Journal of Nutrition,Fasting and Health

Journal of Nutrition,Fasting and Health

Thyrotoxic Periodic Paralysis Associated with Post-Fasting Refeeding during Ramadan in Graves’ disease

Articles in Press

Document Type : Case Report

Authors
Sulaiman Saloojee 1
Dzingai Takudzwa Chaumba 2
Adam Mahomed 3, 4
Muhammed Vally 2, 3
1 Department of Internal Medicine, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa.
2 Department of Internal Medicine, Tambo Memorial Hospital, University of the Witwatersrand, Johannesburg, South Africa.
3 Division of Medical Gastroenterology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.
4 Wits Donald Gordon Medical Centre, Johannesburg, South Africa.
10.22038/jnfh.2026.95317.1627
Abstract
Introduction: Thyrotoxic periodic paralysis (TPP) is a rare, potentially life-threatening complication of thyrotoxicosis characterized by acute hypokalaemia and flaccid muscle weakness due to transcellular potassium shifts. We describe a case temporally associated with post-fasting refeeding during Ramadan.
Case Presentation: A 33-year-old Southeast Asian male presented with recurrent acute lower-limb flaccid weakness. Serum potassium level was 1.6 mmol/L during the first episode and 2.3 mmol/L upon re-presentation. Thyroid function tests showed TSH <0.01 mIU/L and free T4 of 41 pmol/L. TSH-receptor antibody level was elevated at 12.5 IU/L, confirming Graves’ disease. Symptoms began about two hours after iftar, which consisted of a high-carbohydrate, rice-based meal and dessert. Serum magnesium, creatinine, bicarbonate, and urinary potassium levels were within normal ranges, supporting an intracellular shift rather than total-body potassium depletion.
Methods and Results: Cautious potassium replacement (80 mmol over 24 hours), oral propranolol 40 mg three times daily, and carbimazole 20 mg twice daily led to rapid resolution of weakness and normalization of serum potassium without rebound hyperkalemia.
Conclusion: This case highlights the importance of considering TPP in cases of unexplained hypokalaemic paralysis, particularly in Asian males, and draws attention to post-fasting refeeding during Ramadan as a potential precipitating factor mediated by insulin-driven potassium shifts.
Keywords
Thyrotoxic Periodic Paralysis
Graves Disease
Hypokalemia
Fasting
Insulin
Subjects
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Journal of Nutrition,Fasting and Health

Articles in Press, Accepted Manuscript
Available Online from 29 September 2026

  • Receive Date 28 April 2026
  • Revise Date 21 August 2026
  • Accept Date 28 September 2026