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Hyponatraemia is common following major head injury and is associated with significant morbidity and mortality. A 20-year-old man presented with reduced consciousness after head trauma and was found to have a fractured skull base with bilateral frontal contusions. On day 3 of his admission, he developed hyponatraemia with raised urine sodium and osmolality, despite receiving dexamethasone and intravenous fluid therapy. His hyponatraemia worsened after the treatment with fluid restriction and oral salt. He was in negative fluid balance suggesting possible renal salt wasting. A trial of isotonic normal saline resulted in a further fall in serum sodium level. He was subsequently treated for suspected syndrome of inappropriate ADH with a hypertonic (3%) saline infusion. His sodium level and neurological status improved. This case report illustrates the confounding factors that commonly affect clinical decision-making when treating patients with hyponatraemia following head injury. The guidelines for diagnosis and management are discussed.

A woman aged 67 years was referred with pituitary enlargement identified on CT scan. Imaging was performed to investigate a progressive, incapacitating, 12-month history of nausea, vertigo, gait disturbance and recurrent falls. Her presentation included chronic occipitofrontal headaches, which had increased in severity and were exacerbated by upright posture. She had a history of lumboperitoneal (LP) shunting for idiopathic intracranial hypertension, systemic hypertension, ischaemic heart disease and pulmonary disease secondary to cigarette smoking. Physical examination demonstrated normal cranial nerves, bilateral upper motor neuron signs in both upper and lower limbs and severe gait instability. Her anterior pituitary function testing showed mildly …

A 31 year old man presented with a four day history of anxiety, insomnia, and confusion. Over the past few months he had intermittently noticed red eyes and a “tummy ache.” A concomitant history from his parents revealed a previous episode of confusion and concern about excessive alcohol intake—he had been drinking 10 units of vodka a day for the past six years. He denied any medical history or current drugs. On examination, he was agitated, tachycardic (heart rate 110 beats/min), and he had bilateral conjunctivitis. Initial investigations showed a calcium concentration of 3.54 mmol/L (reference range 2.15-2.6) and metabolic alkalosis (table⇓). He was treated for acute hypercalcaemia with fluids and discharged when levels normalised. View this table: The patient’s biochemistry results at different time points Before further outpatient investigations were performed, he was readmitted two weeks later with confusion and a witnessed seizure. Investigations again showed a raised calcium (3.80 mmol/L), metabolic alkalosis, and new onset acute renal failure (table). Plasma glucose was normal. He was once again treated for acute hypercalcaemia and stabilised. On day three of admission, calcium carbonate tablets were discovered on his bedside table. He reported regularly ingesting up to three packets a day to treat symptoms of indigestion. ### 1 How do you explain this patient’s ocular symptoms? #### Short answer Bilateral conjunctivitis is a rare complication of severe hypercalcaemia. #### Long answer Although rare, hypercalcaemia can cause ocular complications, …