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A Life-Threatening Paradox in Managing a Case of Severe Hypokalemia
Journal article   Open access

A Life-Threatening Paradox in Managing a Case of Severe Hypokalemia

Mohamed Fawzi Mudarres and Chih-Jen Cheng
Kidney International Case Reports, 100089
07/2026
DOI: 10.1016/j.kintcr.2026.100089
url
https://doi.org/10.1016/j.kintcr.2026.100089View
Published (Version of record) Open Access

Abstract

Severe hypokalemia, defined as a serum potassium (K+) concentration < 2.5 mEq/L, is a medical emergency associated with an increased risk of sudden cardiac death. Unlike chronic K+ depletion, K+ redistributive disorders cause rapid, massive, and unpredictable transcellular K+ shifts, complicating management. We present a young man who presented with progressive limb weakness, respiratory acidosis, and severe hypokalemia (2.4 mEq/L). Despite immediate intravenous K+ infusion at 10 mEq/hour, his serum K+ level plummeted to 1.5 mEq/L, triggering ventricular arrhythmia, which required escalating the K+ infusion to 40 mEq/hour. Following clinical recovery, the patient developed rebound hyperkalemia (6.2 mEq/L), necessitating K+-lowering therapy. He was ultimately diagnosed with Graves’ disease and thyrotoxic periodic paralysis (TPP). TPP pathogenesis involves a "dual hit" mechanism, in which hyperthyroidism-induced activation of Na+, K+-ATPase against a background of reduced endogenous K+ channels aggressively traps K+ inside skeletal myocytes. This case underscores that the safe management of life-threatening hypokalemia requires rapid assessment and intensive surveillance. K+ supplementation needs to be adjusted in a timely manner based on serum K+ levels and symptomatic severity.
 acute hypokalemia paradoxical fall rebound hyperkalemia thyrotoxic periodic paralysis

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