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Sharif MW, Singh A, Enabi J, Karkee R, Sanivarapu R. Delayed Presentation of Osmotic Demyelination Syndrome Treated With Plasmapheresis. Cureus 2023; 15:e47399. [PMID: 38021548 PMCID: PMC10657736 DOI: 10.7759/cureus.47399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
We present a unique case of a 42-year-old gentleman with alcohol use disorder who developed osmotic demyelination syndrome (ODS) despite appropriate hyponatremia correction. This patient initially presented with severe hyponatremia (Na 97 mEq/L) due to beer potomania, which was corrected gradually over eight days, resulting in no observed neurological deficits upon discharge. However, he was readmitted with respiratory failure from aspiration pneumonia, leading to endotracheal intubation. Laboratory findings revealed a sodium level of 134 mEq/L and serum osmolality (293 mOsm/kg). The patient had neurological exam findings of spontaneous eye opening with left gaze preference and decreased power ⅕ in all extremities. Following extubation, he experienced a relapse with evolving subacute central pontine myelinolysis and bulbar weakness necessitating reintubation. Subsequently, five sessions of plasmapheresis were conducted, resulting in stable clinical findings. Despite remaining non-verbal, the patient demonstrated gradual neurological motor improvement, progressing from 1/5 power in all extremities to 4/5 on the right side and 3/5 on the left side. He was discharged with ventilator support, tracheostomy, and PEG tube placement to a long-term care facility. This case underscores the importance of vigilant monitoring in high-risk individuals following hyponatremia treatment because ODS presentation can be delayed.
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Affiliation(s)
| | - Arjan Singh
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Joud Enabi
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Roman Karkee
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Raghavendra Sanivarapu
- Pulmonary and Critical Care Medicine, Permian Basin Campus, Texas Tech University Health Sciences Center, Midland, USA
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V V A, Narayanan S, Bhasi R, Kg R. Central Pontine Myelinolysis and Hypokalemic Paralysis as Presenting Manifestations of Sjogren's Syndrome. Cureus 2023; 15:e45233. [PMID: 37842502 PMCID: PMC10576509 DOI: 10.7759/cureus.45233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/17/2023] Open
Abstract
Neurological involvement in Sjogren's syndrome can have varied manifestations and can precede the classical sicca symptoms of Sjogren's syndrome. A 32-year-old woman presented with acute quadriparesis and dysarthria. She had severe hypokalemia, and an MRI of the brain showed a lesion in the central pons that was hyperintense on T2 and fluid-attenuated inversion recovery (FLAIR) sequences sparing the periphery, a trident appearance characteristic of central pontine myelinolysis (CPM). On further evaluation, she was found to have distal renal tubular acidosis (dRTA) due to primary Sjogren's syndrome. She was treated with steroids and other supportive measures, and she recovered completely in one month. We describe a mild form of CPM with classical MRI features in a patient with Sjogren's syndrome and hypokalemia due to dRTA.
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Affiliation(s)
- Ashraf V V
- Neurology, Aster Malabar Institute of Medical Sciences (MIMS) Hospital, Calicut, IND
| | - Sajith Narayanan
- Nephrology, Aster Malabar Institute of Medical Sciences (MIMS) Hospital, Calicut, IND
| | - Remesh Bhasi
- Rheumatology, Aster Malabar Institute of Medical Sciences (MIMS) Hospital, Calicut, IND
| | - Ramakrishnan Kg
- Radiology, Aster Malabar Institute of Medical Sciences (MIMS) Hospital, Calicut, IND
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Sun WP, Wang YD, Gao S, Wang YF, Li DW. A rare presentation of central pontine myelinolysis secondary to hyperglycaemia. BMC Endocr Disord 2023; 23:106. [PMID: 37165361 PMCID: PMC10170667 DOI: 10.1186/s12902-023-01361-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 05/04/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Central pontine myelinolysis (CPM) is a rare demyelinating disorder caused by the loss of myelin in the center of the basis pontis. CPM typically occurs with rapid correction of severe chronic hyponatremia and subsequent disturbances in serum osmolality. Although hyperglycaemia is recognized as a pathogenetic factor in serum osmolality fluctuations, CPM is rarely seen in the context of diabetes. CASE PRESENTATION A 66-year-old Chinese male presented with a history of gait imbalance, mild slurred speech and dysphagia for two weeks. MRI showed the mass lesions in the brainstem, and laboratory examinations showed high blood glucose and HbA1c, as well as increased serum osmolality. The patient was diagnosed with CPM secondary to hyperosmolar hyperglyceamia and received insulin treatment as well as supportive therapy. After six weeks of followup, the patient had fully recovered to a normal state. CONCLUSION CPM is a potentially fatal neurological condition and can occur in uncontrolled diabetes mellitus. Early diagnosis and timely treatment are crucial for improving the prognosis.
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Affiliation(s)
- Wen-Ping Sun
- Department of General Practice, Songjiang Hospital Affiliated Shanghai Jiao Tong University School of Medicine, Shanghai, 201600, China
| | - Ying-Di Wang
- Department of Urinary Surgery, Tumor Hospital of Jilin Province, Changchun, 132000, China
| | - Song Gao
- Department of Anesthesiology, Tumor Hospital of Jilin Province, Changchun, 132000, China
| | - Yi-Fan Wang
- Department of Neurology, Shenzhen Sami Medical Center, 1 JinNiu Xi Steet, Shenzhen, 518000, P.R. China
| | - Da-Wei Li
- Department of Neurology, Shenzhen Sami Medical Center, 1 JinNiu Xi Steet, Shenzhen, 518000, P.R. China.
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Sandhya P, Akaishi T, Fujihara K, Aoki M. A novel association of osmotic demyelination in Sjögren's syndrome prompts revisiting role of aquaporins in CNS demyelinating diseases: A literature review. Mult Scler Relat Disord 2023; 69:104466. [PMID: 36584554 DOI: 10.1016/j.msard.2022.104466] [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: 09/30/2022] [Revised: 11/21/2022] [Accepted: 12/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Primary Sjögren's syndrome (SS) is a chronic systemic autoimmune disease with varied neurological manifestations. SS is associated with anti-aquaporin-4 antibody (AQP4-IgG)-positive neuromyelitis optica spectrum disorder (NMOSD), a demyelinating autoimmune disorder of the central nervous system (CNS). Intriguingly, there are reports of osmotic demyelinating syndrome (ODS), a supposedly non-inflammatory disorder, in the context of SS and renal tubular acidosis (RTA), both of which are not yet established risk factors for ODS. METHODS A literature search was undertaken to identify case reports of ODS in patients with SS. Details of the clinical and laboratory features of these patients were compiled. Additionally, we searched for NMOSD in patients with SS. We looked for co-existing RTA in patients with SS-ODS as well as SS-NMOSD. We also screened for reports of ODS in RTA without underlying SS. RESULTS & DISCUSSION We identified 15 patients (all women, median age 40 years) with ODS in SS, and all of these patients had comorbid RTA. There were only three reported cases of ODS in RTA without underlying SS. We identified a total of 67 patients with SS-NMOSD, of whom only 3 (4.5%) had RTA. Hence, unlike NMOSD, the development of ODS in SS requires a prolonged osmotic or electrolyte abnormality caused by the comorbid RTA. The 15 patients with ODS and SS -RTA, showed heterogeneous clinical manifestations and outcomes. The most common symptom was quadriparesis, seen in 14 of the 15 patients. Eleven of the 15 patients had one of the following features, either alone or in combination: worsening of the sensorium, extensor plantar response, dysphagia/dysarthria, and facial palsy. The latter four manifestations were present at the onset in 7 patients and later in the course of the illness in the remaining 4 patients. Ocular palsy was seen in only four of the 15 patients and was a late manifestation. One patient who had extensive long-segment myelitis and subsequent ODS died, but most patients recovered without significant sequelae. None had hyponatremia, while all patients had hypokalemia and/or hypernatremia. Hypokalemia causing nephrogenic diabetes insipidus (NDI) followed by rapid rise in sodium and the resultant osmotic stress could potentially explain the occurrence of ODS in SS-RTA. Aquaporin (AQP) in astrocytes is implicated in ODS, and renal AQP is downregulated in NDI. Antibodies against AQPs are present in some patients with SS. Defective AQP is therefore a common link underlying all the connected diseases, namely SS, NDI, and ODS, raising the possibility of immune-mediated AQP dysfunction in the pathogenesis. CONCLUSION The hitherto unreported association between SS-RTA and ODS may implicate SS and/or RTA in the development of ODS. In the setting of SS-RTA, ODS must be suspected when a patient with flaccid quadriparesis does not respond to the correction of potassium or develops additional neurological features along with a rise in sodium. Defective functions of AQPs may be a possible mechanism linking demyelinating CNS lesions, SS, and RTA. Studies evaluating AQP functions and serum antibodies against AQPs in these conditions are warranted.
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Affiliation(s)
- Pulukool Sandhya
- Department of Rheumatology, St Stephen's Hospital, Delhi-110054, India.
| | - Tetsuya Akaishi
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Kazuo Fujihara
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Masashi Aoki
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan.
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Jia S, Kumar P. Con: Metabolic Acidosis Should Not Be Corrected With Sodium Bicarbonate in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2021; 36:619-621. [PMID: 34776352 DOI: 10.1053/j.jvca.2021.10.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 10/15/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Shawn Jia
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
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Cruz SL, Carranza-Aguilar CJ, Pérez-García IP. Sodium chloride injection to treat opioid overdose; Does it work? A preclinical study. Neurotoxicology 2021; 87:24-29. [PMID: 34478770 DOI: 10.1016/j.neuro.2021.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/15/2021] [Accepted: 08/28/2021] [Indexed: 12/22/2022]
Abstract
Opioid overdoses (ODs) are increasing in Mexico's northern border. Because naloxone is usually not available, witnesses inject common salt (NaCl) into a vein of OD victims in an attempt to help them regain consciousness. Despite this widespread practice, no preclinical studies have addressed the efficacy of NaCl as an opioid antidote. Here we tested saline solutions at different concentrations. Because the highest (31.6 %) caused tail necrosis, we selected 17.7 % as a hypertonic saline solution (HSS) to determine if it could prevent the lethal effect of morphine (Mor), fentanyl (Fen), or Mor + Fen in adult Wistar male rats. We also evaluated if NaCl could modify the opioid antagonist effect of naloxone. Our results show that HSS: a) sensitizes animals to thermal but not mechanical stimuli; b) does not prevent mortality caused by high morphine or fentanyl doses; c) decreases the latency to recovery from the sedative effects caused by low doses of morphine or fentanyl; and d) increases naloxone's efficacy to prevent the lethality produced by Mor or Fen, but not by Mor + Fen. These results suggest that HSS is marginally effective in shortening the recovery time from nonfatal opioid ODs and increases naloxone's efficacy to counteract opioid-induced ODs.
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Affiliation(s)
- Silvia L Cruz
- Departamento de Farmacobiología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional (Cinvestav, IPN), Calzada de los Tenorios No. 235, Mexico City, 14330, Mexico; Member of the Global Studies Seminar, Faculty of Medicine, National Autonomous University of Mexico, Mexico.
| | - César J Carranza-Aguilar
- Departamento de Farmacobiología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional (Cinvestav, IPN), Calzada de los Tenorios No. 235, Mexico City, 14330, Mexico
| | - Iker P Pérez-García
- Departamento de Farmacobiología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional (Cinvestav, IPN), Calzada de los Tenorios No. 235, Mexico City, 14330, Mexico
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Di Agostino S, Costanzo AA, Andreone P, Maurantonio M. Central pontine myelinolysis secondary to glycemic variability in type 1 diabetes: a case report and a systematic review of the literature. EXPLORATION OF MEDICINE 2021. [DOI: 10.37349/emed.2021.00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Central pontine myelinolysis (CPM) is a rare manifestation of osmotic demyelination syndrome (ODS) which involves the pons and causes significant morbidity and mortality. CPM usually occurs in the setting of rapid correction of severe chronic hyponatremia. A rare case of CPM due to hyperglycemia in a 27-year-old man with type 1 diabetes is reported. During the patient’s hospitalization, his plasma glucose level showed a wide variability ranging from 38 mg/dL to 530 mg/dL, while plasma sodium level was constantly normal. At computed tomography (CT) scans, areas of hypodensity with a hyperdense ring were identified in the anterior part of the pons. At magnetic resonance imaging (MRI) scan, pontine abnormalities compatible with CPM were observed. According to laboratory tests, we concluded that CPM resulted from rapid and wide shifts in osmolar gradient owing to variability in plasma glucose levels. While universally recognized in several clinical settings, CPM is rarely observed in diabetic patients. Our report supports the notion that hyperosmolarity per se plays a key role in the pathogenesis of CPM, which may occur independently of sodium abnormalities.
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Affiliation(s)
- Stefania Di Agostino
- Division of Metabolic Internal Medicine, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Arianna A.C. Costanzo
- Division of Metabolic Internal Medicine, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Pietro Andreone
- Department of Internal Medicine, General, Emergency and Post-Acute, Division of Metabolic Internal Medicine, University Hospital of Modena, 41126 Modena, Italy
| | - Mauro Maurantonio
- Department of Internal Medicine, General, Emergency and Post-Acute, Division of Metabolic Internal Medicine, University Hospital of Modena, 41126 Modena, Italy
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Kalampokini S, Artemiadis A, Zis P, Hadjihannas L, Parpas G, Kyrri A, Hadjigeorgiou GM. Osmotic demyelination syndrome improving after immune-modulating treatment: Case report and literature review. Clin Neurol Neurosurg 2021; 208:106811. [PMID: 34358802 DOI: 10.1016/j.clineuro.2021.106811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Osmotic demyelination syndrome (ODS), which embraces central pontine and extrapontine myelinolysis, is an uncommon neurological disorder that occurs due to plasma osmotic changes. CASE PRESENTATION We present the case of a 55-year-old man, who presented with severe hyponatremia due to repeated vomiting, antidepressant treatment and consumption of large amounts of water. Fifteen days after sodium correction, the patient showed fluctuation of vigilance, dysarthria and dysphagia, tremor, cogwheel rigidity, bilateral facial palsy, ophthalmoplegia and tetraparesis. A brain MRI scan revealed extrapontine and later on pontine myelinolysis. He received intravenous steroids and subsequently immunoglobulin. His status began to improve gradually after completion of immunoglobulin and at three month-follow-up had no neurological deficit. LITERATURE REVIEW A comprehensive literature search of all reported ODS cases that received immunoglobulin, steroids or plasmapheresis was conducted in the electronic databases PubMed and Web of science. CONCLUSIONS Improvement was seen in most cases that received immunoglobulin either during treatment or in the first days after treatment. With regard to steroids, although most cases reported improvement in the following months their effect on the outcome is unclear. Most cases treated with plasmapheresis reported favorable outcome at variable follow-up time. Immunoglobulin and steroids have immunomodulatory effects, which could contribute to promotion of myelin repair in ODS. Plasmapheresis has effects on the immune system beyond removing myelinotoxins from the circulation. More evidence is required to support their use in ODS. However, in view of the disease severity, these therapeutic choices should be considered in the clinical management of ODS.
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Affiliation(s)
- Stefania Kalampokini
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus.
| | - Artemios Artemiadis
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
| | - Panagiotis Zis
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
| | - Linos Hadjihannas
- Department of Internal medicine, Nicosia General Hospital, Nicosia, Cyprus
| | - Giorgos Parpas
- Department of Internal medicine, Nicosia General Hospital, Nicosia, Cyprus
| | - Artemis Kyrri
- Department of Internal medicine, Nicosia General Hospital, Nicosia, Cyprus
| | - Georgios M Hadjigeorgiou
- Medical School, University of Cyprus, Nicosia, Cyprus; Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
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Wijayabandara M, Appuhamy S, Weerathunga P, Chang T. Effective treatment of osmotic demyelination syndrome with plasmapheresis: a case report and review of the literature. J Med Case Rep 2021; 15:6. [PMID: 33430956 PMCID: PMC7798224 DOI: 10.1186/s13256-020-02573-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/03/2020] [Indexed: 11/21/2022] Open
Abstract
Background Treatment options for chronic osmotic demyelination syndrome are limited to case reports and only a very few show complete recovery. We report a case of complete recovery of chronic osmotic demyelination syndrome with plasmapheresis. Case presentation A 43-year-old Sri Lankan man presented with fever, repeated vomiting, unsteady gait, increased tonicity of his right upper limb and paucity of speech for three days. He was treated in the local hospital with antibiotics and antivirals as per central nervous system infection. He had hyponatraemia, which was rapidly corrected with hypertonic saline from 97 to 119 mmol/L. He was transferred to our hospital because of progressive reduction of consciousness, rapidly worsening rigidity and bradykinesia of all four limbs and worsening dysarthria and bradyphrenia. Magnetic resonance imaging of the brain was compatible with osmotic demyelination syndrome. He was commenced on plasmapheresis twenty-two days after rapid correction of sodium. He regained independent mobility with complete resolution of rigidity, bradykinesia and speech dysfunction after five cycles of alternate day plasmapheresis. Conclusion Plasmapheresis can be considered as an effective treatment modality in chronic osmotic demyelination syndrome.
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Affiliation(s)
| | - Shenal Appuhamy
- University Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Praveen Weerathunga
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Thashi Chang
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Raciti L, Pizzurro R, Occhipinti F, Manuli A, Corallo F, Calabrò RS. A multidisciplinary advanced approach in central pontine myelinolysis recovery: considerations about a case report. Disabil Rehabil Assist Technol 2020; 18:350-356. [PMID: 33290136 DOI: 10.1080/17483107.2020.1854875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Central pontine myelinolysis (CPM) is a solitary, symmetric, demyelination in the central pons. This case study aimed to report the effects of an intensive robotic gait training with Lokomat-Pro on mobility and quality of life in a case of CPM. CASE DESCRIPTION AND INTERVENTION A 33-year-old female patient with tetraparesis and gait disturbance due to CPM was hospitalized to undergo intensive rehabilitation training for about 2 months. Daily session of Lokomat-Pro and psychotherapy by telemedicine were performed, besides nursing care and occupational and physical therapy. Motor evaluation and quality of life were assessed by using standardized scales. OUTCOMES The multidisciplinary therapy led to significant improvements both in functional motor outcomes (as per 10-Meter Walk Test, Berg Balance and Tinetti scale) and quality of life. DISCUSSION Innovation technology, including robotics and telemedicine, may be a valuable tool to improve functional outcomes in patients with severe motor impairment due to chronic CPM.IMPLICATIONS FOR REHABILITATIONA multidisciplinary approach involving robotics plus virtual reality is mandatory to reduce medical and bedridden complications in patients affected by CPM.
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Affiliation(s)
- Loredana Raciti
- G.C.A.-Spoke Center, A.O. Cannizzaro Catania, IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy
| | - Roberto Pizzurro
- G.C.A.-Spoke Center, A.O. Cannizzaro Catania, IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy
| | - Flavia Occhipinti
- G.C.A.-Spoke Center, A.O. Cannizzaro Catania, IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy
| | - Alfredo Manuli
- Behavioral and Robotic Neurorehabilitation Unit, IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy
| | - Francesco Corallo
- Behavioral and Robotic Neurorehabilitation Unit, IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy
| | - Rocco Salvatore Calabrò
- G.C.A.-Spoke Center, A.O. Cannizzaro Catania, IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy
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Eze C, Agha YH, Duran B. Favorable Outcomes Following the Use of Triple Therapy in a Patient with Osmotic Demyelination Syndrome. Kans J Med 2020; 13:191-193. [PMID: 32695264 PMCID: PMC7363172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/08/2020] [Indexed: 11/03/2022] Open
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Verbeek TA, Stine JG, Saner FH, Bezinover D. Osmotic demyelination syndrome: are patients with end-stage liver disease a special risk group? Minerva Anestesiol 2020; 86:756-767. [DOI: 10.23736/s0375-9393.20.14120-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Fang LJ, Xu MW, Zhou JY, Pan ZJ. Extrapontine myelinolysis caused by rapid correction of pituitrin-induced severe hyponatremia: A case report. World J Clin Cases 2020. [DOI: 10.12998/wjcc.v8.i5.947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Fang LJ, Xu MW, Zhou JY, Pan ZJ. Extrapontine myelinolysis caused by rapid correction of pituitrin-induced severe hyponatremia: A case report. World J Clin Cases 2020; 8:946-953. [PMID: 32190632 PMCID: PMC7062620 DOI: 10.12998/wjcc.v8.i5.946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/06/2020] [Accepted: 02/11/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Severe hyponatremia is considered a rare complication of pituitrin, which is widely used for the treatment of pulmonary hemorrhage. However, the management of pituitrin-associated hyponatremia can be challenging because a rapid correction of hyponatremia may cause the development of osmotic demyelination syndrome, resulting in life-threatening neurological injuries.
CASE SUMMARY A 20-year-old Chinese man with massive hemoptysis developed symptomatic hyponatremia (116 mmol/L) after therapy by a continuous intravenous drip of pituitrin. To normalize his serum sodium, a hypertonic saline infusion was applied for 3 d, and the pituitrin administration was stopped concurrently. Then, an overly rapid increase in serum sodium level (18 mmol/L in 24 h) was detected after treatment. One day later, the patient experienced a sudden onset of generalized tonic-clonic seizures, as well as subsequent dysarthria and dystonia. Magnetic resonance imaging revealed increased signal intensity in the bilateral symmetric basal ganglia on the T2-weighted images, compatible with a diagnosis of extrapontine myelinolysis. The patient received an intravenous administration of high-dose corticosteroids, rehabilitation, and neurotrophic therapy. Finally, his clinical abnormalities were vastly improved, and he was discharged with few residual symptoms.
CONCLUSION Physicians should be fully aware that pituitrin can cause profound hyponatremia and its correction must be performed at a controlled rate to prevent the development of osmotic demyelination syndrome.
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Affiliation(s)
- Liang-Jie Fang
- Department of Respiratory Medicine, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Ming-Wei Xu
- Department of Neurology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Jian-Ying Zhou
- Department of Respiratory Medicine, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Zhi-Jie Pan
- Department of Respiratory Medicine, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
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Hsieh HC, Wu SH, Chiu CC, Ko KC. Excessive Sodium Bicarbonate Infusion May Result in Osmotic Demyelination Syndrome During Treatment of Diabetic Ketoacidosis: A Case Report. Diabetes Ther 2019; 10:765-771. [PMID: 30843157 PMCID: PMC6437239 DOI: 10.1007/s13300-019-0592-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION We present a case wherein diabetic ketoacidosis (DKA) was treated with a large amount of sodium bicarbonate and potassium chloride, resulting in the development of osmotic demyelination syndrome (ODS). CASE PRESENTATION Our patient was a 29-year-old male with a history of post-surgical repair for ventricular septal defect. Upon arrival, the patient's Glasgow Coma Scale (GCS) score was E2M4V3. Laboratory examinations revealed leukocytosis, severe metabolic acidosis, hypokalemia, and hyperglycemia. His consciousness status and hemodynamics improved after resuscitation (GCS: E3M6Ve). However, they declined at the 40th hour of admission and dropped to GCS E2M2Ve. Magnetic resonance imaging revealed multifocal abnormal signal intensity changes in the whole brain stem. The diagnosis of type 1 diabetes mellitus was made during the hospitalization period. The patient exhibited improved consciousness status after 17-day medical care at the ICU. CONCLUSIONS We recommend that in the case of DKA, the correction of hypokalemia should be prioritized during treatment. Sodium bicarbonate infusion should be reserved for pH < 6.9. In addition, close monitoring of the serum sodium level and prompt actions to lower it if it exceeds the threshold may be necessary.
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Affiliation(s)
- Hui-Chi Hsieh
- Division of Critical Care, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Shin-Hwar Wu
- Division of Critical Care, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Chun-Ching Chiu
- Division of Critical Care, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Keng-Chu Ko
- Division of Critical Care, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.
- Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.
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16
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Abstract
Hyperkalemia is a potentially life-threatening electrolyte disorder appreciated with greater frequency in patients with renal disease, heart failure, and with use of certain medications such as renin angiotensin aldosterone inhibitors. The traditional views that hyperkalemia can be reliably diagnosed by electrocardiogram and that particular levels of hyperkalemia confer cardiotoxic risk have been challenged by several reports of patients with atypic presentations. Epidemiologic data demonstrate strong associations of morbidity and mortality in patients with hyperkalemia but these associations appear disconnected in certain patient populations and in differing clinical presentations. Physiologic adaptation, structural cardiac disease, medication use, and degree of concurrent illness might predispose certain patients presenting with hyperkalemia to a lower or higher threshold for toxicity. These factors are often overlooked; yet data suggest that the clinical context in which hyperkalemia develops is at least as important as the degree of hyperkalemia is in determining patient outcome. This review summarizes the clinical data linking hyperkalemia with poor outcomes and discusses how the efficacy of certain treatments might depend on the clinical presentation.
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Affiliation(s)
- John R Montford
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; .,Renal Section, Medicine Service, Veterans Affairs Eastern Colorado Health System, Denver, Colorado; and
| | - Stuart Linas
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Division of Nephrology, Department of Medicine, Denver Health and Hospitals, Denver, Colorado
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17
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Atchaneeyasakul K, Tipirneni A, Gloria S, Berry AC, Shah K, Yavagal DR. Osmotic demyelination syndrome: plasmapheresis versus intravenous immunoglobulin? Intern Emerg Med 2017; 12:123-126. [PMID: 27091143 DOI: 10.1007/s11739-016-1452-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Kunakorn Atchaneeyasakul
- Department of Neurology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL, USA
| | - Anita Tipirneni
- Department of Neurology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL, USA
| | - Salomon Gloria
- Department of Neurology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL, USA
| | - Andrew C Berry
- Department of Medicine, University of South Alabama, 2451 Fillingim St., Mobile, AL, 36617-2238, USA.
| | - Kush Shah
- Department of Radiology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL, USA
| | - Dileep R Yavagal
- Department of Neurology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL, USA
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18
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Abstract
A 71-year-old Japanese woman presented with progressive fatigue, lethargy, dysarthria and a gait disorder. Her laboratory data revealed hyponatremia (Na 101 mEq/L), and we started correcting her serum sodium level. Within a few days, she became comatose, bedridden, and was intubated. We diagnosed osmotic demyelination syndrome (ODS) and started performing plasma exchange (PE) on the 39th day of hospitalization. She fully recovered after starting PE, and was discharged on foot unassisted. PE can be a beneficial treatment in patients with chronic ODS.
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Affiliation(s)
- Saeko Kumon
- Division of Nephrology, Department of Medicine, Tokyo Women's Medical University Yachiyo Medical Center, Japan
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19
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Abstract
Sodium bicarbonate is a well-known antidote for tricyclic antidepressant (TCA) poisoning. It has been used for over half a century to treat toxin-induced sodium channel blockade as evidenced by QRS widening on the electrocardiogram (ECG). The purpose of this review is to describe the literature regarding electrophysiological mechanisms and clinical use of this antidote after poisoning by tricyclic antidepressants and other agents. This article will also address the literature supporting an increased serum sodium concentration, alkalemia, or the combination of both as the responsible mechanism(s) for sodium bicarbonate's antidotal properties. While sodium bicarbonate has been used as a treatment for cardiac sodium channel blockade for multiple other agents including citalopram, cocaine, flecainide, diphenhydramine, propoxyphene, and lamotrigine, it has uncertain efficacy with bupropion, propranolol, and taxine-containing plants.
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20
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Ritzenthaler T, Laurencin C, André Obadia N, Bodonian C, Dailler F. Not everything that shakes is a seizure… Role of continuous EEG in the intensive care unit. Neurophysiol Clin 2016; 47:13-18. [PMID: 27856078 DOI: 10.1016/j.neucli.2016.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 10/04/2016] [Accepted: 10/04/2016] [Indexed: 01/05/2023] Open
Abstract
Treatment of status epilepticus often requires highly sedative drugs with risk of side effects. Correct diagnosis is mandatory in order to prevent introduction of usefulness treatments. We report a case of suspected myoclonic status epilepticus. A thalamic lesion secondary to an osmotic demyelination syndrome was found to be the likely etiology of the myoclonus. Electrophysiological data (electroencephalography and electromyography) provided evidence for a subcortical origin of myoclonus and use of continuous EEG allowed monitoring of drug withdrawal.
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Affiliation(s)
- Thomas Ritzenthaler
- Service de réanimation neurologique, hôpital neurologique, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron cedex, France; Université de Lyon CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, université Lyon-I, hospices civils de Lyon, 69677 Bron cedex, France.
| | - Chloé Laurencin
- Service de neurologie C, hôpital neurologique, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron cedex, France
| | - Nathalie André Obadia
- Service de neurologie fonctionnelle et d'épileptologie, hôpital neurologique, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron cedex, France
| | - Carole Bodonian
- Service de réanimation neurologique, hôpital neurologique, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron cedex, France
| | - Frédéric Dailler
- Service de réanimation neurologique, hôpital neurologique, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron cedex, France
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21
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Abdulla MC, Alungal J, Ahammed S, Narayan R. Central pontine myelinolysis in Sjogren's syndrome with hypokalemia. Int J Rheum Dis 2016; 20:2168-2170. [PMID: 26929036 DOI: 10.1111/1756-185x.12847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mansoor C Abdulla
- Department of General Medicine, M.E.S. Medical College, Perinthalmanna, Kerala, India
| | - Jemshad Alungal
- Department of General Medicine, M.E.S. Medical College, Perinthalmanna, Kerala, India
| | - Shameem Ahammed
- Department of Radio Diagnosis, M.E.S. Medical College, Perinthalmanna, Kerala, India
| | - Ram Narayan
- Department of General Medicine, M.E.S. Medical College, Perinthalmanna, Kerala, India
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22
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Bates MC, Roady P, Lehner AF, Buchweitz JP, Heggem-Perry B, Lezmi S. Atypical bromethalin intoxication in a dog: pathologic features and identification of an isomeric breakdown product. BMC Vet Res 2015; 11:244. [PMID: 26419228 PMCID: PMC4584469 DOI: 10.1186/s12917-015-0554-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 09/14/2015] [Indexed: 12/31/2022] Open
Abstract
Background Definitive post mortem confirmation of intoxication by the neurotoxic rodenticide bromethalin can be challenging. Brain lesions are not specific and detection of bromethalin and its metabolites are unpredictable due to rapid photodegradation and inconsistent behavior in tissues. Case presentation A 2-year-old dog presented with rapid onset of severe muscle tremors and death within hours after a known ingestion of a reportedly low dosage of bromethalin and subsequent decontamination using activated charcoal. Marked meningeal hemorrhages and multifocal myelin sheath vacuolation were observed in the brain. A marked reactive astrocytosis and neuronal hypoxia/necrosis were identified using immunohistochemistry (IHC) for glial fibrillary acidic protein (GFAP) and for neuron specific protein (NeuN). Bromethalin exposure and tissue absorption was confirmed by identification of one of two isomeric 543.7 molecular weight (MW) breakdown products in the patient’s adipose and kidney samples using gas chromatography (GC) combined with tandem quadrupole mass spectrometry (MS/MS). Conclusions The severity of clinical signs and subsequent death of this dog was not expected with the low dosage of bromethalin reportedly ingested, and the use of activated charcoal possibly precipitated a hypernatremic status. Meningeal hemorrhages are atypical of bromethalin intoxication, and might have been caused by hyperthermia, secondary to tremors or hypernatremia. Identification of one of two isomeric breakdown products in the adipose tissue and kidney provides an additional molecule to the toxicologic testing regime for bromethalin intoxication.
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Affiliation(s)
- Maria C Bates
- College of Veterinary Medicine, Department of Pathobiology & Veterinary Diagnostic Laboratory, University of Illinois, 2001 S. Lincoln Ave, Urbana, IL, 61802, USA.
| | - Patrick Roady
- College of Veterinary Medicine, Department of Pathobiology & Veterinary Diagnostic Laboratory, University of Illinois, 2001 S. Lincoln Ave, Urbana, IL, 61802, USA.
| | - Andreas F Lehner
- Diagnostic Center for Population and Animal Health, Toxicology Section, Michigan State University, 4125 Beaumont Rd, Lansing, MI, 48910, USA.
| | - John P Buchweitz
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, 784 Wilson Rd, East Lansing, MI, 48824, USA.
| | - B Heggem-Perry
- College of Veterinary Medicine, University of Illinois, Veterinary Teaching Hospital 1008 W. Hazelwood Dr., Urbana, IL, 61802, USA.
| | - Stephane Lezmi
- College of Veterinary Medicine, Department of Pathobiology & Veterinary Diagnostic Laboratory, University of Illinois, 2001 S. Lincoln Ave, Urbana, IL, 61802, USA.
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23
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Straube A, Klein M, Erbguth F, Maschke M, Klawe C, Sander D, Hilz MJ, Ziemssen T, Klucken J, Kohl Z, Winkler J, Bettendorf M, Staykov D, Berrouschot J, Dörfler A. Metabolische Störungen. NEUROINTENSIV 2015. [PMCID: PMC7175475 DOI: 10.1007/978-3-662-46500-4_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Im folgenden Kapitel werden die verschiedenen metabolischen Störungen betrachtet. Zunächst wird auf die allgemeinen und spezifischen neurologischen Komplikationen bei Organtransplantation eingegangen. Dann geht es um die metabolischen Enzephalopathien: Störungen der Gehirntätigkeit bei angeborenen und erworbenen Stoffwechselerkrankungen im engeren Sinn, Elektrolytstörungen, Hypovitaminosen, zerebrale Folgen einzelner Organdysfunktionen, zerebrale Hypoxien, Endotheliopathien und Mitochondropathien. Anschließend werden das Alkoholdelir und die Wernicke-Enzephalopathie erörtert. Bei zahlreichen akuten Erkrankungen von Gehirn, Rückenmark und peripherem Nervensystem treten typische Störungen vegetativer Systeme auf, deren Erkennung und Therapie insbesondere bei Intensivpatienten eine vitale Bedeutung haben kann: die autonomen Störungen. Bei der zentralen pontinen Myelinolyse kommt es zu einer akuten, vorwiegend fokal-symmetrischen Demyelinisierung im Hirnparenchym. Auch Basalganglienerkrankungen können intensivmedizinisch relevant werden. Und schließlich wird die akute Stressreaktion betrachtet, die aufgrund der vielfältigen metabolischen und endokrinen Veränderungen bei kritischen Erkrankungen entsteht. Gerade das RCVS als neuere Krankheitsentität und wichtige Differenzialdiagnose zur Vaskulitis des ZNS verdient einen eigenen Platz, in diesem Unterkapitel werden ebenfalls verwandte Syndrome wie die hypertensive Enzephalopathie und das PRES abgehandelt.
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