Neuromyotonia is a neuromuscular hyperexitability disorder characterized by muscle stiffness caused by continuous muscle fiber activity. It is an immune mediated disorder with elevated antibody level against presynaptic, voltage gated potassium channels, either as isolation or as a paraneoplastic process. Symptoms usually include muscle twitching during rest (myokymia), cramps, peudomyotonia (delayed relaxation), increased sweating, and sometimes motor weakness. In this case report, we present a seventy two year old man who presented with pain in both thighs for one month. It gradually became worse to involve feet and chest. His brain CT scan showed features of brain atrophy. EMG showed fasciculation along neuromyotonic discharges with characteristic wave in frequency and amplitude typical of Isaacs syndrome. Potassium channel antibodies were very high. Diagnosis of Isaacs syndrome was made. He was followed up for two months with treatment by three day course of methyl prednisolone followed by oral steroid and methotrexate with much improvement. This is the first case of Isaacs syndrome in Kurdistan.

This case report highlights the role of hyperglycaemia in a dissociative syndrome that may be overlooked by physicians, until it results in significant consequences. Traditionally dissociation is considered as an escape from overwhelming distress with partial or complete loss of control on voluntary actions or alienation of oneself or external world. Possible biological factors implicated in pathogenesis include reduced perfusion in inferior prefrontal and anterior temporal regions in the right hemisphere and abnormal functioning of the Hypothalamo-Pituitary-Adrenal dysfunction, Glutamate/N-Methyl-D-Aspartate (NMDA) receptor, Serotonin (5-HT2a, 5-HT2c), Gama-Amino Butyric Acid (GABA), and Opioid receptors.

Repeated transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation method that may be preferred as an augmentation strategy for psychiatric patients who may not have responded well enough to psychotropic drugs. In psychoses rTMS may act via changing cortical excitability, connectivity and plasticity. rTMS may induce transcallosal inhibition and antipsychotic drugs may extend the duration of this inhibition. We present a first episode psychosis patient initially unresponsive to antipsychotic treatment, in whom 20 sessions of right 1Hz rTMS augmentation resulted in clinical response and who remained in remission by the 8th month of treatment. We suggest that rTMS is a well-tolerated treatment that may not be reserved only for treatment resistant patients but may also be considered early on in the management of psychiatric disorders.