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Serotonin syndrome and neuroleptic malignant syndrome are two drug toxidromes that have often overlapping and confusing clinical pictures. We report a case of a young man who presented with alteration of mental status, autonomic instability and neuromuscular hyperexcitability following ingestion of multiple psychiatric and antiepileptic medications. The patient satisfied criteria for serotonin syndrome and neuroleptic malignant syndrome, and based on the characteristic clinical features, laboratory findings and clinical course it was concluded that the patient had both toxidromes. The patient was managed with cyproheptadine and supportive measures, and recovered over the course of 3 weeks. A brief review of literature highlighting the diagnostic clues as well as the importance of recognising and distinguishing the often missed and confounding diagnoses follows.

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SUMMARYSecondary diabetes mellitus is known to occur in acromegaly due to insulin resistance caused by growth hormone excess. However, diabetes in acromegaly usually does not lead to ketosis. We describe an unusual case of a patient that presented with diabetic ketoacidosis in the emergency room with thirst, polyuria and dyspnoea. The patient was subsequently diagnosed with a growth hormone-secreting pitutary macroadenoma as the underlying pathology; after initial stabilisation with insulin and fluids, the patient was successfully treated with trans-sphenoidal surgery. BACKGROUND

Wilson's disease is a rare metabolic disease involving copper metabolism. Neuroimaging plays an important part in evaluation of patients with a neuropsychiatric presentation. We present a case of a 14-year-old girl with atypical confluent white matter disease and cystic degeneration on MRI, with a rapidly progressive course, who succumbed to complications despite treatment with trientine. Wilson's disease should be considered as a differential for leucoencephalopathy in young patients with progressive neurological disease for its early recognition and optimum outcome.