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Toilet bowl palsy from prolonged prayer posture

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An 18-year-old man was admitted to a Cambodian hospital with severe bilateral lower leg weakness and an acute kidney injury requiring renal replacement therapy. Three days before his hospitalisation, he had consumed tramadol hydrochloride and codeine phosphate, and injected heroin. While intoxicated in his hostel, he adopted a prayer posture (Box) and subsequently lost consciousness, remaining in this position for 8 hours on a tiled floor. Upon regaining consciousness, he was unable to stand due to a profound weakness in both legs that persisted for 3 days. During this time his urine changed to a cola colour although it was of normal volume. On the fourth day of ongoing symptoms, the patient sought medical care and was found to be in acute renal failure. He received two sessions of haemodialysis.

After his discharge from the intensive care unit, the patient’s mother escorted him to an Australian hospital. On presentation to the emergency department, he was oriented to time and place, but had persisting weakness, loss of sensation in his lower limbs and an ulnar nerve paresis. An isolated patch of paraesthesia over the forehead was noted at the site of contact with the ground. He had no features of uraemia. He was anuric and tests showed a creatinine level of 1040 μmol/L (reference interval [RI], 73–108 μmol/L) and a markedly elevated creatine kinase level of 123 000 U/L (RI, 46–171 U/L). Urine…