Periodic Paralyses

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Background

The heterogeneous group of muscle diseases known as periodic paralyses (PP) is characterized by episodes of flaccid muscle weakness occurring at irregular intervals. Most of the conditions are hereditary and are more episodic than periodic. They can be divided conveniently into primary and secondary disorders.

General characteristics of primary PP include the following: (1) they are hereditary; (2) most are associated with alteration in serum potassium levels; (3) myotonia sometimes coexists; and (4) both myotonia and PP result from defective ion channels.

Pathophysiology

A clinically useful classification of primary periodic paralyses, shown in Table 1, includes hypokalemic, hyperkalemic, and paramyotonic forms.

Table 1. Primary Periodic Paralysis (modified from Jurkat-Rott and Lehmann-Horn[1] )



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The physiologic basis of flaccid weakness is inexcitability of the muscle membrane (ie, sarcolemma). Alteration of serum potassium level is not the principal defect in primary PP; the altered potassium metabolism is a result of the PP. In primary and thyrotoxic PP, flaccid paralysis occurs with relatively small changes in the serum potassium level, whereas in secondary PP, serum potassium levels are markedly abnormal.

No single mechanism is responsible for this group of disorders. Thus, they are heterogeneous but share some common traits. The weakness usually is generalized but may be localized. Cranial musculature and respiratory muscles usually are spared. Stretch reflexes are either absent or diminished during the attacks. The muscle fibers are electrically inexcitable during the attacks. Muscle strength is normal between attacks but, after a few years, some degree of fixed weakness develops in certain types of PP (especially primary PP). All forms of primary PP (except Becker myotonia congenita [MC]) are either autosomal dominant inherited or sporadic (most likely arising from point mutations).

Voltage-sensitive ion channels closely regulate generation of action potentials (brief and reversible alterations of the voltage of cellular membranes). These are selectively and variably permeable ion channels. Energy-dependent ion transporters maintain concentration gradients. During the generation of action potentials, sodium ions move across the membrane through voltage-gated ion channels. The resting muscle fiber membrane is polarized primarily by the movement of chloride through chloride channels and is repolarized by movement of potassium. Sodium, chloride, and calcium channelopathies, as a group, are associated with myotonia and PP. The functional subunits of sodium, calcium, and potassium channels are homologous. Sodium channelopathies are better understood than calcium or chloride channelopathies. All forms of familial PP show the final mechanistic pathway involving aberrant depolarization, inactivating sodium channels, and muscle fiber inexcitability.

Discussion in this article primarily addresses the sodium, calcium, and potassium channelopathies as well as secondary forms of PP. Chloride channelopathies are not associated with episodic weakness and are discussed in more detail in the articles on myotonic disorders.

Summary of channel dysfunction in various types of PP

With HyperPP fast channel inactivation, mutations are usually situated in the inner parts of transmembrane segments or in the intracellular loops affecting the docking sites for the fast inactivating particle, thus impairing fast channel inactivation leading to persistent Na+ current.

With HypoPP hyperpolarization-activated cation leak counteracting K+ -rectifying current, mutations cause outermost arginine or lysine substitution.

With NormoPP depolarization-activated cation leak, mutations are in deeper locations of voltage sensor of domain II at codon R675.[1, 2]

Ion channel dysfunction is usually well compensated with normal excitation, and additional triggers are often necessary to produce muscle inexcitability owing to sustained membrane depolarization.

Glucose and potassium intake has the opposite effects in these disorders. In HyperPP, potassium intake triggers the attack, whereas glucose ameliorates it. In contrast, glucose provokes hypokalemic attacks and potassium is the treatment for the attack.[2]

Note the image below.



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Mutations in periodic paralysis.

Muscle sodium channel gene

The sodium channel has an alpha subunit and a beta subunit. The alpha subunit of the sodium channel is a 260-kd glycoprotein comprising about 1800-2000 amino acids. This channel is highly conserved evolutionarily from Drosophila to human. It has 4 homologous domains (I-IV) that fold to form a central pore, each with 225-325 amino acids. Each domain consists of 6 hydrophobic segments (S1-S6) traversing the cell membrane. The main functions of the channel include voltage-sensitive gating, inactivation, and ion selectivity. The extracellular loop between S5 and S6 dips into the plasma membrane and participates in the formation of the pore. The S4 segment contains positively charged amino acids at every third position and functions as a voltage sensor. Conformation changes may occur during depolarization, resulting in activation and inactivation of the channel. The cellular loop between domain III-S6 and domain IV-S1 acts as an inactivating gate.

The sodium channel has 2 gates (activation and inactivation) and can exist in 3 states. At rest with the membrane polarized, the activation gate is closed and the inactivation gate is opened. With depolarization, the activation gate opens, allowing sodium ions to pass through the ion channel and also exposing a docking site for the inactivation gate. With continued depolarization, the inactivation gate closes, blocking the entry of sodium into the cell and causing the channel to enter the fast-inactivation state. This inactivation of the channel allows the membrane to become repolarized, resulting in a return to the resting state with the activation gate closed and the inactivation gate opened. Two inactivation processes occur in mammalian skeletal muscle: Fast inactivation involves terminating the action potential and acts on a millisecond time scale. Slow inactivation takes seconds to minutes and can regulate the population of excitable sodium channels.

Sodium channel mutations that disrupt fast and slow inactivation are usually associated with a phenotype of HyperPP and myotonia, where as mutations that enhance slow or fast inactivation producing loss of sodium channel function cause HypoPP.

Mutations of the sodium channel gene (SCN4A) have several general features. Most of the mutations are in the "inactivating" linker between repeats III and IV, in the "voltage-sensing" segment S4 of repeat IV or at the inner membrane where they could impair the docking site for the inactivation gate. The clinical phenotype differs by specific amino acid substitution and, while some overlap may occur between hyperkalemic PP, paramyotonia congenita (PC), and potassium-aggravated myotonias (PAM), the 3 phenotypes are generally distinct (as described below). Nearly all mutant channels have impaired fast-inactivation of sodium current. Most patients are sensitive to systemic potassium or to cold temperature.

Two populations of channels exist, mutant and wild-type; the impaired fast-inactivation results in prolonged depolarization of the mutant muscle fiber membranes and can explain the 2 cardinal symptoms of these disorders, myotonia and weakness. In hyperkalemic PP, a gain of function occurs in mutant channel gating, resulting in an increased sodium current excessively depolarizing the affected muscle. Mild depolarization (5-10 mV) of the myofiber membrane, which may be caused by increased extracellular potassium concentrations, results in the mutant channels being maintained in the noninactivated mode. The persistent inward sodium current causes repetitive firing of the wild-type sodium channels, which is perceived as stiffness (ie, myotonia).

If a more severe depolarization (20-30 mV) is present, both normal and abnormal channels are fixed in a state of inactivation, causing weakness or paralysis. Thus, subtle differences in severity of membrane depolarization may make the difference between myotonia and paralysis. Temperature sensitivity is a hallmark of PC. Cold exacerbates myotonia and induces weakness. A number of mutations are associated with this condition, 3 of them at the same site (1448) in the S4 segment. These mutations replace arginine with other amino acids and neutralize this highly conserved S4 positive charge. Mutations of these residues are the most common cause of PC. Some of the possible mechanisms responsible for temperature sensitivity include the following:

Most cases of hyperkalemic PP are due to 2 mutations in SCN4A, T704M, and M1592V. Mutations in the sodium channel, especially at residues 1448 and 1313, are responsible for paramyotonia congenita. A small proportion of hypokalemic periodic paralysis cases are associated with mutations at codons 669 and 672 (HypoPP2). In HypoPP2, sodium channel mutations enhance inactivation to produce a net loss of function defect.

Normokalemic PP resembles both HyperPP (potassium sensitivity) and HypoPP (duration of attacks) and is caused by SCN4A mutations at a deeper location of voltage sensor DII at codon 675. R675 mutations differ from HypoPP in that these mutations result in depolarization-activated gating pore generating ω-current with reversed voltage dependence as this site is exposed to extracellular sites at stronger depolarization.[3]

Calcium channel gene

The calcium channel gene (CACNL1A3) is a complex of 5 subunits (alpha-1, alpha-2, beta, gamma, and delta). The skeletal muscle dihydropyridine (DHP) receptor is located primarily in the transverse tubular membrane. The alpha-1 subunit has binding sites for DHP drugs and conducts the slow L-type calcium current. It also participates in excitation-contraction (EC) coupling and acts as a voltage sensor through its linkage with the ryanodine receptor of sarcoplasmic reticulum (ie, calcium release channel). Any changes in the membrane potential are linked to intracellular calcium release, enabling EC coupling. Point mutations in DHP receptor/calcium channel alpha-1 subunit cause hypokalemic PP (HypoPP1). Two mutations of CACNA1S gene, R528H and R1239H, are responsible for most cases of hypokalemic PP.

The physiological basis of disease is still not understood, but is more likely due to a failure of excitation rather than a failure of EC coupling. However, hypokalemia-induced depolarization may reduce calcium release, affecting the voltage control of the channel directly or indirectly through inactivation of the sodium channel. Insulin and adrenaline may act in a similar manner. Mutations of the calcium channel gene have some similarities to SCN4A mutations. Mutations modify channel inactivation but not voltage-dependent activation. Recordings from myotube cultures from affected patients revealed a 30% reduction in the DHP-sensitive L-type calcium current. Channels are inactivated at low membrane potentials.

Calcium channel mutations cause a loss of function manifested as a reduced current density and slower inactivation. How this inactivation is related to hypokalemia-induced attacks is not understood. At least in R528H mutation, a possible secondary channelopathy occurs, tied to a reduction in the ATP-sensitive potassium current from altered calcium homeostasis. The lower currents associated with CACNL1A3 mutations could slightly alter intracellular calcium homeostasis, which could affect the properties and expression of K+ channels, particularly KATP (ATP-sensitive potassium channel) belonging to inward rectifier class of channels. Insulin also acts in HypoPP by reducing this inward rectifier K+ current.

Voltage sensor charge loss accounts for most cases of HypoPP. Sodium and calcium channels have homologous pore-forming alfa subunits. Point mutations in CACNL1A3 and SCN4A affect argentine residues in the S4 voltage sensors of these channels. Arginine mutations in S4 segments are responsible for 90% of HypoPP cases.[4]

Voltage sensor charge loss accounts for most cases of HypoPP. Sodium and calcium channels have homologous pore-forming α subunits. Almost all of the mutations in Cav1.1 (HypoPP-1) and Nav1.4 (HypoPP-2) neutralize a positively charged amino acid in one of the outermost arginines or lysines of voltage sensors. The Nav1.4 mutations are most commonly situated in the voltage sensors of I, II, and III repeats, causing a cation leak.

Substitution of outermost arginine with a smaller amino acid such as glycine opens a conductive pathway at hyperpolarized potential, resulting in an inward cation current (cation leak or ω current to distinguish from (ω-) through ion–conducting pore, is a hyperpolarization-activated current of monovalent cations through S4 gating pore counteracting rectifying K+ currents) depolarizing or destabilizing the resting potential.

S4 segment moves outward during depolarization closing the conductive pathway. Muscle fibers with severe voltage sensor mutations are depolarized not only during hypokalemia but also at potassium levels in the normal range, explaining interictal and permanent weakness. Severe myopathy with fatty replacement of muscle tissue is commonly found in patients with Cav1.1 R1239H (DIV mutations).[1]

Glucocorticosteroids cause HypoPP by stimulating Na+ K+ ATPase mediated by insulin and amylin.[5]

Potassium channel gene

Inward rectification is an important property of Kir channels. Rectification involves voltage-dependent conduction-pore blockage of pore with polyamines and Mg++ during depolarization, and this blockage is removed during potential gradient during hyperpolarization. Potassium channel mutations are seen in Andersen-Tawil syndrome and thyrotoxic PP.

The triad of dysmorphic features, periodic paralysis, and cardiac arrhythmias characterizes Andersen-Tawil syndrome. This syndrome is associated with mutations in the KCNJ2 gene.[6] The KCNJ2 gene encodes the inward-rectifying potassium channel Kir2.1. Potassium channel mutations in KCNE3 are reported to cause hypokalemic PP, but this has not been substantiated.

Mutations in Kir2.6 cause susceptibility to thyrotoxic PP. Episodic weakness seen in thyrotoxic PP is similar to that seen in HypoPP and Andersen-Tawil syndrome. This disorder is most prevalent in Asians and Latin American men. Thyrotoxic PP is a genetic disorder unmasked by thyrotoxicosis. Kir2.6 is primarily expressed in skeletal muscle. Triiodothyronine enhances KCNJ18 transcription, which may drive enhanced expression of Kir2.6. PKC is activated during thyrotoxicosis because of increased PIP2 turnover and Kir channels directly interact with PIP2 during normal gating. In Andersen-Tawil syndrome, there is decreased PIP2 affinity. In thyrotoxic PP, none of the mutations alters Kir2.6 rectification.[7]

Epidemiology

Frequency

The frequencies of hyperkalemic periodic paralysis, paramyotonia congenita (PC), and potassium-aggravated myotonias (PAM) are not known. Hypokalemic periodic paralysis has a prevalence of 1 case per 100,000 population.

Thyrotoxic PP is most common in males (85%) of Asian descent with a frequency of approximately 2%.

History

All periodic paralyses (PPs) are characterized by episodic weakness. Strength is normal between attacks. Fixed weakness may develop later in some forms. Most patients with primary PP develop symptoms before the third decade.[8]

Hyperkalemic periodic paralyses

Hypokalemic periodic paralyses

Paramyotonia congenita

Thyrotoxic periodic paralyses

Andersen-Tawil syndrome

Physical

Most of the patients with a periodic paralysis (PP) have similar clinical features, which are as follows:

Table 2. Distinguishing Features Among the Common Forms of Periodic Paralyses



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Laboratory Studies

Hypokalemic periodic paralyses

Serum potassium level decreases during attacks but not necessarily below normal. Creatine phosphokinase (CPK) level rises during attacks. In a recent study, transtubular potassium concentration gradient (TTKG) and potassium-creatinine ratio (K/C) distinguished primary hypokalemic PP from secondary PP resulting from a large deficit of potassium. Values of more than 3.0 mmol/mmol (TTKG) and 2.5 mmol/mmol (PCR) indicated secondary hypokalemic PP.

A random urine potassium-creatinine ratio (K/C) of less than 1.5 is indicative of poor intake, gastrointestinal loss, and potassium shift into the cells. If hypokalemia is associated with paralysis, one should consider hyperthyroidism or familial or sporadic periodic paralysis.

Some of the medical conditions associated with hypokalemia are included in the table below (modified from Assadi 2008[13] ).

Table 5. Medical Conditions Associated With Hypokalemia



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ECG may show sinus bradycardia and evidence of hypokalemia (flattening of T waves, U waves in leads II, V 2 , V 3 , and V 4 , and ST-segment depression).

Hyperkalemic periodic paralyses

Serum potassium level may increase to as high as 5-6 mEq/L. Sometimes, it may be at the upper limit of normal, and it seldom reaches cardiotoxic levels. Serum sodium level may fall as potassium level rises. This results from sodium entry into the muscle. Water also moves in this direction, causing hemoconcentration and further hyperkalemia. Hyperregulation may occur at the end of an attack, causing hypokalemia. Water diuresis, creatinuria, and an increase in CPK level also may occur at the end of an attack.

ECG may show tall T waves.

Table 6. Diagnostic Studies of Hypokalemic and Hyperkalemic Periodic Paralyses



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Other Tests

Electrodiagnosis and provocative testing can be performed for periodic paralysis.

Electrodiagnosis

Nerve conduction studies

The compound muscle action potential (CMAP) amplitude declines during the paralytic attack, more so in hypokalemic periodic paralysis. Sensory nerve conduction study findings are normal in most patients with periodic paralyses. Nerve conduction findings may be abnormal when the patient has peripheral neuropathy associated with thyrotoxicosis.

Repetitive nerve stimulation in hyperkalemic periodic paralysis may show a decrement in CMAP (accentuated by cooling) that is steadily progressive without tendency to recover as in myasthenia gravis. The amount of decrement is variable and increases with increased frequency of stimulation. In some patients, it is seen only with stimulation greater than 25 Hz.[14]

Muscle cooling

Cooling of muscle to 20°C leads to force reduction and prolonged twitch-relaxation in PC and hyperkalemic periodic paralyses. Muscle paralysis is prolonged and persistent even after rewarming.

As the muscle depolarizes at different temperatures in different patients, a muscle temperature of 20-25°C is preferable. This is best achieved by immersing the whole arm in ice water. This alone causes weakness in many patients.

Short periods of exercise (2-3 1-second short exercises) enhance the weakness and result in a very small CMAP.[14]

Exercise test in periodic paralyses

This is one of the most informative diagnostic tests for periodic paralyses. The test is based on 2 previously described observations: that CMAP amplitude is low in the muscle weakened by periodic paralyses and the weakness can be induced by exercise. Recording electrodes are placed over the hypothenar muscle and a CMAP is obtained by giving supramaximal stimuli. The stimuli are repeated every 30-60 seconds for a period of 2-3 minutes, until a stable baseline amplitude is obtained. Two kinds of exercise tests can be performed.

A short exercise test is one in which the muscle is contracted strongly in isometric conditions for 10-12 seconds. CMAPs are obtained 2 seconds immediately after exercise an then every 10 seconds for 50 seconds. In hyperkalemic periodic paralyses patients carrying T704M mutations, increase in CMAP amplitude (approximately 23%) occurs. In HypoPP1 and HypoPP2 patients, the increase is not significantly different from the control subjects (about 5%).

In the long exercise test, the muscle is contracted for 5 minutes, with brief (3- to 4-second) rests every 15 seconds to prevent muscle ischemia. The CMAP is recorded every minute during exercise and every 1-2 minutes after exercise for a period of 30 minutes or until no further decrement is observed in the amplitude of CMAP. Percentage of decrement is calculated by subtracting the smallest amplitude after exercise from the greatest amplitude after exercise and dividing it by the greatest amplitude after exercise. After a brief increase in CMAP amplitude, a decrease of more than 40% in the CMAP amplitude after 20 minutes is considered abnormal. An abnormal result is highly suggestive of periodic paralyses (98% specificity) but does not distinguish between hyperkalemic, hypokalemic, and thyrotoxic periodic paralyses. Different electrophysiologic patterns are identified in different group of patients with distinct mutations by using both these tests.

Table 7. Electrophysiological Patterns to Exercise Testing



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Needle electrode examination

See the list below:

Provocative Testing

General precautions for such testing include (1) physician presence during testing, (2) performance of testing in an intensive care setting, (3) avoidance of testing patients with serum potassium disturbances, diabetes mellitus, or renal or cardiac dysfunction, (4) close monitoring of ECG, and (5) capability for rapid electrolyte and glucose testing and correction.

Hypokalemic periodic paralyses

Provocative testing is dangerous and is not the first line of diagnostic testing.

Hyperkalemic periodic paralyses

Potassium chloride 0.05 g/kg in a sugar-free liquid is given orally over 3 minutes in a fasting state, just after exercise. If no weakness occurs, an additional amount of potassium chloride (0.10-0.15 g/kg) is given. Electrolyte profile, ECG, and strength are tested every 15 minutes for 2 hours and then every 30 minutes for the next 2 hours. Weakness usually is detected between 90-180 minutes after initiation of testing.

Histologic Findings

Muscle biopsy is abnormal, more typically in patients with hypokalemic periodic paralysis (PP) than in patients with hyperkalemic periodic paralysis (PP). Histologic findings in hypokalemic PP include the following:

Medical Care

Treatment is often necessary for acute attacks of hypokalemic periodic paralysis but seldom for hyperkalemic periodic paralysis. Prophylactic treatment is necessary when the attacks are frequent.

Dichlorphenamide, a carbonic anhydrase inhibitor, was approved by the FDA in August 2015 for the management of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants. Approval was based on 2 randomized, double-blinded placebo-controlled studies that included 138 patients. Treatment with dichlorphenamide resulted in significantly fewer muscle weakness attacks/week compared with placebo (2.3 to 3.9 fewer attacks/week with hyperkalemic periodic paralysis; 2.2 fewer attacks/week with hypokalemic periodic paralysis).[16]

Hypokalemic periodic paralyses

During attacks, oral potassium supplementation is preferable to IV supplementation. The latter is reserved for patients who are nauseated or unable to swallow. Potassium chloride is the preferred agent for an acute attack (assuming a normal renal function).[17] A reasonable initial dose for a 60-120 kg man (ie, 0.5-1 mEq/kg) is 60 mEq. Typically, 40-60 mEq of K+ raises the potassium concentration by 1.0-1.5 mEq/L, and 135-160 mEq of K+ raises plasma potassium by 2.5-3.5 mEq/L. Aqueous potassium is favored for quicker results. If there is no response in 30 minutes, an additional 0.3 mEq/kg may be given. This should be repeated up to 100 mEq of potassium. Beyond this, monitoring of serum potassium is warranted prior to further supplementation. Typically, one should not exceed a total dose of 200 mEq in a day.

Intravenous potassium is reserved for cardiac arrhythmia or airway compromise due to ictal dysphagia or accessory respiratory muscle paralysis. IV potassium chloride 0.05-0.1 mEq/kg body weight in 5% mannitol as a bolus is preferable to continuous infusion. Mannitol should be used as solvent, as both sodium and dextrose worsen the attack. Only 10 mEq at a time should be infused with intervals of 20-60 minutes, unless in situations of cardiac arrhythmia or respiratory compromise. This is to avoid hyperkalemia at the end of an attack with shift of potassium from intracellular compartment into the blood. Continuous ECG monitoring and sequential serum potassium measurements are mandatory.

For prophylaxis, dichlorphenamide 50-100 mg BID may be considered for the management of primary hypokalemic periodic paralysis. Acetazolamide is an off-label alternative that is administered at a dose of 125-1500 mg/d in divided doses. Potassium-sparing diuretics like triamterene (25-100 mg/d) and spironolactone (25-100 mg/d) are second-line drugs to be used in patients in whom the weakness worsens, or in those who do not respond to carbonic anhydrase inhibitors. Spironolactone may cause gynecomastia, but this is less with eplerenone. Blood pressure monitoring is advised. Because these diuretics are potassium sparing, potassium supplements may not be necessary.

Approximately 50% of genotyped patients with HypoPP respond to acetazolamide. Poor response is predicted with substitution of arginine with smaller glycine in the residues of voltage sensors near the extracellular side of the sarcolemma. Almost 60% of patients with common CACNA1S mutations show favorable response to acetazolamide, whereas only 16% of patients with SCN4A mutations benefited from acetazolamide. In both cohorts, this poor response is predicted with substitution of arginine with smaller glycine in the residues of the voltage sensor near the extracellular side of the sarcolemma.[18]

Thyrotoxic periodic paralysis

Treatment consists of controlling thyrotoxicosis and beta-blocking agents. Potassium supplementation, dichlorphenamide, propranolol, and spironolactone may be helpful during the attacks as well as for prophylaxis. Dichlorphenamide 50-100 mg BID or propranolol in doses of 20-40 mg twice a day may be sufficient to control recurrent attacks of periodic paralysis.

Hyperkalemic periodic paralyses

Fortunately, attacks are usually mild and rarely require treatment. Weakness promptly responds to high-carbohydrate foods. Beta-adrenergic stimulants, such as inhaled salbutamol, also improve the weakness (but are contraindicated in patients with cardiac arrhythmias).

In severe attacks, therapeutic measures that reduce hyperkalemia are utilized. Continuous ECG monitoring is always needed during the treatment. Dichlorphenamide 50-100 mg BID is indicated for hyperkalemic periodic paralysis. Thiazide diuretics and carbonic anhydrase inhibitors are used as prophylaxis. Thiazide diuretics have few short-term side effects; they are tried as first-line treatment. Occasionally, thiazide diuretics may result in paradoxical hypokalemic weakness, which responds to potassium supplementation.

Paramyotonia congenita

Because weakness is uncommon, treatment is aimed at reducing myotonia. While the above-mentioned diuretics can be tried, they are often not effective. Mexiletine has been shown to be helpful but is contraindicated in patients with heart block.

Potassium-associated myotonia

Treatment with mexiletine or a thiazide diuretic may reduce the severity of the myotonia.

Andersen-Tawil syndrome

A combination of amiodarone and acetazolamide resulted in a long-lasting improvement in one study.[19]

Implantation of a cardiac defibrillator has rarely been performed.

Carbonic anhydrase inhibitors are used for preventing periodic paralysis.

Potassium supplementation prevents periodic paralysis and also reduces cardiac arrhythmia, shortening the QT interval.

For the control of cardiac symptoms, β-blockers or calcium channel blockers may be used.

Flecainide has been shown to be successful in treating bidirectional ventricular tachycardia, ventricular ectopy, and tachycardia-induced cardiomyopathy.[20]

Surgical Care

Malignant hyperthermia susceptibility has been noted in HypoPP with calcium channel mutations. It is prudent to monitor all patients with periodic paralysis for this complication.

Diet

See the list below:

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Dichlorphenamide (Keveyis)

Clinical Context:  Carbonic anhydrase inhibitor, but the exact mechanism by which dichlorphenamide is able to treat periodic paralysis is unknown. Inhibits H+ ion excretion in renal tubule, resulting in increased sodium, potassium, bicarbonate, and water excretion and producing alkaline diuresis. It is indicated for primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants.

Acetazolamide (Diamox)

Clinical Context:  Exact mechanism of action unknown. In hypokalemic PP, may decrease potassium inflow to muscle because of metabolic acidosis. In hyperkalemic PP, kaliopenic effect of CA inhibitors may be beneficial. Recent data suggest carbonic anhydrase inhibitors activate skeletal muscle BK channel (Ca2+ -activated potassium channel).

Class Summary

Carbonic anhydrase (CA) is an enzyme found in many tissues of the body, including the eye. It catalyzes a reversible reaction whereby carbon dioxide becomes hydrated and carbonic acid dehydrated.

Prognosis

See the list below:

Patient Education

See the list below:

What is periodic paralyses (PP)?How is primary periodic paralyses (PP) classified?What is the pathophysiology of periodic paralyses (PP)?What is the role of channel dysfunction in the pathophysiology of periodic paralyses (PP)?What is the role of muscle sodium channel gene in the pathophysiology of periodic paralyses (PP)?What is the role of temperature sensitivity in the pathophysiology of periodic paralyses (PP)?Which genetic mutations cause hyperkalemic periodic paralyses (PP)?Which genetic mutations cause normokalemic periodic paralyses (PP)?What is the role of calcium channel gene in the pathophysiology of periodic paralyses (PP)?What is the role of voltage sensor charge loss in the pathophysiology of hypokalemic periodic paralyses (HypoPP)?What is the role of potassium channel gene in the pathophysiology of periodic paralyses (PP)?What is the prevalence of periodic paralyses (PP)?Which clinical history findings are characteristic of periodic paralyses (PP)?Which clinical history findings are characteristic of hyperkalemic periodic paralyses (PP)?Which clinical history findings are characteristic of hypokalemic periodic paralyses (HypoPP)?Which clinical history findings are characteristic of paramyotonia congenita?Which clinical history findings are characteristic of thyrotoxic periodic paralyses (TPP)?Which clinical history findings are characteristic of Andersen-Tawil syndrome?Which physical findings are characteristic of periodic paralyses (PP)?Which conditions should be included in the differential diagnoses of periodic paralyses (PP)?What are the differential diagnoses for Periodic Paralyses?What is the role of lab testing in the workup of hypokalemic periodic paralyses (HypoPP)?Which lab studies are used for the workup of hyperkalemic periodic paralyses (HyperPP)?What is the role of nerve conduction studies in the workup of periodic paralyses (PP)?What is the role of muscle cooling in the workup of periodic paralyses (PP)?What is the role of exercise testing in the workup of periodic paralyses (PP)?What is the role of a needle electrode exam in the workup of periodic paralyses (PP)?What are general precautions for provocative testing in patients with periodic paralyses (PP)?What is the role of provocative testing in the workup of hypokalemic periodic paralyses (HypoPP)?What is the role of provocative testing in the workup of hyperkalemic periodic paralyses (HyperPP)?Which histologic findings are characteristic of periodic paralyses (PP)?How is periodic paralyses (PP) treated?How is hypokalemic periodic paralyses (HypoPP) treated?What is the role of dichlorphenamide in hypokalemic periodic paralyses (HypoPP) prophylaxis?How is thyrotoxic periodic paralyses (TPP) treated?How is hyperkalemic periodic paralyses (HyperPP) treated?How is paramyotonia congenita treated?How is potassium-associated myotonia, treated?How is Andersen-Tawil syndrome treated?What is the role of surgery in the treatment of periodic paralyses (PP)?Which dietary modifications are used in the treatment of periodic paralyses (PP)?What are the goals of drug treatment for periodic paralyses (PP)?Which medications in the drug class Carbonic anhydrase inhibitors are used in the treatment of Periodic Paralyses?What is the prognosis of periodic paralyses (PP)?Where are patient education resources about periodic paralyses (PP) found?

Author

Naganand Sripathi, MD, Director, Neuromuscular Clinic, Department of Neurology, Henry Ford Hospital

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Glenn Lopate, MD, Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University in St Louis School of Medicine; Consulting Staff, Department of Neurology, Barnes-Jewish Hospital

Disclosure: Nothing to disclose.

Chief Editor

Nicholas Lorenzo, MD, MHA, CPE, Co-Founder and Former Chief Publishing Officer, eMedicine and eMedicine Health, Founding Editor-in-Chief, eMedicine Neurology; Founder and Former Chairman and CEO, Pearlsreview; Founder and CEO/CMO, PHLT Consultants; Chief Medical Officer, MeMD Inc; Chief Strategy Officer, Discourse LLC

Disclosure: Nothing to disclose.

Additional Contributors

Paul E Barkhaus, MD, FAAN, FAANEM, Professor of Neurology and Physical Medicine and Rehabilitation, Chief, Neuromuscular and Autonomic Disorders Program, Director, ALS Program, Department of Neurology, Medical College of Wisconsin

Disclosure: Nothing to disclose.

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Mutations in periodic paralysis.

Mutations in periodic paralysis.

Disease Gene Protein Inheritance Mutation
HyperPP SCN4A Nav1.4DominantGain
NormoPP   Gain (ω-pore)
ParamyotoniacongenitaGain
HypoPP Type IIGain (ω-pore)
HypoPP Type I CACNA1S Cav1.1DominantGain (ω-pore)
ThyrotoxicPP KCNJ18 Kir2.18DominantLoss
Andersen-Tawil syndrome KCNJ2 Kir2.1DominantLoss
Syndrome Age of Onset Duration of Attack Precipitating



Factors



Severity of Attacks Associated



Features



Hyper-kalemic periodic paralysesFirst decade of lifeFew minutes to less than 2 h (mostly less than 1 h)Low carbohydrate intake (fasting)



Cold



Rest following exercise



Alcohol



Infection



Emotional stress



Trauma



Menstrual period



Rarely severePerioral and limb paresthesias



Myotonia frequent



Occasional pseudo-hypertrophy of muscles



Hypo-kalemic periodic paralysesVariable -Childhood to third decade



Majority of cases before 16 years



Few hours to almost a week



Typically no longer than 72 h



Early morning attacks after previous day physical activity



High-carbohydrate meal, Chinese food, alcohol



Cold, change in barometric pressure or humidity



Fever, upper respiratory tract infections



Lack of sleep,



fatigue



Menstrual cycle



Severe



Complete paralysis



Occasional myotonic lid lag



Myotonia between attacks rare



Unilateral, partial, monomelic



Fixed muscle weakness late in disease



Potassium- associated myotoniaFirst decadeNo weaknessCold



Rest after exercise



Attacks of stiffness can be mild to severeMuscle hypertrophy
Para-myotonia congenitaFirst decade2-24 hColdRarely severePseudo-hypertrophy of muscles



Paradoxical myotonia



Fixed weakness rare



Thyrotoxic periodic paralysesThird and fourth decadesFew hours to 7 dSame as hypokalemic PP



Hyper-insulinemia



Same as hypokalemic PPFixed muscle weakness may develop



Hypokalemia during attacks



Hypokalemic Hyperkalemic
Urinary potassium-wasting syndromes
  • Hyperaldosteronism
  • Conn syndrome
  • Bartter syndrome
  • Licorice intoxication
 
AlcoholAddison disease



Chronic renal failure



Hyporeninemic



Hypoaldosteronism



Drugs - Amphotericin B, bariumIleostomy with tight stoma
Renal tubular acidosisPotassium load
GI potassium-wasting syndromes
  • Laxative abuse
  • Severe diarrhea
Potassium-sparing diuretics
Disorder Pattern and



Distribution of



Weakness



Transient ischemic attacksFollow CNS distribution (ie, hemiparetic)



May have sensory symptoms and signs



Sleep attacksOccur at onset or termination of sleep



Last only minutes



Myelopathy
  • Traumatic
  • Transverse myelitis
  • Ischemic
Sensory symptoms



Presence of a sensory level



Sphincter involvement



Myasthenia gravis



Lambert-Eaton myasthenic syndrome



Subacute in onset



Associated autonomic symptoms in LEMS



Hyporeflexia in LEMS



Abnormal repetitive nerve stimulation



Presence of distinct antibodies



Peripheral neuropathy of acute onset
  • Acute inflammatory
  • demyelinating poly-radiculoneuropathy
  • Porphyria
Pattern of weakness



Absent stretch reflexes



Toxins
  • Ciguatera
  • Tetrodotoxin
Clinical presentation
Urine K/C Ratio Acid Base Status Other Associated Features Medical



Conditions



< 1.5Metabolic acidosis Lower GI loss – Laxative abuse, diarrhea
< 1.5Metabolic alkalosisNormal BPSurreptitious vomiting
>1.5Metabolic acidosis DKA, type 1 or type 2 distal RTA
>1.5Metabolic alkalosisNormal BPDiuretic use, Bartter syndrome, Gitelman syndrome
≥1.5Metabolic alkalosisHypertensionPrimary aldosteronism, Cushing syndrome, renal artery stenosis, congenital adrenal hyperplasia, apparent mineralocorticoid excess, Liddle syndrome
  Hypokalemic PP Hyperkalemic PP
Serum potassiumMildly depressed; may reach 1-5 mEq/LIncreases from baseline but may not increase beyond normal range
Serum CPKModerately elevated during attacksMildly elevated during attacks
ECGBradycardia



Flat T waves, U waves, ST-segment depression



Tall T waves
  Para-



myotonia



Congenita



Hyper-



kalemic



Periodic Paralysis



Hypo-



kalemic



Periodic Paralysis



Electrophysiological



pattern



IIVV
Channel mutationsSodium T1313M, R1448CSodium T704MCalcium R528H
Short Exercise Test:    
Post exercise myotonic potentialsYesNoNo
CMAP amplitude



change after First trial



Increase or



decrease



IncreaseNo
CMAP amplitude



change after second



and third trial



Gradual



increase



Gradual



increase



No
Long Exercise Test:    
Immediate change of



CMAP amplitude



DecreaseIncreaseNo
Late change of CMAP amplitudeDecreaseDecreaseDecrease
Modified from Fournier et al, 2004.[15]