Recurrent Hypoglycaemia due to Insulin Autoimmune Disease (Hirata Disease) Associated with Monoclonal Gammopathy of Unknown Significance.

Hirata disease is a rare disease characterised by recurrent episodes of hypoglycaemia due to anti-insulin antibody. In most of these cases causative agents were sulfhydryl containing compounds like Penicillamine, Glutathione, and Methimazole. The presentation of disease closely mimics insulinoma. We report 52 years female patient presenting with recurrent episodes of hypoglycaemia due to anti-insulin antibody. On evaluation, underlying cause of antibody was found to be monoclonal gammopathy of unknown significance (MGUS).

Extra-Pontine Myelinolysis in a Case of Pan-hypopituitarism Due to Empty Sella Syndrome.

Rapid correction of hyponatremia is known to cause central pontine myelinolysis (CPM). It may concurrently involve other areas of brain as well, referred as extra-pontine myelinolysis (EPM). Isolated EPM however is a very rare occurrence. We present a case of EPM where the hyponatremia was secondary to hypothyroidism due to empty sella syndrome. Chronic hyponatremia should always be corrected slowly to avoid such osmotic myelinolysis syndromes (OMS).

Spontaneous intracranial hypotension.

Spontaneous intracranial hypotension (SIH) is an increasingly recognised syndrome. Postural headache with typical findings on magnetic resonance imaging (MRI) are the key to diagnosis. Orthostatic headache, low cerebrospinal fluid opening pressure, and diffuse meningeal enhancement on post-contrast T1-weighted MRI brain studies are the major features of this increasingly recognised syndrome. Headache due to SIH is similar to headache occurring after lumbar puncture. Delay in diagnosing this condition may subject patients to unnecessary procedures and prolong morbidity. We describe a patient with SIH and outline the important clinical and radiographic features of this syndrome. Patients with postural headaches should have brain MRI before lumbar puncture. When correctly diagnosed, SIH management, in most cases, is easy and highly effective.

Recurrent cardiac tamponade in a young woman.

A young woman presented with recurrent pericardial effusion, she had previously been treated with antitubercular medications. She had clinical features of systemic sclerosis (SSc) which was subsequently confirmed on further workup. She was also found to be profoundly hypothyroid. Cardiac tamponade is uncommon in both SSc as well as hypothyroidism, unlike in our patient who was found to have both of these disorders. In her case, the pericardial involvement probably ante-dated the other features of SSc.

Migraine: pitfalls in the diagnosis.

Although the understanding of the pathophysiology and the pharmacology of migraine has exploded there are still many pitfalls that may occur in the clinical assessment and management of migraine. This may prevent the patient from receiving optimal treatment. A diagnosis of migraine may be missed in the presence of other headache types that occur more frequently than migraine. Also, migraine may be misdiagnosed when treating physicians inappropriately interpret specific symptoms and co-morbid conditions as indicators of the presence of a non-migraine headache type such as sinus headache or tension headache. Migraine and tension-type headache share common triggers and this also contributes to the difficulty in their differential diagnosis. The non-availability of any diagnostic laboratory investigation only makes this job further difficult.