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A young man with seizures, abusive behaviour, and drowsiness
  1. A G Unnikrishnan,
  2. S Rajaratnam
  1. Department of Endocrinology, CMC Hospital, Vellore—632 004, Tamil Nadu, India
  1. Dr Rajaratnamsimonraj{at}hotmail.com

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Answers on p 58.

A 20 year old man was brought to hospital with progressive drowsiness and vomiting for three days. Two weeks before admission his relatives noted that he was becoming agitated, violent, and abusive. He had previously fractured his left humerus owing to a fall during a seizure. He had been on phenytoin and phenobarbitone for seizure control for the past two months. There was no history of substance abuse or alcohol intake, neither was there a history of previous neck surgery.

On examination he was dehydrated and he had a tachycardia, a low blood pressure (90/70 mm Hg), and low central venous pressure (+4 cm). He was found to be talking irrelevantly and not obeying commands. He had generalised rigidity. There was no papilloedema. Systemic examination revealed no other abnormality.

Haematological investigations were normal. Serum biochemical investigation results were as follows (mmol/l unless stated): sodium 130, potassium 3.6, bicarbonate 13, chloride 105, magnesium 0.53, calcium 1.025 (corrected calcium 1.36), phosphorus 1.81, albumin 23 g/l, urea nitrogen 38.1, creatinine 318 μmol/l, and intact parathormone (PTH) 2.1 pmol/l (normal 1.3 to 7.6 pmol/l). Ultrasound of the abdomen showed normal sized kidneys with no parenchymal lesions. Computed tomography of the brain is shown in fig1.

Figure 1

Computed tomography of the brain.

Questions

(1)
What is the diagnosis?
(2)
What factors could have worsened the hypocalcaemia in this patient?
(3)
What is the differential diagnosis on the computed tomograph of the brain?

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