Dengue-related hypokalemic paralysis-more questions than answers
S Senthilkumaran1, N Balamurugan2, F Benita3, P Thirumalaikolundusubramanian4,
1 Department of Emergency and Critical Care Medicine, Sri Gokulam Hospitals and Research Institute, Salem, Tamil Nadu, India
2 Department of Neurosciences, SIMS Chellam Hospital, Salem, Tamil Nadu, India
3 Department of Emergency Medicine, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India
4 Department of Internal Medicine, Chennai Medical College and Research Centre, Trichy, Tamil Nadu, India
Dr. S Senthilkumaran
Department of Emergency and Critical Care Medicine, Sri Gokulam Hospitals and Research Institute, Salem, Tamil Nadu
|How to cite this article:|
Senthilkumaran S, Balamurugan N, Benita F, Thirumalaikolundusubramanian P. Dengue-related hypokalemic paralysis-more questions than answers.J Postgrad Med 2014;60:419-420
|How to cite this URL:|
Senthilkumaran S, Balamurugan N, Benita F, Thirumalaikolundusubramanian P. Dengue-related hypokalemic paralysis-more questions than answers. J Postgrad Med [serial online] 2014 [cited 2020 May 27 ];60:419-420
Available from: http://www.jpgmonline.com/text.asp?2014/60/4/419/143997
We read the article by Gupta, et al. with interest. Recent reports have revealed that the dengue virus (DENV), otherwise thought to be non neurotropic, exhibits neurotropism. This in turn reflects the changing clinical spectrum of dengue infection. Dengue-related hypokalemic paralysis is an emerging neuromuscular complication, and warrants special citation, in view of its rapidly evolving course, and excellent response to minimal potassium supplementation. Unfortunately it is mistaken with other entities causing rapidly progressive quadriparesis. 
Interestingly, until now dengue-related hypokalemic paralysis was attributed to redistribution of potassium or an increased loss from the body. It is mostly reported from northern parts of India, whereas similar findings were not reported from dengue prevalent tropical and sub-tropical countries. It is interesting to note that only few patients had manifested quadriparesis when more than two-thirds exhibited hypokalemia.  This observation provokes important questions about the geographical variation and whether the incidence has something to do with the genetic susceptibility. The pathophysiology behind the development of hypokalemic paralysis in these patients is not well understood and we highlight here molecular mechanisms and the importance of recognizing such entities.
Hypokalemic periodic paralysis has been shown to be precipitated by mutations in the two skeletal muscle genes imparting susceptibility to the affected patients. Is it possible that patients with dengue-related hypokalemic quadriparesis have some kind of channelopathy contributing to their susceptibility to develop paralysis similar to what has been observed in hypokalemic periodic paralysis?
The occurrence of dengue related - hypokalemic paralysis/quadriparesis in a limited number of cases makes one recall factors related to DENV and host cellular response. Is it possible that serotypes of DENV and/ or their effects on dengue-sensitized individual host cell membrane, intra-cellular organelle, mitochondrial dynamics or immune signaling would have contributed to the development of hypokalemia paralysis?
Such cases must be reassured and provided with dietary modifications, and educated to consult their practitioners, if they develop weakness following viral fever. Also, the practitioners should be made to realize and distinguish post infectious hypokalemic paralysis from other acute flaccid paralysis or Guillain-Barre syndromes. The possibility of the recurrence of paralysis following overt or covert infection in one and the same individual again has to be remembered and informed. Such cases require further studies so as to ascertain the underlying mechanisms in terms of prevention and therapy. Similarly, one has to search for hypokalemic paralysis in other viral infections and consider the susceptibility of some to viruses belonging to the Flaviviridae family.
|1||Gupta N, Garg A, Chhabra P. Dengue infection presenting as acute hypokalemic quadriparesis. J Postgrad Med 2014;60:327-8.|
|2||Malhotra HS, Garg RK. Dengue-associated hypokalemic paralysis: Causal or incidental? J Neurol Sci 2014;340:19-25.|
|3||Widodo D, Setiawan B, Chen K, Nainggolan L, Santoso WD. The prevalence of hypokalemia in hospitalized patients with infectious diseases problem at Cipto Mangunkusumo Hospital, Jakarta. Acta Med Indones 2006;38:202-5.|