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Sterns RH, Rondon-Berrios H, Adrogué HJ, Berl T, Burst V, Cohen DM, Christ-Crain M, Cuesta M, Decaux G, Emmett M, Garrahy A, Gankam-Kengne F, Hix JK, Hoorn EJ, Kamel KS, Madias NE, Peri A, Refardt J, Rosner MH, Sherlock M, Silver SM, Soupart A, Thompson CJ, Verbalis JG. Treatment Guidelines for Hyponatremia: Stay the Course. Clin J Am Soc Nephrol 2024; 19:129-135. [PMID: 37379081 PMCID: PMC10843202 DOI: 10.2215/cjn.0000000000000244] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/22/2023] [Indexed: 06/29/2023]
Abstract
International guidelines designed to minimize the risk of complications that can occur when correcting severe hyponatremia have been widely accepted for a decade. On the basis of the results of a recent large retrospective study of patients hospitalized with hyponatremia, it has been suggested that hyponatremia guidelines have gone too far in limiting the rate of rise of the serum sodium concentration; the need for therapeutic caution and frequent monitoring of the serum sodium concentration has been questioned. These assertions are reminiscent of a controversy that began many years ago. After reviewing the history of that controversy, the evidence supporting the guidelines, and the validity of data challenging them, we conclude that current safeguards should not be abandoned. To do so would be akin to discarding your umbrella because you remained dry in a rainstorm. The authors of this review, who represent 20 medical centers in nine countries, have all contributed significantly to the literature on the subject. We urge clinicians to continue to treat severe hyponatremia cautiously and to wait for better evidence before adopting less stringent therapeutic limits.
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Affiliation(s)
- Richard H. Sterns
- University of Rochester School of Medicine and Dentistry, Rochester, New York
- Rochester General Hospital, Rochester, New York
| | | | | | - Tomas Berl
- University of Colorado Aschutz School of Medicine, Aurora, Colorado
| | - Volker Burst
- University of Cologne Faculty of Medicine, Cologne, Germany
| | | | | | | | - Guy Decaux
- Erasmus University Hospital, Brussels, Belgium
| | | | | | | | - John K. Hix
- Rochester General Hospital, Rochester, New York
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2
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Rondon-Berrios H. Diagnostic and Therapeutic Strategies to Severe Hyponatremia in the Intensive Care Unit. J Intensive Care Med 2023:8850666231207334. [PMID: 37822230 DOI: 10.1177/08850666231207334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Hyponatremia is the most common electrolyte abnormality encountered in critically ill patients and is linked to heightened morbidity, mortality, and healthcare resource utilization. However, its causal role in these poor outcomes and the impact of treatment remain unclear. Plasma sodium is the main determinant of plasma tonicity; consequently, hyponatremia commonly indicates hypotonicity but can also occur in conjunction with isotonicity and hypertonicity. Plasma sodium is a function of total body exchangeable sodium and potassium and total body water. Hypotonic hyponatremia arises when total body water is proportionally greater than the sum of total body exchangeable cations, that is, electrolyte-free water excess; the latter is the result of increased intake or decreased (kidney) excretion. Hypotonic hyponatremia leads to water movement into brain cells resulting in cerebral edema. Brain cells adapt by eliminating solutes, a process that is largely completed by 48 h. Clinical manifestations of hyponatremia depend on its biochemical severity and duration. Symptoms of hyponatremia are more pronounced with acute hyponatremia where brain adaptation is incomplete while they are less prominent in chronic hyponatremia. The authors recommend a physiological approach to determine if hyponatremia is hypotonic, if it is mediated by arginine vasopressin, and if arginine vasopressin secretion is physiologically appropriate. The treatment of hyponatremia depends on the presence and severity of symptoms. Brain herniation is a concern when severe symptoms are present, and current guidelines recommend immediate treatment with hypertonic saline. In the absence of significant symptoms, the concern is neurologic sequelae resulting from rapid correction of hyponatremia which is usually the result of a large water diuresis. Some studies have found desmopressin useful to effectively curtail the water diuresis responsible for rapid correction.
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Affiliation(s)
- Helbert Rondon-Berrios
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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3
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Park K, Kim SB, Yoon SS, Woo HG. Osmotic demyelination syndrome caused by rapid correction of hyperammonemia and continuous hyperbilirubinemia: a case report and review of the literature. ENCEPHALITIS 2023; 3:119-124. [PMID: 37797653 PMCID: PMC10598282 DOI: 10.47936/encephalitis.2023.00108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/07/2023] Open
Abstract
Osmotic demyelination syndrome (ODS) is an acute demyelinating disorder characterized by the loss of myelin in the center of the basis pons, defined as central pontine myelinolysis (CPM), and demyelination in locations outside the pons, defined as extrapontine myelinolysis (EPM). ODS including CPM and EPM is mainly caused by rapid correction of hyponatremia. However, there are several reports of ODS in medical conditions such as malnutrition; alcoholism; liver transplantation; malignancy; sepsis; and electrolyte imbalance including hypernatremia, hypokalemia, hypophosphatemia, and chronic illness. ODS caused by rapid correction of hyperammonemia or continuous hyperbilirubinemia without sodium fluctuations has rarely been reported. Because ODS may be irreversible, prevention is crucial. Herein, we report a case of ODS secondary to rapid correction of hyperammonemia and continuous hyperbilirubinemia.
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Affiliation(s)
- Kunwoo Park
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sang Beom Kim
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sung Sang Yoon
- Department of Neurology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Ho Geol Woo
- Department of Neurology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
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4
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Feigin E, Feigin L, Ingbir M, Ben-Bassat OK, Shepshelovich D. Rate of Correction and All-Cause Mortality in Patients With Severe Hypernatremia. JAMA Netw Open 2023; 6:e2335415. [PMID: 37768662 PMCID: PMC10539989 DOI: 10.1001/jamanetworkopen.2023.35415] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023] Open
Abstract
Importance Hypernatremia is common among hospitalized patients and is associated with high mortality rates. Current guidelines suggest avoiding fast correction rates but are not supported by robust data. Objective To investigate whether there is an association between hypernatremia correction rate and patient survival. Design, Setting, and Participants This retrospective cohort study examined data from all patients admitted to the Tel Aviv Medical Center between 2007 and 2021 who were diagnosed with severe hypernatremia (serum sodium ≥155 mmol/L) at admission or during hospitalization. Statistical analysis was performed from April 2022 to August 2023. Exposure Patients were grouped as having fast correction rates (>0.5 mmol/L/h) and slow correction rates (≤0.5 mmol/L/h) in accordance with current guidelines. Main Outcomes and Measures All-cause 30-day mortality. Results A total of 4265 patients were included in this cohort, of which 2621 (61.5%) were men and 343 (8.0%) had fast correction rates; the median (IQR) age at diagnosis was 78 (64-87) years. Slow correction was associated with higher 30-day mortality compared with fast correction (50.7% [1990 of 3922] vs 31.8% [109 of 343]; P < .001). These results remained significant after adjusting for demographics (age, gender), Charlson comorbidity index, initial sodium, potassium, and creatinine levels, hospitalization in an ICU, and severe hyperglycemia (adjusted odds ratio [aOR], 2.02 [95% CI, 1.55-2.62]), regardless of whether hypernatremia was hospital acquired (aOR, 2.19 [95% CI, 1.57-3.05]) or documented on admission (aOR, 1.64 [95% CI, 1.06-2.55]). There was a strong negative correlation between absolute sodium correction during the first 24 hours following the initial documentation of severe hypernatremia and 30-day mortality (Pearson correlation coefficient, -0.80 [95% CI, -0.93 to -0.50]; P < .001). Median (IQR) hospitalization length was shorter for fast correction vs slow correction rates (5.0 [2.1-14.9] days vs 7.2 [3.5-16.1] days; P < .001). Prevalence of neurological complications was comparable for both groups, and none were attributed to fast correction rates of hypernatremia. Conclusions and Relevance This cohort study of patients with severe hypernatremia found that rapid correction of hypernatremia was associated with shorter hospitalizations and significantly lower patient mortality without any signs of neurologic complications. These results suggest that physicians should consider the totality of evidence when considering the optimal rates of correction for patients with severe hypernatremia.
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Affiliation(s)
- Eugene Feigin
- Internal Medicine Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Libi Feigin
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Merav Ingbir
- Internal Medicine Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Nephrology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Orit Kliuk Ben-Bassat
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Nephrology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Daniel Shepshelovich
- Internal Medicine Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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5
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Johnson RJ, Lee SMK, Sánchez-Lozada LG, Kanbay M, Bansal A, Tolan DR, Bjornstad P, Lanaspa MA, Maesaka J. Fructose: A New Variable to Consider in SIADH and the Hyponatremia Associated With Long-Distance Running? Am J Kidney Dis 2023; 82:105-112. [PMID: 36940740 PMCID: PMC10330032 DOI: 10.1053/j.ajkd.2023.01.443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/01/2023] [Indexed: 03/23/2023]
Abstract
Fructose has recently been proposed to stimulate vasopressin secretion in humans. Fructose-induced vasopressin secretion is not only postulated to result from ingestion of fructose-containing drinks but may also occur from endogenous fructose production via activation of the polyol pathway. This raises the question of whether fructose might be involved in some cases of vasopressin-induced hyponatremia, especially in situations where the cause is not fully known such as in the syndrome of inappropriate secretion of diuretic hormone (SIADH) and exercise-associated hyponatremia, which has been observed in marathon runners. Here we discuss the new science of fructose and vasopressin, and how it may play a role in some of these conditions, as well as in the complications associated with rapid treatment (such as the osmotic demyelination syndrome). Studies to test the role of fructose could provide new pathophysiologic insights as well as novel potential treatment strategies for these common conditions.
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Affiliation(s)
- Richard J Johnson
- Division of Renal Diseases and Hypertension, Anschutz Medical Campus, University of Colorado, Aurora, Colorado.
| | | | | | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, School of Medicine, Koc University, Istanbul, Turkey
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
| | - Dean R Tolan
- Biology Department, Boston University, Boston Massachusetts
| | - Petter Bjornstad
- Division of Renal Diseases and Hypertension, Anschutz Medical Campus, University of Colorado, Aurora, Colorado; Section of Endocrinology, Department of Pediatrics, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
| | - Miguel A Lanaspa
- Division of Renal Diseases and Hypertension, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
| | - John Maesaka
- Department of Medicine and Division of Nephrology and Hypertension, NYU Langone Hospitals, Mineola, New York
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6
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Jin D, Jin S, Liu B, Ding Y, Zhou F, Jin Y. Association between serum sodium and in-hospital mortality among critically ill patients with spontaneous subarachnoid hemorrhage. Front Neurol 2022; 13:1025808. [PMID: 36388235 PMCID: PMC9662614 DOI: 10.3389/fneur.2022.1025808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The aim of this study was to retrospectively explore the relationship between serum sodium and in-hospital mortality and related factors in critically ill patients with spontaneous subarachnoid hemorrhage (SAH). Methods Data were collected from the Medical Information Mart for Intensive Care IV database. Restricted cubic splines were used to explore the relationship between serum sodium and in-hospital mortality. Receiver operating characteristic analysis was used to calculate the optimal cutoff value of sodium fluctuation, and decision curve analysis was plotted to show the net benefit of different models containing serum sodium. Results A total of 295 patients with spontaneous SAH were included in the retrospective analysis. The level of sodium on ICU admission and minimum sodium in the ICU had a statistically significant non-linear relationship with in-hospital mortality (non-linear P-value < 0.05, total P-value < 0.001). Serum sodium on ICU admission, minimum serum sodium during ICU, and sodium fluctuation were independently associated with in-hospital mortality with odds ratios being 1.23 (95% confidence interval (CI): 1.04-1.45, P = 0.013), 1.35 (95% CI: 1.18-1.55, P < 0.001), and 1.07 (95% CI: 1.00-1.14, P = 0.047), respectively. The optimal cutoff point was 8.5 mmol/L to identify in-hospital death of patients with spontaneous SAH with sodium fluctuation, with an AUC of 0.659 (95% CI 0.573-0.744). Conclusion Among patients with spontaneous SAH, we found a J-shaped association between serum sodium on ICU admission and minimum sodium values during ICU with in-hospital mortality. Sodium fluctuation above 8.5 mmol/L was independently associated with in-hospital mortality. These results require being tested in prospective trials.
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Affiliation(s)
| | | | | | | | | | - Yuhong Jin
- Department of Critical Care Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, China
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7
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Ahmed M, Moffett P. Osmotic Demyelination Syndrome in a Patient With Tremors. Cureus 2022; 14:e30076. [PMID: 36381866 PMCID: PMC9639865 DOI: 10.7759/cureus.30076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 11/07/2022] Open
Abstract
Osmotic demyelination syndrome is a neurological disorder caused by damage to the myelin sheath of brain cells secondary to rapid correction of hyponatremia. Clinical features are variable depending on the location of demyelination, with diagnosis confirmed by MRI. Once diagnosed, treatment is supportive. We present a 49-year-old female recently discharged from an outside hospital who presented with symptoms of tremors, ataxia, slurred speech, and confusion. The patient was diagnosed with osmotic demyelination syndrome based on the classic trident sign on MRI imaging. A review of her records showed rapid correction of serum sodium during her initial hospital visit.
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8
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Hyponatremia in the emergency department. Am J Emerg Med 2022; 60:1-8. [PMID: 35870366 DOI: 10.1016/j.ajem.2022.07.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 11/20/2022] Open
Abstract
Hyponatremia, defined as a serum sodium <135 mmol/L, is frequently encountered in patients presenting to the emergency department. Symptoms are often unspecific and include a recent history of falls, weakness and vertigo. Common causes of hyponatremia include diuretics, heart failure as well as Syndrome of Inappropriate Antidiuresis (SIAD) and correct diagnosis can be challenging. Emergency treatment of hyponatremia should be guided by presence of symptoms and focus on distinguishing between acute and chronic hyponatremia.
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9
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Liu YC, Yang YK, Chen PS, Chang WH. Central Pontine Myelinolysis in a Normonatremic Patient with Depression. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2021; 19:564-567. [PMID: 34294627 PMCID: PMC8316663 DOI: 10.9758/cpn.2021.19.3.564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/07/2020] [Accepted: 12/15/2020] [Indexed: 11/18/2022]
Abstract
A 76-year-old male presented with a recurrent depressive episode, an unsteady gait and cognitive impairment. Extensive blood tests, including hemogram, biochemical tests, folic acid, vitamin B12, and thyroid hormone, showed normal results. With the exception of the unsteady gait, neurological examination was negative. Brian magnetic resonance imaging (MRI) showed the typical feature of central pontine myelinolysis (CPM); however, there was no history of alcoholism, liver transplantation, malnutrition or rapid correction of hyponatremia. The patient had taken venlafaxine to treat major depressive disorder for more than 20 years. After discontinuation of venlafaxine, the unsteady gait gradually resolved, and subsequent MRI revealed reduction of the lesions over 6 months. We discuss herein the possible correlation between chronic use of venlafaxine and CPM.
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Affiliation(s)
- Yu Chia Liu
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Psychiatry, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
| | - Yen Kuang Yang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Psychiatry, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Po See Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan
| | - Wei Hung Chang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan
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10
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Chen Y, Li R, Wu A, Qiu W, Hu X, Hu Z, Yang Q, Zhou Z. Comparison of Thalamus and Basal Ganglia Signs Between Multiple Sclerosis and Primary Angiitis of the Central Nervous System: An Exploratory Study. Front Neurol 2021; 12:513253. [PMID: 34393963 PMCID: PMC8358104 DOI: 10.3389/fneur.2021.513253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/30/2021] [Indexed: 12/02/2022] Open
Abstract
Based on the symptoms, especially those affecting small vessels, it is difficult to distinguish multiple sclerosis (MS) from primary angiitis of the central nervous system (PACNS). Magnetic resonance imaging (MRI) helps understand the characteristics of deep gray matter lesions (DGML) in MS and PACNS. We aimed to compare the MRI characteristics of thalamus and basal ganglia lesions between relapsing-remitting MS and PACNS. In our study, 49 relapsing-remitting MS patients and 16 PACNS with MRI-confirmed thalamus or basal ganglia lesions were enrolled. Among the DGMLs in basal ganglia, putamen had significantly higher (P = 0.037) involvement in PACNS than in MS. More importantly, larger lesion sizes in thalamus helps to distinguish PACNS (12.4 ± 4.3 mm) from MS (7.9 ± 3.7 mm) (P = 0.006). But using lesions in basal ganglia, researchers were unable to differentiate the two disorders. Presently, our study shows that MRI performances of deep gray matter differ between MS and PACNS.
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Affiliation(s)
- Ying Chen
- Department of Neurology, Yijishan Hospital, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Rui Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Aimin Wu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xueqiang Hu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhaoqi Hu
- Department of Orthopaedics, Wuhu Traditional Chinese Medicine Hospital, Wuhu, China
| | - Qian Yang
- Department of Neurology, Yijishan Hospital, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
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11
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Shi XY, Cai MT, Shen H, Zhang JX. Central pontine myelinolysis mimicking glioma in diabetes: A case report. World J Clin Cases 2021; 9:4837-4843. [PMID: 34222456 PMCID: PMC8223854 DOI: 10.12998/wjcc.v9.i18.4837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/09/2021] [Accepted: 03/31/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Central pontine myelinolysis (CPM) usually occurs during rapid correction of serum osmolality, typically with brainstem lesions presenting uniform signals following enhancement on magnetic resonance imaging (MRI). We report a case of CPM caused by diabetes, which was characterized by glioma-like imaging features and the patient responded well to corticosteroids.
CASE SUMMARY A 49-year-old man with type 2 diabetes was admitted due to numbness and weakness for 6 mo with progressive aggravation for 2 wk. His complete blood count, serum electrolytes, renal and liver function parameters were within the normal range. MRI showed mass lesions in the brainstem, with unusually inhomogeneous signal intensity after contrast-enhanced scans. His symptoms worsened after hypoglycemic therapy. Due to his clinical history and examination results, CPM was considered the most likely diagnosis. Treatment with corticosteroids was administered with a methylprednisolone pulse in the acute phase followed by dose tapering. During the 8-mo follow-up period, his clinical symptoms and imaging features significantly improved.
CONCLUSION Diabetes could rarely be accompanied by CPM, and patients who experience this neurological complication could benefit from corticosteroid treatment. Clinicians should recognize the special relationship between diabetes and CPM, and improve awareness of early identification and appropriate treatment.
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Affiliation(s)
- Xiao-Yong Shi
- Department of Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Meng-Ting Cai
- Department of Neurology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Hao Shen
- Department of Neurology, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Jin-Xia Zhang
- Department of Clinical Psychology (Sleep Medical Center), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
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12
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Kusumoto K, Koriyama N, Kojima N, Ikeda M, Nishio Y. Central pontine myelinolysis during treatment of hyperglycemic hyperosmolar syndrome: a case report. Clin Diabetes Endocrinol 2020; 6:23. [PMID: 33292743 PMCID: PMC7667752 DOI: 10.1186/s40842-020-00111-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/26/2020] [Indexed: 01/20/2023] Open
Abstract
Background Central pontine myelinolysis (CPM) is a non-inflammatory demyelinating lesion of the pons. CPM and extrapontine demyelination (EPM) are together termed osmotic demyelination syndrome (ODS), a known and serious complication of acute correction of hyponatremia. Conversely, hyperglycemic hyperosmolarity syndrome (HHS) develops in patients with type 2 diabetes who still have some insulin secretory ability due to infection, non-compliance with treatment, drugs, and coexisting diseases, and is often accompanied by ketosis. HHS represents a life-threatening endocrine emergency (mortality rate, 10–50%) associated with marked hyperglycemia and severe dehydration. HHS may develop ODS, and some cases have been associated with hypernatremia. Case presentation The patient was an 87-year-old woman with hyperglycemia, dehydration, malnutrition, and potential thrombus formation during long-term bed rest. HHS was suspected to have developed due to progression of hyperglycemia and dehydration caused by pneumonia. Furthermore, ketoacidosis developed from ketosis and prerenal renal failure associated with circulating hypovolemia shock, which was also associated with disseminated intravascular coagulation. Treatment was started with continuous intravenous injection of fast-acting insulin and low-sodium replacement fluid. In addition, ceftriaxone sodium hydrate, heparin sodium, thrombomodulin α, human serum albumin, and dopamine hydrochloride were administered. Blood glucose, serum sodium, serum osmolality, and general condition (including vital, infection/inflammatory findings, and disseminated intravascular coagulation) improved promptly, but improvements in disturbance of consciousness were poor. Diffusion-weighted imaging of the brain 72 h after starting treatment showed no obvious abnormalities, but high-intensity signals in the midline of the pons became apparent 30 days later, leading to definitive diagnosis of CPM. Conclusions Fluctuation of osmotic pressure by treatment from hyperosmolarity due to hyperglycemia and hypernatremia in the presence of risk factors such as malnutrition, severe illness, and metabolic disorders may be a cause of CPM onset. When treating HHS with risk factors, the possibility of progression to ODS needs to be kept in mind.
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Affiliation(s)
- Koshi Kusumoto
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853, Japan.,Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Nobuyuki Koriyama
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853, Japan.
| | - Nami Kojima
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853, Japan.,Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Maki Ikeda
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853, Japan.,Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Yoshihiko Nishio
- Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
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13
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Jahan M, Sharma S, Rehmani R. Osmotic Demyelination Syndrome Despite Appropriate Hyponatremia Correction. Cureus 2020; 12:e8209. [PMID: 32577327 PMCID: PMC7305570 DOI: 10.7759/cureus.8209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Acute demyelination of the pons or extrapontine areas results in an osmotic demyelination syndrome (ODS), previously referred to as central pontine myelinolysis (CPM) or extra pontine myelinolysis (EPM). It is caused by osmotic dysregulation in the brain. Multiple risk factors have been known to contribute to these osmotic disturbances. Among them, osmotic stress caused by rapid correction of hyponatremia is the most common cause. Other risk factors include liver failure, alcohol dependence, malnutrition, and malignancy. Symptoms can vary depending on the location of the demyelination. It has a high rate of morbidity and mortality. We present a case of ODS in a malnourished patient who was found to have alcoholic hepatitis and invasive colon cancer. The initial presentation was sepsis secondary to pneumonia. The patient was found to be severely hyponatremic at the time of admission, and the hyponatremia was corrected as per the recommendations. The initial non-contrast head computed tomography (CT) scan was unremarkable. However, the hospital course was complicated by a deteriorating neurological exam with encephalopathy despite not overcorrecting the sodium. A short-term follow-up brain magnetic resonance imaging (MRI) eventually revealed ODS. Initially, the findings of ODS were masked due to symptoms of alcohol withdrawal. However, the patient had a quick recovery with the improvement of all the neurological findings.
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Affiliation(s)
- Mansura Jahan
- Internal Medicine, St. Barnabas Hospital Health System, Bronx, USA
| | - Shorabh Sharma
- Internal Medicine, St. Barnabas Hospital Health System, Bronx, USA
| | - Razia Rehmani
- Radiology, St. Barnabas Hospital Health System, Albert Einstein College of Medicine, Bronx, USA
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Sterns RH. Evidence for Managing Hypernatremia: Is It Just Hyponatremia in Reverse? Clin J Am Soc Nephrol 2019; 14:645-647. [PMID: 31064771 PMCID: PMC6500936 DOI: 10.2215/cjn.02950319] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Richard H Sterns
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester New York; and .,Rochester General Hospital, Rochester, New York
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