Impact of Otitis Media With Effusion in Early Age on Auditory Processing Abilities in Children: A Systematic Review and Meta-Analysis.

Objective: Early-onset otitis media with effusion (OME) can affect the development of the auditory nervous system and thus lead to auditory processing abnormalities. This study aims to review the effect of childhood OME on auditory processing abilities in children. Methods: A systematic review of the literature, restricted to the English language from 1990 to 2022 was conducted using search engines like PubMed, Embase, and Google Scholar. After selecting the articles following predefined inclusion and exclusion criteria, the data were extracted and meta-analysis was performed. Results: A total of 10 articles met the inclusion criteria. Children with a history of OME had poorer performance in most behavioral and electrophysiological tests. Pooled analysis of various tests such as the gap in noise test, frequency pattern test (verbal and nonverbal), and latencies of auditory brainstem response-I, V, I to III, and I to V showed a difference between the 2 groups. Conclusion: Childhood OME can significantly affect auditory processing abilities in children.

Amoxicillin-induced bullous erythema multiforme: a case report.

Introduction: Bullous erythema multiforme (BEM), an immune-mediated, acute condition, frequently includes erosion affecting the oral, genital, and/or ocular mucosa in addition to discrete target-like lesions on the skin. BEM has been linked to various factors, including infections, medications, malignancy, autoimmune disease, immunization, and radiation. Case presentation: Here, we report a case of a 38-year-old married woman who presented with symptoms of reddish-raised, fluid-filled and painful, nonpruritic lesions along with the swelling of bilateral hand and feet. This patient had a history of taking some unrecorded ayurvedic medication for bloating and abdominal pain in a background of antibiotic use before exhibiting the dermatological symptoms of BEM 2 days later. She was successfully managed with ampicillin and cloxacillin, acyclovir and prednisolone. Clinical discussion: A few incidence of BEM after the administration of amoxicillin has been reported, which precipitated only after consuming ayurvedic medication. BEM has a clinical diagnosis with biopsy rarely required. Here, the hypersensitivity reaction induced by the antibiotic itself or by altering the immune response to the concomitant consumed herbal medicine could explain the BEM. Conclusion: Physicians should note that amoxicillin can trigger BEM, regardless of its use with ayurvedic drugs. Antibiotics should be used with caution, especially in patients with a history of BEM.

Utilization rates of intravenous thrombolysis for acute ischemic stroke in Asian countries:: A systematic review and meta-analysis.

BACKGROUND: Despite intravenous thrombolysis (IVT) being used for the treatment of acute ischemic stroke (AIS) for over two decades, its accessibility remains limited in various regions of the world. The Asian region, which experiences the highest age-standardized incidence of AIS, currently lacks comprehensive data on the utilization of IVT. AIMS: This study aimed to provide precise estimates of IVT usage for AIS in Asian countries. METHODS: A literature search was conducted on PubMed and Google using appropriate search terms. English language, peer reviewed articles published after 2010 were included in the analysis. The pooled proportion was calculated utilizing the DerSimonian and Laird random-effects model. Additionally, a subgroup analysis was conducted, taking into account factors such as the study's country, the economic status of the country, specific Asian regions, publication year (before 2015 and from 2015 onwards), study location, study setting, hospital stroke protocol, and national stroke guidelines. RESULTS: 67 observational studies with 778,046 patients with AIS were included in the meta-analysis. The overall utilization rate of IVT was found to be 9.1%. High-income countries had a higher rate (11.3%) compared to lower-middle-income (8.1%) and upper-middle-income countries (9%). Central and North Asia had the highest rate (17.5%) and Southeast Asia had the lowest rate (6.8%). Studies conducted after 2015 had a higher thrombolysis rate (11.3%) compared to those before 2015 (1.5%). Presence of hospital stroke protocols (10.7%) and national stroke guidelines (10.1%) were associated with higher thrombolysis rates. CONCLUSION: The overall utilization rate of IVT for AIS in Asia stood at 9.1%, showcasing noteworthy disparities across countries, regions, and income brackets. To improve thrombolysis rates in the region, addressing prehospital delays, increasing public awareness, and implementing stroke protocols and national guidelines are key strategies.

High-Altitude Exposure and Cerebral Venous Thrombosis: An Updated Systematic Review.

Kharel, Sanjeev, Suraj Shrestha, Samriddha Raj Pant, Suman Acharya, Amit Sharma, Santosh Baniya, and Sanjeeb S. Bhandari. High-altitude exposure and cerebral venous thrombosis: an updated systematic review. High Alt Med Biol. 24:167-174, 2023. Background: High altitude (HA) may increase the risk of cerebral venous thrombosis (CVT). Differentiating it from other HA illnesses is crucial for prompt treatment and better outcomes. We aimed to summarize the clinical data, etiology, and risk factors of this poorly understood entity at an HA. Materials and Methods: A systematic literature search of various databases, including PubMed, Embase, and Google Scholar, was done using relevant keywords; cerebral venous thrombosis; HA, up to May 1, 2022. Results: A total of nine studies, including 75 cases of CVT at HA (3,000-8,848 m), with 66 males and 9 females, were included in this review. Headache and seizure were the most common clinical presentations. Smoking, drinking habits, and the use of oral contraceptive pills (OCP) were the most common risk factors for the development of CVT. Similarly, various underlying hypercoagulable states were also present among cases of CVT associated with HA exposure. Conclusion: Our review concludes that HA exposure can predispose individuals with risk factors such as preexisting hypercoagulable states, smoking, drinking habits, and use of OCP to an increased risk of CVT.

Breakage of an orogastric tube in a critically Ill patient: a case report.

Orogastric and nasogastric tubes are common methods of enteral feeding. Although the methods of tube feeding are simple, these methods are not free of complications. Case presentation: This case report describes a 58-year-old patient with the diagnosis of stroke, in whom there was breakage of an orogastric tube during a prolonged ICU stay. Clinical discussion: Early enteral feeding in patients without any contraindications is associated with improved organ survival and recovery, and decreased incidence of infections, which decreases the ICU stay and improves the overall outcome. Nasogastric and orogastric tubes are the most commonly inserted feeding tubes. Breakage of an orogastric tube is a rare complication that can occur due to manufacturing defects, exposure to a harsh acidic environment, and forceful flushing of an obstructed tube. Conclusions: Timely identification of the broken feeding tube can help the treating clinicians retrieve it easily even with the help of a laryngoscope in selected patients.

Severe hyponatremia as an atypical manifestation of pituitary macroadenoma: a case report.

Pituitary macroadenoma most commonly presents with visual disturbances, headache, and other symptoms secondary to adeno hypophyseal hormonal deficiencies and usually alleviates after tumor resection. Pituitary adenomas may be the cause of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) causing hyponatremia, although so far, there have only been a few documented cases. Here, we present a case of pituitary macroadenoma with SIADH and hyponatremia. This case has been reported in line with CARE (CAse REport) criteria. Case presentation: We present a case of a 45-year-old woman who presented with symptoms of lethargy, vomiting, altered sensorium, and seizure. Her initial sodium level was 107 mEq/l, plasma and urinary osmolality were 250 and 455 mOsm/kg, respectively, and her urine sodium level was 141 mEq/day, suggestive of hyponatremia due to SIADH. MRI scan of the brain revealed approximately 14×13×11 mm pituitary mass. Prolactin and cortisol levels were 41.1 ng/ml and 5.65 µg/dl, respectively. Clinical discussion: Hyponatremia can result from various diseases, making it hard to identify the cause. A pituitary adenoma is a rare cause of hyponatremia due to SIADH. Conclusion: Pituitary adenoma rarely might be the cause of SIADH presenting as severe hyponatremia. So, in case of hyponatremia due to SIADH, clinicians should keep pituitary adenoma as well in their differential diagnoses.

MRI of the brain mimicking autoimmune encephalitis in Sjögren syndrome with chorea: a case report.

Neurologic manifestations in primary Sjögren syndrome (SS) range in prevalence from 8 to 49%, and most of the studies suggest a prevalence of 20%. The incidence of SS patients developing movement disorders is about 2%. Case presentation: The authors herein report a case of a 40-year-old lady with MRI of the brain mimicking autoimmune encephalitis in SS who presented with chorea. Her MRI findings revealed T2 and FLAIR (fluid-attenuated inversion recovery) high signal intensity areas in bilateral middle cerebellar peduncles, dorsal pons, dorsal midbrain, hypothalami, and medial temporal lobes. Clinical discussion: There is still no evidence to support the definite use of MRI in characterizing the central nervous system involvement in primary SS, especially due to overlapping findings with age and cerebrovascular disease. Multiple areas of increased signal intensity in periventricular and subcortical white matter in FLAIR and T2-weighted image is commonly seen in primary SS patients. Conclusion: It is crucial to consider autoimmune diseases like SS as a cause of chorea in adults, even in those whose imaging findings are suggestive of autoimmune encephalitis.

Wallerian degeneration in the brain after organophosphorus poisoning: a case report.

The type, quantity, and potency of the organophosphorus compound (OPC) taken determine the symptoms of OPC poisoning as well as their severity. The exact etiology for organophosphorus (OP) poisoning delay neuropathy regulating Wallerian degeneration is still unknown. Case Presentation: We report here a rare case of a 25-year-old lady with Wallerian degeneration in the brain found in an MRI in a patient after OPC ingestion. MRI of the brain, in our case, shows Wallerian degeneration of the corona radiata, internal capsule, and midbrain. Clinical Discussion: Some OPCs can lead to OP-induced delayed neuropathy, a form of delayed neurotoxicity in humans (OPIDN). The distal axonopathy's (in OPIDN) morphological pattern resembles Wallerian degeneration, which happens in vitro following nerve damage. Although delayed Wallerian degeneration from organophosphate poisoning often affects the peripheral nervous system, it can also affect the central nervous system. Rehabilitation therapy combined with appropriate nursing care has been demonstrated to improve the disease. Conclusion: Central nervous system involvement after OP poisoning is rare, and MRI of the brain and spinal cord can document evidence of Wallerian degeneration after OP poisoning.

Pontine and bilateral cerebellar lesion in osmotic demyelination syndrome associated with uncontrolled type II diabetes mellitus: a case report.

Osmotic demyelination syndrome (ODS) as a result of the hyperosmolar hyperglycemic state is rare and can present with variable neurological manifestation due to lysis of myelin sheath. Case presentation: A 44-year diabetic male presented with complaints of sudden onset, progressive bilateral weakness in lower limbs, and slurring of speech for the past 1.5 months. Cerebellar examination showed a bilaterally impaired finger nose test, dysdiadochokinesia, impaired heel shin test, and an impaired tandem gait. MRI brain (T2 and fluid-attenuated inversion recovery sequences) showed high signal intensity in the central pons and bilateral cerebellum. With a diagnosis of ODS with poorly controlled diabetes, he was treated with insulin, metformin, and supportive measures following which his symptoms subsided gradually. Clinical discussion: A rapid correction of hyponatremia is considered the most common cause of ODS. Variations in plasma glucose levels, a rare cause of ODS, can cause an abrupt osmolality change causing pontine and extrapontine myelinolysis. Prevention of rapid correction of hyponatremia and rapid changes in plasma osmolality in vulnerable patients is the mainstay of treatment. Conclusions: Clinical features, imaging studies, and monitoring of serum osmolality, serum glucose, and electrolytes aid in diagnosis and favorable outcomes for the patient.

Idiopathic recurrent pyoderma gangrenosum with cobalamin deficiency in a 62-year-old male: a case report.

Pyoderma gangrenosum (PG) is a rare, neither infectious nor gangrenous, neutrophil-mediated inflammatory dermatosis. In 50-70% of cases, systemic disease is the underlying cause, and the remaining is idiopathic. Case Presentation: The authors here present a case of a 62-year-old male with a history of recurrent ulcer over the dorsum of hand diagnosed with recurrent PG with cobalamin deficiency treated with intralesional steroid injection and topical antibiotics along with intramuscular vitamin B12 injections. The patient returned after a year with a history of swelling in the left hand for 1 week, which was managed with intravenous antibiotics. Clinical Discussion: The most common kind of PG is ulcerative, which accounts for around 85% of cases that have been found. Ulcerative PG begins as small, painful erythematous or violaceous papules and pustules that quickly develop into ulcers with an exudative, mucopurulent, hemorrhagic base or with areas of necrosis and high, well-defined, serpiginous, violet-blue, or metallic grey borders, which are its defining feature. Glucocorticoids, along with a wide range of additional systemic immunomodulatory medication as alternatives and antibiotics to prevent infection are used for treatment. Conclusion: PG is a rare form of neutrophilic dermatosis that can be difficult to diagnose and treat. PG has a mixed nutritional deficiency and a history of ulcers. It is crucial to have a high degree of suspicion when making a diagnosis, as well as to look for associated diseases and start treatment as soon as possible.

A Case of Pembrolizumab-Induced Diabetic Ketoacidosis and Hyperthyroidism in a Patient With Recurrent Esophageal Adenocarcinoma.

Immune checkpoint inhibitors (ICI) such as program cell death protein 1 (PD-1) inhibitors are widely used for the treatment of patients with recurrent, locally advanced or metastatic, gastric or gastroesophageal (GE) junction adenocarcinoma. Immune-related adverse events (irAE) such as endocrinopathies have been reported after patients received ICI. We report a case of pembrolizumab-induced hyperthyroidism and type 1 diabetes mellitus (DM1) presenting with diabetic ketoacidosis (DKA). A 53-year-old African American male with no history of diabetes or hyperthyroidism was treated with two cycles of pembrolizumab for recurrent GE junction adenocarcinoma after which he was admitted with hyperthyroidism (thyroid stimulating hormone [TSH] 0.070mIU/L, free thyroxine 1.85mIU/L) and DKA (pH 7.06, glucose 583 mg/dL, beta-hydroxybutyrate 8.63 mmol/L, anion gap 27 meq/L). The patient was treated with intravenous insulin and aggressively hydrated. Given the lack of other precipitating factors for the two endocrinopathies, it was determined that the most likely etiology was recent treatment with pembrolizumab (a PD-1 inhibitor). In our case, pembrolizumab monotherapy developed two irAE (hyperthyroidism and DKA), which is unique as most combined immunotherapy regimens are associated with the development of multiple endocrinopathies. Our case emphasizes the importance of baseline monitoring of thyroid function and blood glucose prior to the start of ICI to monitor and evaluate patients with immune-related adverse events, including endocrinopathies.

Stiff person syndrome in a Nepalese man with uncontrolled diabetes mellitus and ketonuria: A rare case report.

Stiff Person Syndrome (SPS), a progressive Central Nervous System disorder is accompanied by progressive muscle rigidity, hyperreflexia, and spasms mainly in truncal and proximal leg muscles mainly associated with autoimmune disorders. Here, we report a rare case of SPS in a middle-aged Nepalese man with uncontrolled diabetes mellitus and ketonuria.

Pembrolizumab-induced encephalitis in a patient with renal cell carcinoma post nephrectomy: A case report.

A new category of immune-related adverse effects has been identified due to increasing use of immune checkpoint inhibitor therapy to treat solid organ cancers. Pembrolizumab approved for renal cell carcinoma also has neurological immune-related adverse effects causing long-term morbidity. We here present a case of renal cell carcinoma post nephrectomy with suspected pembrolizumab (anti-PD-1)-induced encephalitis presenting as light headedness and dizziness treated with high dose of corticosteroid and intravenous immunoglobulin. Lumbar puncture was performed which showed elevated protein, nucleated cells with lymphocyte predominant, suggestive of chemical meningitis. Scans were found to be normal while electroencephalogram showed diffuse cerebral dysfunction indicating encephalopathy. The patient was under pembrolizumab treatment so encephalitis was suspected. Clinical attention is necessary when patients receiving immune checkpoint inhibitors appear with new neurological symptoms to prevent long-term morbidity or even possible mortality.

Clinical profile and management of perforation peritonitis in Bharatpur hospital, Nepal: A prospective study.

Introduction: The most common surgical emergency in general surgery is perforation peritonitis. It is a serious condition with a mortality rate of up to 20%, and it is the third most common cause of surgical abdomen after appendicitis and intestinal obstruction. The aim of this study to discuss clinical profile and management of perforation peritonitis in a hospital in central Nepal. Methods: This prospective study was done for one year at Bharatpur Hospital, Chitwan Nepal. In our study, only patient above 15 years were included and those who were not fit for anesthesia and surgery were excluded. Most of the patient were diagnosed clinically supported by lab investigations and imaging like X-ray and ultrasonography of abdomen. The variables analyzed were the risk factors of the patient like smoking, alcohol, liver disease and previous abdominal surgeries. Results: The majority of the patients were in the age group 50-59 years in male and 40-49 years in female. Among sixty cases, 31 were female and 29 were male with Female: Male ratio of 1.06:1. The most common cause of perforation found was peptic ulcer compromising 88.3% (53 cases) followed by appendicular perforation accounting 8.3% (5 cases). Similarly, Tubercular perforation was found in 3.3%. Smoking was most common risk factor accounting 88.3%, followed by alcohol consumption (48.33%) while, 15% of patients had positive history of NSAIDs consumption. On imaging, 38.33% patient had air fluid level on X-ray and 78.33% had gas under diaphragm. On blood investigation, leukocytosis was found in 53.33% of patients, hyponatremia in 10% of patients and hypokalemia in 18.33% of patients. While on urine examination, albumin was found in 5% of patients. The repair of perforation along with omentopexy was done in 73.3% of patients while only repair was done in 15% of patients. Only 8.3% opted for appendectomy while a very few patients (3.3%) went for resection with anastomosis. The Postoperative complications found were wound infection (43.3%), paralytic ileus (18.33%), sepsis (15%), followed by electrolyte imbalance (11.6%), postoperative bowel obstruction (6.6%) and burst abdomen (1.6%). While, there were only 3 cases of mortality. Conclusions: Perforation peritonitis is a frequently encountered surgical emergency. Various factors like age, sex, duration, site of perforation, extent of peritonitis and delay in surgical intervention are associated with morbidity and mortality. A successful management depends upon early surgical intervention, source control and exclusive intraoperative peritoneal lavage.

Safety and efficacy of low-cost alternative urokinase in acute ischemic stroke: A systematic review and meta-analysis.

INTRODUCTION: Use of intravenous thrombolysis (IVT) for treatment of acute ischemic stroke (AIS) varies greatly between countries, ranging from 10% to 15% in high-income countries to less than 2% in low- and middle income countries (LMICs). This is because alteplase is expensive and has been cited as one of the most common barriers to IVT in LMICs. Urokinase (UK) is a thrombolytic agent which is almost 50 times cheaper with easier production and purification than alteplase. UK may become a cost-effective option for IVT in LMICs if it is found to be safe and effective. We conducted this study to assess the existing evidence on the safety and efficacy of UK vs alteplase for IVT in AIS. METHODS: The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and meta-Analyses) guideline. Systematic literature search was done in PubMed, EMBASE, and Google Scholar for English literature published from 2010 to 2021. RESULTS: A total of 4061 participants in the alteplase and 2062 participants in the UK group were included in the final statistical analysis. After IVT, a good functional outcome at last follow-up was found among 80.57 % of patients in the alteplase group compared to 73.79 % of patients in the UK group (OR: 1.11; 95 % CI: 0.95- 1.31; I2 = 0 %; P = 0.18). Symptomatic Intracerebral Hemorrhage (sICH) was found among 1.77 % of patients in the alteplase group compared to 2.83 % of patients in the UK group (OR: 0.84; 95 % CI: 0.56- 1.26; I2 = 0 %; P = 0.41). Similarly, mortality was found among 5.03 % of patients in the alteplase group compared to 5.42 % of patients in the UK group (OR: 0.87; 95 % CI: 0.66-1.14; I2 = 0 %; P = 0.30). CONCLUSION: Our meta-analysis found that intravenous UK is not inferior to alteplase in terms of safety and efficacy and can be a viable alternative for IVT in AIS patients in LMICs.

A rare incidental finding of an isolated S1 butterfly vertebra: A case report.

Butterfly vertebra is an uncommon type of vertebral anomaly (sometimes referred to as a sagittal cleft vertebra or an anterior rachischisis) caused by persistent notochordal tissue. Butterfly vertebrae of S1, which is rarer anomaly compared to thoraco-lumbar region, may be associated with syndromic causes and usually asymptomatic with a funnel shaped defect seen in imaging which can later give rise to disk problems, facet joint degeneration and chronic low back pain. We here share a case of 35-year female presented with intermittent low back pain diagnosed with S1 butterfly vertebrae as an incidental finding in radiograph and magnetic resonance imaging. Radiologist and orthopedicians should be vigilant about this rare entity as a differential of low back pain and its association with other syndromes.

Safety and efficacy of endovascular thrombectomy in patients with severe cerebral venous thrombosis: A meta-analysis.

Background: Cerebral venous thrombosis (CVT) is a rare thrombotic condition which is traditionally treated with anti-coagulation therapy. Subsets of patients with severe CVT have been treated with endovascular thrombectomy (EVT). Despite the high estimated mortality associated with severe CVT, there has been only one randomized control trial done regarding safety and efficacy of EVT in severe CVT compared to standard medical management. Evidence in this area is lacking. Objective: The aim of this systematic review is to analyze all existing literature and generate robust information regarding the role of EVT in the management of patients with severe CVT. Methods: This systematic review and meta-analysis followed PRISMA guideline. PubMed, Embase, Google Scholar, and CNKI were searched for eligible studies from 2007 to 2021. Safety and efficacy of EVT were evaluated by meta-analyzing recanalization status, the good functional outcome at follow-up, recurrent CVT, new hematoma. A pooled proportion with a 95% confidence interval was derived from a meta-analysis of various outcomes (CI). Results: A total of 33 studies comprising 610 patients treated with EVT were included for analysis which comprised one randomized control trial, one prospective study and 31 retrospective studies. Based on pooled data, 85% of patients had good functional outcome, 62% had complete recanalization, 5% had all-cause mortality, and 3% had catheter related complications. The efficacy outcomes in this analysis had a significant heterogeneity and a subgroup analysis was also done to explain these findings. The minimum time of follow up was 3 months and varied EVT techniques were used across the studies. Conclusion: This meta-analysis suggests EVT may be safe and efficacious in treating patients with severe CVT. Registration: Our protocol was registered with PROSPERO: International prospective register of systematic reviews with the registration number CRD42021254760.

Levetiracetam versus Oxcarbazepine as monotherapy in newly diagnosed focal epilepsy: A systematic review and meta-analysis.

OBJECTIVE: To compare the efficacy and safety of Levetiracetam (LEV) and Oxcarbazepine (OXC) as monotherapy for the treatment of newly diagnosed focal epilepsy. METHODS: We searched PubMed, Cochrane Library, EMBASE, and Google Scholar from January 1, 2000 to May 11, 2022, with no language restrictions along with The ClinicalTrials.gov website and the WHO International Controlled Trials Registry platforms. We pooled the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for the efficacy and safety outcomes. The quality of included trials was assessed using the Cochrane Collaboration's tool. RESULTS: Two RCTs included a total of 574 newly diagnosed focal epilepsy patients (the LEV group [282 patients] and the OXC group [292 patients]). LEV group when compared with the OXC group had no significant difference in the pooled estimate of seizure freedom at week 24. (RR: 0.81; 95% CI: 0.62-1.05, p = .11). Similarly, there was no significant difference in the pooled estimate of withdrawal due to adverse events (AEs) (RR: 0.87; 95% CI: 0.34-2.23, p = .77). The commonly reported AEs in both trials were dizziness, headache, rash, somnolence, and nasopharyngitis with zero medication-related death and few serious AEs. CONCLUSIONS: LEV is noninferior to OXC in terms of seizure freedom at week 24 and treatment withdrawal rate due to AEs among adults but long-term treatment data is still missing. Future multicentric double-blinded RCTs and real-world studies are of great need.

Thyrotoxic periodic paralysis in a patient with Graves' disease: A case report.

Introduction and importance: Thyrotoxic periodic paralysis (TPP) is a rare and often misdiagnosed, hypokalemic periodic paralysis with features of mainly recurrent acute limb weakness with good treatment outcome if diagnosed early. Case presentation: We here report a case of a 25-year-old male with a history of recurrent bilateral upper and lower limbs weakness resolved by potassium infusion later found to have Thyrotoxicosis (Graves' disease). MRI scans of the brain had no abnormal finding while thyroid scintigraphy showed diffuse toxic goiter. Clinical discussion: Graves' disease shares a majority of TPP while, other causes like toxic adenoma, thyroiditis, toxic multinodular goiter, amiodarone induced thyrotoxicosis, levothyroxine intoxication and thyrotropin (TSH) producing pituitary adenoma are also associated with TPP. The management of thyrotoxicosis by medical therapy, surgery or radioactive iodine therapy is the mainstay of treatment of TPP patients. For the treatment of acute attacks, potassium administration is necessary keeping in mind the problem of hyperkalemia because of excess doses of potassium as it shifts to extracellular space. Conclusion: TPP should be considered as a differential in the cases of limb weakness and the secondary causes especially Thyrotoxicosis and precipitating factors should be identified.