An unusual case of episodic quadriparesis
A 29-year-old male, presented with the complaint of sudden onset weakness of all four limbs since last night. History was negative for unusually high carbohydrate intake, excessive exertion or alcohol intake in the previous night. He also denied symptoms of unexplained sweating, tremors, heat intolerance, prolonged vomiting or any drug intake over a prolonged period of time. He had a preceding history of muscle cramps and paresthesia for about a month. Past history dates back in the year 2002, which revealed that the patient had similar mode of presentation. Subsequently, he had been admitted in a local hospital and improved symptomatically with conservative therapy. This episode repeated 1 year back and he was treated in the similar way. However, the details of further treatment history could not be gathered. Neurological examination revealed bilaterally symmetrical weakness (Gr 2/5) of all four limbs and generalized hyporeflexia with bilaterally flexor plantar response. Eyes, face, tongue, pharynx, larynx, diaphragm and sphincters were not involved. Higher functions, cranial nerves and sensory system were intact.\nThe present investigations revealed serum potassium: 4.3 mEq/L (reference range: 3.5-5), corrected calcium: 13 mg/dl (8.5-10.5), phosphate: 2.6 mg/dl (3-5) and alkaline phosphatase: 216 U/L (80-306). All other electrolytes were within the normal limit. Routine blood examinations, complete hemogram, creatinine, thyroid function tests, serum creatine phosphokinase, serologic viral markers and serum protein electrophoresis did not reveal any abnormality. Further evaluation of muscular weakness by electromyography was normal. Nerve conduction velocity study was also normal. However on examination of the abdomen by ultrasonography, multiple renal calculi were found in both kidneys. X-ray abdomen reassured the evidence of bilateral nephrolithiasis. On further plan, serum immunoassay for parathyroid hormone value was found to be 147 pg/ml (reference range: 10-69) and 25-hydroxy vitamin D value was 25 ng/dl (reference range: 11.1-42.9). T score at wrists had evidence of osteopenia (~1.0). His serum calcitonin was normal (7.4 pg/ml) (reference range: <5) and 24 h urinary calcium excretion reported as high (396 mg) (reference range <300). Though, Technetium 99m (99m TC) sestamibi scan [] could not confirm the possible etiology but ultrasound and computed tomography (CT) scan of neck the evidence of bilaterally enlarged parathyroids [Figures and ]. He was treated with volume correction and supportive measures. He improved dramatically again within 24 h and with the diagnosis of PHPT, he has been planned for surgery.