Introduction: Toxic multinodular goitre, first described by H.S. Plummer in 1913, is unremitting and often develops slowly, with more subtle symptoms than Graves' disease. Cardiac symptoms such as tachycardia, heart failure, or arrhythmia and atrial fibrillation are most frequent. Here we describe a case who presented with symptoms of thyroid enlargement and heart failure. Case report: A 48-year old female presented to us with complaints of dysphagia, hoarseness of voice, breathlessness on exertion and palpitations since one month ago. Furthermore, the patient gave history of swelling of the neck which was initially pea sized and gradually increased to the current size over a period of two months. On examining the swelling of the neck, thyroid gland appears enlarged, firm with multiple nodules. Two-dimensional echocardiography revealed a dilated left ventricle with generalized hypokinesia. Computed Tomography of the neck suggested enlarged thyroid gland (12.1 cm × 6.5 cm) with heterogenous architecture, and thyroid gland encircling the trachea for approximately 270 degree with mass effect. Thyroid scan showed multinodular goitre with multiple hyperfunctioning nodules of both lobes and warm nodules only in left lobe. The patient was diagnosed as multinodular goitre with cardiomyopathy. The patient was treated medically with methimazole, propranolol, aspirin, ramipril, sustained release urodeoxycholic acid, rosuvastatin, pantoprazole and multivitamin. The patient underwent near total thyroidectomy with radioactive iodine ablation, as and when required. Conclusion: Patients with toxic multinodular goitre very frequently present with cardiovascular symptoms, which when identified and treated early can reduce the morbidity significantly.

Leptospiroisis presents with a wide range of clinical symptoms, ranging from mild disease symptoms to life threatening complications. The clinical features and routine laboratory findings are not specific, and therefore a high index of suspicion must be maintained for the diagnosis. We documented a case of a patient, who presented with high grade fever, diarrhea, vomiting, had icterus on examination. Initial laboratory investigations revealed low platelet count, along with raised liver enzymes. IgM leptospirosis came positive and patients received broad spectrum antimicrobials and supportive fluid therapy. During admission, patient developed sudden onset breathlessness, which was diagnosed as acute respiratory distress syndrome after doing immediate arterial blood gases. The patient received noninvasive ventilation with positive airway pressure, from which the patient eventually recovered. Most of the cases of leptospirosis are uneventful with complete recovery. However, a minority of these cases may end with life threatening complications. A vaccine for human use is not available in most countries. Therefore, the prevention involves reducing exposure, either by avoiding situations that pose a risk of transmission or using protective clothing.

Multiple Sclerosis (MS) involves an immune mediated process in which an abnormal response of the body's immune system is directed against the central nervous system (CNS). Multiple sclerosis is a very variable condition and the symptoms depend on which areas of the CNS have been affected. There is no set pattern for MS and everyone with MS has a different set of symptoms, which vary from time to time and can change in severity and duration, even in the same person. Hence diagnosing MS at the earliest is very essential. Therefore we report an unusual case of a 30-yearold female with complaints of headache, vomiting & hiccups since 2 months followed by weakness of bilateral lower limbs and later upper limbs which eventually were diagnosed as Multiple Sclerosis. We are reporting this case because of the vague clinical presentation of Multiple Sclerosis. Aim: To recognize the symptoms of MS at the earliest and start treatment early.

ABSTRACT. We report a case of hemophagocytic syndrome as a complication of Plasmodium vivax malaria which is a rare presentation according to the data. This patient presented with high grade fever with chills (P. vivax positive), fever however did not respond to anti-malarials. The patient continued to have high grade fever with altered sensorium and deranged liver function with pancytopenia. Since she fulfilled the criteria of (HPS), patient was put on injectable steroids and responded dramatically. Hemophagocytic syndrome is a potentially fatal syndrome and therefore high index suspicion and early treatment is the key to reduce the mortatlity.

Primary hyperaldosteronism is not as uncommon as we thought, and by recent estimates the prevalance may be as high as 11% among hypertensives. We present a case of a 33 years old male patient came with a complaint of headache in occipital area & weakness in both lower limb since 4 weeks. The patient was a diagnosed case of hypertension and was already on tablet Atenolol (25 mg) once a day. At the time of admission, the patient was found to have a pulse of 96/min and blood pressure of 170/100 mm of Hg. Power was 3/5 for both right and left lower limbs. At the time of admission, serum potassium was 2.8. As a result, the patient was shifted to tablet Metroprolol and Amlodipine (50 + 5 mg) once a day. We also added tablet Cilnidipine (10 mg) and Telmisartan (80 mg) once a day and syrup Potklor thrice a day with water. The patient was sent for renal artery doppler, urine for metanephrines and vanillylmandelic acid, serum aldosterone, plasma aldosterone/plasma renin activity ratio (PAC/PRA ratio), urinary aldosterone, urinary cortisol and adrenocorticotrophic hormone level and computed tomography (CT) abdomen to rule out hyperaldostronism. Plasma aldosterone/plasma renin activity ratio, urinary aldosterone was high and CT abdomen revealed a solitary nodule in the left adrenal gland measuring 1.2 × 1.0 cm in maximum transverse diameter, which was suggestive of adrenal adenoma. Diagnosis of Conn's syndrome secondary to adrenal adenoma was made. The patient was advised tablet Aldactone (25 mg) once a day and serum electrolytes were repeated which showed normalization with normal blood pressure.