Thyrotoxic periodic paralysis (TPP) is a dramatic complication of thyrotoxicosis usually seen in young men with untreated Graves' disease. We report the case of a 29-year-old active duty man with TPP attacks atypical in that they occurred during and after resolution of the hyperthyroidism. Our literature review revealed only two previously reported cases of TPP concurrent with euthyroidism. Risk factors for TPP include the postprandial state after carbohydrate-rich meals and the post-exertional state. At least a 2-week "window of vulnerability" for TPP appears to exist after initiation of antithyroid therapy. Hyperthyroid active duty males are especially at risk of TPP, and require physical profiling at the time of diagnosis and for a limited period after they become euthyroid, to minimize the occurrence of this complication.

Multiple endocrine neoplasia type 2 (MEN 2) is a rare syndrome of medullary thyroid carcinoma (MTC) with pheochromocytoma and/or primary hyperparathyroidism (PHP), usually due to multigland hyperplasia. MEN 2 is associated with several RET protooncogene mutations. A 61-year-old woman with a family history of RET-positive MTC presented with a solitary thyroid nodule. Fine-needle aspiration biopsy was suspicious for neoplasm. Biochemical studies revealed basal hypercalcitoninemia (116 pg/mL [normal <26]) and PHP (serum calcium, 10.9 mg/dL; intact PTH, 113.2 pg/mL [10.0-65.0]). Pheochromocytoma screening was negative. A provisional diagnosis of MEN 2 was made, but at surgery, a single parathyroid adenoma was resected and frozen sections of several lymph nodes revealed papillary thyroid carcinoma (PTC). A total thyroidectomy was performed. Final histological diagnosis was PTC and parathyroid adenoma with no evidence of MTC. Postoperatively, RET mutation testing was positive. The basal calcitonin (CT) fell to 25 pg/mL, but peaked at 935 (normal <105) after pentagastrin infusion, consistent with occult MTC. After radioiodine ablation, CT decreased further. Octreotide scanning was negative. Faced with PHP, a thyroid nodule, and a family history of MTC, clinicians tend to diagnose MEN 2. This patient had a single parathyroid adenoma and nonmedullary thyroid cancer, which the literature actually suggests to be an association more frequent than MEN 2. Yet, there remains compelling data in favor of occult MTC, leaving open the possibility of an MEN 2 variant with the rare association of PTC.

Typhoid vaccination is part of the routine immunization of all military personnel on mobility status. We report the cases of Air Force students who presented to our facility with presumed systemic reactions to the typhoid vaccine much more severe than those commonly reported. Review of the literature reveals that an influenza-like reaction of variable severity commonly occurs in these patients, and in addition there are isolated reports of more severe reactions. These findings shed doubt on the overall safety of the currently used vaccine and warrant a consideration of its abandonment. Several safer alternatives, including the new live oral vaccine used in Europe, are discussed.

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