Q. A 58 year-old alcoholic presents to the ER with confusion and hallucinations and while in the ER, he has a seizure. The ED doctor is fresh out of training and is fully aware of the differential diagnosis for seizures. He understands perfectly well that alcohol withdrawal is a common cause of seizures and he also knows the impact that low sodium and low levels of other electrolytes can have on neuronal membranes. So, he loads the patient with Ativan (a benzodiazepine) to treat for alcohol withdrawal, and after stabilizing the patient and treating the seizures with Ativan, he gets a STAT sodium level, which is very low (116 milliequivalents per liter (mEq/L)). He immediately gives a sodium bolus to drive up the sodium level. Unfortunately, he is working the moonlighting shift in the ER in a rural community and has very little help overnight. It so happens that two traumas come in after he gives the sodium bolus. He knows he has to triage the situation and he wants the patient to avoid seizing again, so he orders an Ativan drip and 3% hypertonic saline to drive up the patient's sodium level. Prior to ending his shift, he repeats the patient's sodium level and he is happy to see that it is now 132 milliequivalents per liter (mEq/L), getting closer to normal. The patient is ultimately admitted to the internal medicine service and although initially he was doing well, he slowly starts to develop weakness and slurred speech, trouble raising his arms and legs, and he won't get out of bed. The internal medicine service is convinced that he just doesn't want to leave the hospital but eventually he progresses to what appears to be a comatose state and requires intubation. On exam, he has normal pupil reactivity, normal vertical eye movements, normal volitional blinks, but complete bilateral face and body paralysis, and an absent gag reflex. You are a teleneurologist and are asked to consult on the case. You tell them you suspect the following: