Lower Extremity Paralysis

D. Luke Glancy, MDa,*, Pramilla N. Subramaniam, MDa, and Juan F. Rodriguez, MDb

Severe hypokalemia in the absence of other electrolyte abnormalities, the result of diarrhea,
caused striking electrocardiographic changes, generalized weakness, flaccid paralysis of the
lower extremities, and biochemical evidence of mild skeletal and cardiac rhabdomyolysis in
a 33-year-old man. Repletion of potassium reversed all abnormalities in 24 hours. Ó 2016
Elsevier Inc. All rights reserved. (Am J Cardiol 2016;118:1609e1610)

A 33-year-old laborer had 6 to 8 beers after work. He
awakened at 3 A.M. the next morning to urinate and fell
because his legs would not support him. His arms were
weak as well. He did not lose consciousness, hit his head, or
have any other symptoms. When the paralysis did not
improve, some 8 hours later he was brought to the emer-
gency department where an electrocardiogram was recorded
(Figure 1).
The electrocardiogram showed sinus tachycardia at a rate
of 128 beats/min. The most striking features were wide-
spread marked ST-segment depression with broad tall T
waves and reciprocal changes in lead aVR. Although the
changes could have been interpreted as signs of diffuse
subendocardial ischemia/injury,1 they were actually the
result of severe hypokalemia (serum potassium 1.7 mEq/L,
reference 3.5 to 5.5). What appeared to be large T waves
were instead large U waves superimposed on the T waves.
This patient’s medical history was positive for penicillin
allergy and the consumption of 4 to 6 beers on weekends.
He used no prescription or over-the-counter medications and
no dietary supplements. He had no relevant family history.
Of the legion of causes of hypokalemia,2 this patient’s only
recognizable one was diarrhea with 4 to 6 stools per day for
the past 3 days with the frequency slowing down the day of
admission.
Physical examination revealed only sinus tachycardia
and decreased muscle tone and strength bilaterally, espe-
cially in the lower extremities. He was unable to walk. A
toxicology screen of his urine was negative, and a computed
tomographic scan of his head and neck was normal. An
echo/Doppler study was normal except for trivial mitral and
tricuspid valvular regurgitation and a minimally elevated
pulmonary arterial systolic pressure (37 mm Hg).
As serum potassium falls <3.0 mEq/L, muscle weakness
and generalized fatigue occur, and at extremely low levels,
paralysis and/or rhabdomyolysis may develop.2 This
patient’s serum creatine kinase on admission was 542 U/L
(reference 20 to 200). Gastrointestinal smooth muscle and
cardiac muscle may also be affected.2 Fortunately, the
patient had no arrhythmias, but his serum troponin I was
slightly elevated (0.517 ng/ml, reference <0.034).
Did the large amount of beer contribute to the
hypokalemia? Possibly. Many if not most persons drinking
large amounts of beer eat a considerable portion of salty
food. Acute ingestion of sodium salts may result in kaliu-
resis and may have added to the effects of the diarrhea in
producing hypokalemia in our patient.2
The patient’s potassium was repleted, and within
24 hours, his serum potassium was 4.7 mEq/L. Other
laboratory studies were normal or nearly so, and his elec-
trocardiogram was normal. He had no symptoms and was
discharged home.
Disclosures
The authors have no conflicts of interest to disclose.
1. Hanna EB, Glancy DL. ST-segment depression and T-wave inversion:
classification, differential diagnosis, and caveats. Cleve Clin J Med
2011;78:404e414.
2. Peterson LN, Levi M. Disorders of potassium metabolism. In:
Schrier RW, ed. Renal and Electrolyte Disorders. 6th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2003:171e215.

a
Section of Cardiology, Department of Medicine, Louisiana State
University Health Sciences Center, New Orleans, Louisiana; and bCardiac
Electrophysiology Section, Cardiology Department, University of
California Los Angeles/Good Samaritan Hospital, Los Angeles, California.
Manuscript received July 27, 2016; revised manuscript received and
accepted August 2, 2016.
Dr. Rodriguez completed his cardiovascular disease fellowship at
Louisiana State University Health Sciences Center in New Orleans and
currently is finishing a cardiac electrophysiology fellowship at the UCLA/
Good Samaritan Program in Los Angeles, California.
See page 1609 for disclosure information.
*Corresponding author: Tel: (985) 796-1550; fax: (504) 568-2127.
E-mail address: dglanc@lsuhsc.edu (D.L. Glancy).

0002-9149/16/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. www.ajconline.org
http://dx.doi.org/10.1016/j.amjcard.2016.08.030
1610 The American Journal of Cardiology (www.ajconline.org)

Figure 1. Electrocardiogram of a 33-year-old man on his admission to the emergency department. See text for explication.