.
Arterial blood gas, serum magnesium, serum calcium, blood sugar and renal function were within normal limits. The liver function tests showed mild indirect bilirubinemia. His urine test results were within the normal range. The patient also tested negative for dengue, leptospirosis and HIV. Total T4 was mildly elevated; however, TSH and Total T3 were normal. The summary of the blood investigations is given in Table 2.
The patient received artesunate 120mg IV 12 hourly on day 1 followed by od dose for two days, ceftriaxone 1gm IV 12 hourly for three days and doxycycline 100mg po bid for five days. Injectibles were stopped on day 4 and he was put on artemether/lumefantrine 80/480mg po bid for three days; and to prevent a relapse, primaquine 7.5mg po bid was added for fourteen days after testing for glucose-6-phosphate dehydrogenase deficiency.
The patient was discharged home on day 5. He returned for a follow-up consultation two weeks later. He did not have any complaints, including fever, during that intervening period.
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