You pull the short straw and get stuck with the New Year's Eve shift. A van pulls up to the curb of your ER and rolls a body out onto the doorstep before driving away. The patient looks like he's in his early 20s. He stumbles around looking pretty unsteady. You can't really elicit a history from him; his speech is slurred and he seems to have some memory impairment. His eyes look like this (click on image to make it move!):
With a big sigh, you run tests and rule out head trauma, hypoxia, hypothermia, hepatic encephalopathy, and other metabolic disarrangements. There is an elevated osmolal gap.
Challenge 1: What's the diagnosis? What's seen on the image?
Two days later, a different patient is brought into your ER by the police; he was seen on the streets shouting about the ninjas attacking him and vomiting. He looks to be in his mid-30s and he is very disoriented. He can only tell you about the pink elephant in the room, and any attempt to calm him just riles him up more. On exam, you find tachycardia, tachypnea, hypertension, a low grade fever, and marked diaphoresis. One of the bystanders comments that he's "seen this man before - he's always drinking and panhandling for more booze."
Challenge 2: What's the diagnosis?
Image shown under GNU Free Documentation License.