A young man presenting with paralysis after vigorous exercise.

Thyrotoxic periodic paralysis (TPP) is a rare metabolic disorder characterised by muscular weakness and paralysis in predisposed thyrotoxic patients. Although patients with TPP are almost uniformly men of Asian descent, cases have been reported in Caucasian and other ethnic populations. The rapid increase in ethnic diversity in Western and European nations has led to increase in TPP reports, where it was once considered exceedingly rare. Correcting the hypokalaemic and hyperthyroid state tends to reverse the paralysis. However, failure to recognise the condition may lead to delay in diagnosis and serious consequences including respiratory failure and death. We describe a young man who was diagnosed with hyperthyroidism who presented with acute paralysis. The clinical characteristics, pathophysiology and management of TTP are reviewed.

Cryptogenic stroke in low-risk patients, consider a cardiac shunt at your peril.

Patent foramen ovale (PFO) as a cause of cryptogenic stroke from paradoxical embolisation remains a controversial issue. The optimal care between medical and surgical management of these patients for the attending clinician remains a conundrum. We report a case of cryptogenic stroke in a woman aged 59, with a PFO, concomitant venous thrombosis and cryptogenic stroke. The case highlights the difficulty in diagnosing and managing such patients, particularly as recent evidence challenges the clinical practice of percutaneous closure and pathophysiological rationale.

Tuberculous meningitis, an unusual presentation in a young lady.

A 37-year-old Persian-speaking woman presented with epigastric pain, vomiting and non-specific frontal headache. Examination was unremarkable except for an isolated sixth nerve palsy found a few days after admission. Blood results were normal, as was the chest radiograph and the CT scan of the head. Initial cerebrospinal fluid (CSF) analysis revealed a significantly elevated protein level with reduced glucose, as well as CSF lymphocytosis. Tuberculosis (TB) meningitis was considered and she was commenced on anti-TB treatment before confirmation of the diagnosis. A full contact tracing was performed with regular follow-up with TB nurses. When she was seen in the clinic a month later, her symptoms had subsided completely.

The perils of high carbohydrate drinks in the undiagnosed diabetic patient.

Diabetes mellitus is increasing in its incidence and prevalence. Reduction in refined carbohydrate (sugar) intake is an important part of nutritional advice to patients with known diabetes. Sugar is available in a variety of confectionary products. It is also available in especially packaged 'convenience foods' as high energy drinks. Among people without diabetes, such food can have its own health risks. A significant group of patients with diabetes remain undiagnosed. This group are at especially high risk from all the negative metabolic effects of high sugar intake available as high calorie drinks. The authors report two patients without previously known diabetes who presented similarly with marked hyperglycaemic states, leading to severe metabolic disturbances. Both were obese, had common precipitating factors and consumed large quantities of sugary soft drinks ('lucozade'). Both patients recovered well. They were followed up for over 7 years. One is not diabetic and the second is diabetic requiring a small dose of metformin.