A typical progression of thyrotoxic manifestations while awaiting laboratory confirmation

An ill-nourished man, whose hyperthyroid state was unmasked by respiratory infection, had more than one attack of thyroid storm and rapidly went through several unusual complications which included thyrotoxic periodic paralysis, upper and lower motor neuron manifestations, neuropsychiatric and metabolic disturbances. Diagnosis of hyperthyroidism was established after 14 days with the arrival of thyroid function test which was drawn on admission. Though his symptoms improved after initiating treatment, he continued to suffer from thyroid associated ophthalmopathy and myasthenia gravis. Although these manifestations of hyperthyroidism are well known, their occurrence in a single patient is unusual. This report highlights the need for the physicians to be alert regarding these rare manifestations of thyrotoxicosis in their patients and initiate treatment as it is difficulttoobtain rapid laboratory confirmation in emergency department

Clinical and neurophysiological pattern of Guillain-Barre syndrome in Kuwait

To study the clinical and neurophysiological pattern of Guillain-Barre syndrome [GBS] in Kuwait. The clinical records of consecutive GBS patients admitted to Ibn Sina Hospital, Kuwait, during a 7-year period between 1997 and 2003 were analyzed. Of the 41 cases, 77% were male. The majority of the cases presented during the winter months and a preceding infection was reported in two thirds of them. Proximal lower limb [LL] weakness was the predominant clinical presentation. Nerve conduction studies [NCS] demonstrated a demyelinating pattern in 70%, an axonal pattern in 15%, mixed type in 5% and no abnormality in the remaining 5%. The majority of the patients [73%] improved with one course of intravenous immunoglobulin [IV IG]. Mean recovery time [MRT] was 4.4 weeks. Delayed recovery [MRT =/>6 weeks] was noted in patients with predominant distal weakness in the LL [MRT 7.8 weeks; p = 0.001], proximal weakness in the upper limb [UL] [MRT 6 weeks; p = 0.005], autonomic disturbance [MRT 6.5 weeks; p = 0.05], and axonal type GBS [MRT 6 weeks; p = 0.001]. The presence of predominant distal weakness in LL, proximal weakness in UL, autonomic disturbance and axonal pattern in NCS predict a poor outcome. Hence we recommend early immunomodulatory therapy in patients presenting with these features

Guillain-Barre syndrome in a case of acute lymphoblastic leukaemia. A case report

To report a case of severe Guillain-Barr‚ syndrome in a 32-year old female patient diagnosed with acute lymphoblastic leukaemia who was on chemotherapy. Clinical Presentation and Intervention: The patient received chemotherapy including vincristine and steroids according to the Medical Research Council United Kingdom Acute Lymphoblastic Leukaemia-12 [MRC UKALL-12] protocol. On the 21st day of the first induction course she developed acute fulminant quadriparesis with total areflexia. The clinical features, nerve conduction and the cerebrospinal fluid studies were consistent with acute Guillain-Barr‚ syndrome. She was treated with a 5-day course of intravenous immunoglobulins [IVIG] that resulted in only partial improvement. A second course of IVIG was given 2 weeks later that improved her condition slowly and steadily over a period of 12-16 weeks; the patient was able to walk with minimal support. The fulminant neuropathy was most likely due to the association between Guillain-Barr‚ syndrome and leukaemia rather than vincristine neurotoxicity. IVIG was an effective and non-invasive treatment for Guillain-Barr‚ syndrome associated with the malignancy

Dandy-walker malformation associated with syringomyelia: an unusual presentation

We are reporting a patients with a Dandy-Walker malformation who underwent insertion of a cysto-peritoneal shunt as a neonate. At the age of 17, she presented with difficulty in walking and black-out attacks for 6 months before she was rushed to the hospital in a coma. Following an urgent CT scan, the shunt was revised and was found to be partially obstructed by omentum. After recovery, the patients demonstrated newly developed cerebellar and pyramidal signs. MRI showed evidence of cervical syringomyelia with no brain stem involvement. A second MRI carried out 2 weeks after shunt revision, showed collapse of the syringomyelia that correlated well with the patients clinical improvement. In addition to the rare association of Dandy-Walker malformation and syringomyelia, this case also demonstracts an unusual presentation of shunt malfunction. Revision of the shunt resulted in both clinical and radiological improvement. We believe that cerebrospinal fluid shunting should be the initial step in the management of those cases