INTRODUCTION
Muscle weakness and paralysis often lead patients to seek emergency medical attention (1). Hypokalemia is identified as one of the reasons observed in these cases.
Hypokalemia is a common electrolyte disorder, stemming from changes in potassium intake, excretion, or transcellular shifts. Hypokalemia is defined as a serum potassium level below 3.6 mEq/L and is observed in approximately 21% of hospitalized patients and around 2-3% of outpatient cases. When hypokalemia becomes severe, it can lead to life-threatening cardiac conditions and neuromuscular disorders (2).
Glucocorticoids are using as anti-inflammatory agents in various conditions. Hypokalemia and muscle weakness are rarely observed following high-dose glucocorticoid administration (3).
In this case, we aim to present a scenario of acute-onset muscle weakness and treatment-resistant hypokalemia following a single dose (8mg) of dexamethasone administration.
CASE REPORT
A 27-year-old male patient presented to our emergency department with a complaint of newly onset weakness in all four extremities. Upon arrival, the patient had a Glasgow Coma Scale (GCS) of 14 with no nuchal rigidity, stable vital signs, and no fever. Physical examination revealed hyperemic oropharynx, hyperemic and hypertrophic tonsils without crypts. There were no rashes noted. Muscle strength was assessed as 4/5 in all four extremities. The electrocardiogram (EKG) showed a normal sinus rhythm with no ST-T changes, arrhythmia, or bundle branch block. The patient reported no previous similar episodes in his medical history. Laboratory investigations revealed isolated hypokalemia (K+: 2.4 mEq/L), and potassium replacement therapy was initiated. Further inquiry into the patient’s history revealed that he had presented to the green zone of the emergency department one day earlier with upper respiratory tract infection symptoms, where he received an intramuscular (IM) injection in his right hip. Upon system review, it was determined that the patient had received an 8mg IM injection of dexamethasone. The patient did not respond to the potassium replacement therapy administered in the emergency department, and a subsequent check showed a further decrease in serum potassium levels (K+: 2.2 mEq/L). The patient was admitted to the Internal Medicine Service for advanced monitoring and treatment. Despite replacement therapy during the first 24 hours of admission, the patient’s potassium levels continued to drop (K+: 1.8 mEq/L). However, a positive response to treatment was achieved after 24 hours of admission (K+: 3.2 mEq/L). The patient was discharged in good health on the 4th day of hospitalization.
DISCUSSION
Glucocorticoids are potent and effective anti-inflammatory agents widely used in clinical practice (4). Steroids are utilized as anti-inflammatory agents in collagen vascular diseases, asthma, organ transplantations, and various other conditions in clinical practice (5).
Steroids can induce hypokalemia by increasing Na+/K+-ATPase activity in skeletal muscles and elevating insulin levels, thereby creating a transcellular potassium shift (6-8). Additionally, steroids can lead to muscle weakness by promoting renal loss of potassium (9).
In a case report, acute muscle weakness and hypokalemia, resulting in a muscle strength of 4/5 in all four extremities, were reported following the administration of low-dose methylprednisolone (3).
In another case report, hypokalemia, associated paralysis, and ventricular fibrillation were reported in a patient following steroid therapy (10).
In a case, temporary hypokalemic quadriplegia was reported following lumbar transforaminal epidural dexamethasone injection (11).
In a case, weakness and paralysis were observed following dexamethasone administration. Considering the patient’s history of two similar attacks before, hypokalemic periodic paralysis was considered (12). However, in our case, there was no previous medical history of a similar nature.
In a study, the frequency of mild hypokalemia following dexamethasone was determined to be 14%, while severe hypokalemia was not observed at all (5).
In this case, we presented a case of acute-onset hypokalemia and paralysis that developed after a single dose of dexamethasone, and proved resistant to replacement therapy. To avoid the undesirable side effects of steroids, clinicians should exercise utmost caution when selecting treatment indications.
REFERENCES
1. Elkins, J. C. (2019). Hypokalemic periodic paralysis secondary to dexamethasone injection. Journal of Emergency Nursing, 45(1), 79-81.
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10. Miyashita Y, Monden T, Yamamoto K, Matsumura M, Kawagoe N, Iwata C, Banba N, Hattori Y, Kasai K. Ventricular fibrillation due to severe hypokalemia induced by steroid treatment in a patient with thyrotoxic periodic paralysis. Intern Med. 2006;45(1):11-3. doi: 10.2169/internalmedicine.45.1495. Epub 2006 Feb 1. PMID: 16467598.
11. Tahmasbi Sohi, M., Sullivan, W. J., & Anderson, D. J. (2018). Transient hypokalemic quadriplegia after a lumbar transforaminal epidural dexamethasone injection: a case report. PM&R, 10(5), 544-547.
12. Elkins, J. C. (2019). Hypokalemic periodic paralysis secondary to dexamethasone injection. Journal of Emergency Nursing, 45(1), 79-81.
