An intresting case of quadriparesis

Dr ANVESH NARIMETI

POSTGRADUATE

MD GENERAL MEDICINE

GANDHI MEDICAL COLLEGE/HOSPITAL

NAME Anwar

AGE 33yrs

SEX male

OCCUPATION Daily labourer

RESIDENCE Ameerpet

ADMISSION 8/6/2014 11.00am

Weakness of both upper and lower limbs from last

7hours

Patient was apparently normal yesterday went to

work and came back in the evening and had food

and slept without any complaints.In early hours of

next day morning patients got up to use wash room

and observed that he is unable to get up and move

his upper limbs and lowerlimbs

Weakness is sudden in onset and generalised

involving both proximal and distal muscles.

Weakness is associated with pain in the limbs

No h/o of paresthesias,bladder or bowel involvement

No h/o suggestive of cranial nerve involvement

No h/o of any trauma

No h/o of any drug intake

No h/o of fever

No h/o of any vaccination

No h/o of dog bite

History of similar 5 episodes usually in summer

seasons after excessive exhaustion during work and

use to recover after taking medications which he is

use to get from gandhi hospital. Patient used to

recover in one day and get discharged

No history of any fatiguability, diplopia during his

routine work

In between the episodes patient used to absolutely

well and used to perform all activities without any

difficulty

Mixed diet

No addictions

Bowel and bladder habits are normal

No other family member suffering from similar

complaints

A 33 yr old young male came with sudden onset

quadriparesis occurred over hours and recovering in

2days with history of similar episodes in the past

ELECTROLYTE DISTURBENCES

MUSCLE DISORDERS

NEURO MUSCULAR JUNCTION DISORDERS

CENTRAL NERVOUS SYSTEM DISORDERS

Moderately built and moderately nourished

No pallor

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No pedal edema

No external signs of dehydration

No thyroid swelling

Blood pressure – 130/80 mm of hg rt upper limb in

supine position

Pulse rate- 86 per min regular in rhythm and normal

volume.

Respiratory rate- 16 / min and abdomino-thorasic

type of breathing

Higher mental functionsPatient conscious ,coherent , oriented in

time , place and person

Memory and intellect – normal

Speech – fluency ,comprehension , naming

and repeation are normal

No hallucinations and dellusions

CRANIAL NERVES EXAMINATION -

NORMAL

Bulk – normal

Tone – normal tone in all limbs

Power

Upperlimbs

Shoulder

Flexors

Extensors

Adductors

abductors

1/5 1/5

1/5 1/5

1/5 1/5

1/5 1/5

ElbowFlexors

Extensors

WristFlexor

Extensor

Hand grip – not able to hold finger

lowerlimbHip

Flexor

Extensor

Adductors

Abductors

1/5 1/5

1/5 1/5

1/5 1/5

1/5 1/5

1/5 1/5

1/5 1/5

1/5 1/5

1/5 1/5

KneeFlexionr

Extension

AnklePlantar flexion

Dorsi flexion

Reflexes

Superficial

Plantars

Abdominals

corneal

1/5 1/5

1/5 1/5

1/5 1/5

1/5 1/5

flexors flexors

present present

Present present

Deep tendon reflexes

Biceps

Triceps

Supinator

Knee

Ankle

- -

- -

- -

- -

- -

• Pin prick, Fine touch , vibration and joint

sensation normal

Cortical sensations normal

Cerebellum

No nystagmus

No ataxia

Tests for coordination were not able to perform

Liver and spleen not palpable

No shifting dullness

Per abdomen is soft

Inspection – normal, trachea midline , apical impulse

in left 5th ICS medial to mid clavicular line

Palpation – normal

Percussion – resonant note all areas

Ascultation – vesicular BS in all areas

no added sounds

Inspection – normal

Palpation – no palpable sounds , thrills

Percussion – left heart border corresponds to the

apex , right heart border corresponds to the right

sternal border

Ascultation – S1 + , S2 + , S3 - , S4 - , no murmurs

ELECTROLYTE DISTURBENCES

PERIODIC PARALYSIS

COMPLETE BLOOD PICTURE – NORMAL

RBS-168mg/dl

Blood urea- 30mg/dl

Serum creatinine- 1.0mg/dl

Serum electrolytes- sodium 138

potassium 2.8

chloride 94

magnesium 1.2mg/dl(1.5-2.3)

calcium – 10.6

chest xray – normal study

ECG- showing features of hypokalemia

Thyroid profile – normal

Ultra sonography- normal study

24hrs urinary electrolytes-

1. Sodium 322 meq (100-260)

2. Potassium 144 meq^(25-100)

3. Chloride 516.6 meq^ (110-250)

Serum osmolarity = 2x (sodium)+blood

urea/5.4+RBS/18 = 290 mosm

urine osmolarity = 2x(sodium+potassium)+urine

urea/5.4 =1839 mosm

What is TTKG ?

What does it assess?

What are the prerequisites?

TTKG is the ratio of potassium concentration in the

lumen of CCD to that in peritubular capillaries.

Asseses the net driving force of potassium excretion

Urine osmolarity should exceed that of plasma

osmolarity inorder to calculate an interpretable TTKG

TTKG = Uk x Posm

Sk x Uosm

During hypokalemia -TTKG should fall <3 -

indicating appropriately reduced urinary excretion

of K

TTKG > 4 – indicates renal K loss is due to

increased distal K secretion

TTKG- 8.1

BLOOD PRESSURE IS NORMAL

ABG 8/6/2014 10/6/2014

PCO2 42.15mm hg 41.82mm hg

PH 7.47 7.49

K+ 2.01mmol/l 2.97mmol/l

HCO3 27.18mmol/l 26.76mmol/l

Metabolic alkalosis

URINE CHLORIDE – 516MEQ (> 20)

NEXT STEP MEASURE Urinary calcium/ creatinine

ratio

Urinary calcium /creatinine ratio =0.026 ( <0.15)

GITELMAN’S SYNDROME

AUTOSOMAL RECESSIVE DISORDER

PRESENTS IN LATE CHILDHOOD OR ADULTHOOD

HYPOKALEMIA

METABOLIC ALKALOSIS

HYPOMAGNESEMIA

HYPOCALCIURIA

NORMAL BLOOD PRESSURE

CLINIACL MANIFESTATIONS LESS PRONOUNCED IN HETEROZYGOTES

Cramps of arms and legs which may be severe due

to hypokalemia and hypomagnesimia

Fatigue

Polyuria and nocturia

Chondrocalcinosis related to chronic severe

hypomagnesemia

Mutations in the gene coding for the thiazide

sensitive Na Cl cotransporter in distal tubule NCCT,

SLC12A3.

Life long treatment as tubular defect cannot be

corrected

Treatment aimed at minimising the effects of

secondary increase in renin and aldosterone

production

Correcting electrolyte abnormalities

Potassium sparing diuretics are better than

potassium suplementation.

Spiranolactone> amiloride

Potassium and magnesium supplementation