A 35 years old male, automobile factory worker was brought to emergency room with suddden onset rapidly progressive flaccid quadriparesis of 12 hours duration. He was unable to stand or use his upper limbs. There was tingling in distal aspects of all four limbs. There was no loss of sensation, respiratory muscle, cranial nerve, or cerebellar involvement. He reported no other symptoms. There was no history of alcohol use, drug use, or exposure to sexually transmitted diseases. He worked in night shifts. There was no relevant family history.
On examination he was unable to stand or sit, fully conscious, blood pressure 96/68 mmHg supine, pulse rate 88 beats per minute regular. Cranial nerves, speech, fundi, and sensory examination were normal. Motor system examination revealed flaccid grade I/V (MRC), areflexic, quadriparesis with flexor plantars. There was no diaphragm or respiratory muscle paralysis. Other systems were normal. A diagnosis of Acute Guillain Barre Syndrome was made and he was admitted to intensive care unit. His haemoglobin, full blood counts, plasma glucose, serum ionized calcium, serum phosphate; thyroid function tests were normal. Serum creatinine 160 mmol/l (<133), urea 15 mmol/l (3.67.1), chloride 89 mmol/l (98106), and bicarbonate 16 mmol/l (2128). Electrocardiogram revealed heart rate of 90 per minute, small P waves, broad QRS complexes, and peaked T waves. The serum potassium levels were 8.0 mmol/l (3.55.0) and serum sodium was 125 mmol/l (136145), confirmed on repeated samples. Cranial MRI and CSF examination was normal He was managed with intravenous calcium gluconate, dextrose and insulin. In view of persistent hyperkalemia and hyponatremia, an endocrinology consultation was sought. On further questioning he revealed history of weight loss of 3 kgs, unusual tiredness, and repeated common colds in last six months. A clinical diagnosis of chronic primary adrenal insufficiency presenting with hyperkalemic paralysis was made.