Utilization of Intravenous Immunoglobulin for Basedow Paraplegia in Thyroid Storm

Introduction: Myopathies and flaccid paralysis, often referred to as Basedow’s paraplegia (BP), are rare complications of thyroid storm. BP presents with subacute, symmetric weakness and areflexia, usually of the lower extremities, and often resolves upon resolution of the hyperthyroid state. Though the mechanism of BP is unclear, an immune-mediated aspect is suspected. This case report presents the occurrence of acute flaccid quadriparesis associated with thyroid storm that was managed with antithyroid therapies, intravenous immunoglobulin (IVIG), and physical therapy (PT).


Description: A 64-year-old female was admitted to the ICU intubated, in unstable atrial fibrillation and thyroid storm with free T4 of greater than 7.77 ng/dL and free T3 of 23.4 pg/mL. After 12 days of management with cholestyramine, dexamethasone, esmolol, and methimazole, thyroid hormone levels normalized, and sedation was stopped. Upon physical exam after sedation was discontinued, she was unable to move any extremities, with 0/5 Medical Research Council (MRC) muscle strength grading and absent reflexes in each extremity; however, her eyes were open, tracking, and blinking to threat and on command. Workup for potential causes of paralysis revealed negative EEG, CT of the head and neck, MRI brain and spine, creatinine kinase, and myasthenia gravis panel. Given no other apparent causes of quadriplegia, this was presumed to be thyrotoxic myopathy/BP, and a 5-day-course of IVIG (0.4 g/kg/day) was started on day 14. Following the fifth dose of IVIG, MRC grading improved to 1-2/5 in all extremities. After downgrade from the ICU on day 28, PT visits began. On day 35 she was able to move all extremities with stable MRC grading of 1-2/5, improved her ability to balance independently when seated, and transfer between sitting and supine positions with only moderate assistance. She was then discharged to an inpatient rehabilitation facility for skilled PT.


Discussion: To our knowledge, IVIG has not previously been reported as a treatment option for BP. Given the theorized immune-mediated aspect of BP, IVIG, a therapy utilized for immune-mediated myopathies, was trialed. In this case of thyrotoxic myopathy, normalization of thyroid hormone levels failed to resolve the paralysis, and muscle strength improved after a 5-day course of IVIG.