Effective treatment of osmotic demyelination syndrome with plasmapheresis: a case report and review of the literature

Consequences of Hyponatremia: Central Pontine and Extrapontine Myelinolysis in a Chronic Alcohol User

Central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM) are rare neurological disorders associated with rapid correction of hyponatremia, particularly in individuals with chronic alcohol use. We present the case of a 52-year-old male with a history of chronic alcoholism who developed CPM and EPM following correction of severe hyponatremia. The patient presented with dysarthria, hemiparesis, and altered mental status, which progressed rapidly to pseudobulbar features and spastic quadriparesis. Neuroimaging revealed characteristic findings of CPM and EPM. Treatment with intravenous dexamethasone, intravenous immunoglobulin (IVIG), and methylprednisolone led to gradual neurological improvement. The patient showed significant recovery after two months, highlighting the importance of early recognition and cautious management of electrolyte disturbances in high-risk individuals to prevent devastating neurological complications.

The Response of Osmotic Demyelination Syndrome to Plasmapheresis in a Patient Presenting with Catatonia after Correction of Hyponatraemia in Hyperemesis Gravidarum

Osmotic demyelination syndrome (ODS) is a disorder characterised by the widespread development of demyelination in both pontine and extrapontine regions. It has been recognised as a complication arising from the rapid correction of hyponatraemia. This study presents the case of a 20-year-old Thai female patient at 10 weeks gestation, exhibiting an initial presentation of catatonia - an uncommon manifestation of ODS. The patient developed symptoms following the rapid correction of hyponatraemia in the context of hyperemesis gravidarum. Magnetic resonance imaging (MRI) of the brain revealed a trident or bat-wing-shaped pattern in T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences at the central pons. The patient underwent five cycles of plasmapheresis and received rehabilitation, leading to clinical improvement.

LEARNING POINTS

Osmotic demyelination syndrome (ODS) is a rare but potentially devastating neurological complication, such as catatonia, resulting from the correction of hyponatraemia.Pregnancies complicated by hyperemesis gravidarum tend to exhibit hyponatraemia and hypokalaemia, which serve as contributing risk factors for ODS.Plasmapheresis is considered as an option in the treatment of ODS for the removal of inflammatory substances.

Hand knob sign in osmotic demyelinating syndrome

BACKGROUND

Osmotic demyelinating syndrome, commonly recognized as a consequence of the rapid correction of hyponatremia, has been known to cause motor, neuropsychiatric, or extrapyramidal symptoms. We reported a patient with an unusual presentation involving bilateral hand weakness, and pseudobulbar affect. The imaging was compatible with osmotic demyelinating syndrome with bilateral hand knob lesions, despite no history of overcorrection of hyponatremia.

CASE PRESENTATION

A 44-year-old female presented with three weeks of emotional lability, spastic dysarthria, and bilateral hand weakness following ankle surgery and a mild head injury. Physical examination revealed weakness in the intrinsic hand muscles, leading to a claw-like deformity of the hands, although sensation remained unimpaired. Magnetic resonance imaging (MRI) of the brain revealed several hyperintensities on fluid-attenuated inversion recovery imaging involving various areas, including the hand knob area of the bilateral precentral gyri, caudate, lentiform nuclei, and pons, suggestive of osmotic demyelinating syndrome. Clinical improvement was observed following a trial of intravenous pulse methylprednisolone and plasmapheresis.

CONCLUSIONS

Bilateral hand weakness is an unusual manifestation of osmotic demyelinating syndrome. The precentral gyrus, specifically in the hand knob area, is the vulnerable region that can result from osmotic demyelinating syndrome.

Delayed Presentation of Osmotic Demyelination Syndrome Treated With Plasmapheresis

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.

Loss of Ephaptic Contacts in the Murine Thalamus during Osmotic Demyelination Syndrome

BACKGROUND AND AIM

A murine model mimicking osmotic demyelination syndrome (ODS) revealed with histology in the relay posterolateral (VPL) and ventral posteromedial (VPM) thalamic nuclei adjoined nerve cell bodies in chronic hyponatremia, amongst the damaged 12 h and 48 h after reinstatement of osmolality. This report aims to verify and complement with ultrastructure other neurophysiology, immunohistochemistry, and molecular biochemistry data to assess the connexin-36 protein, as part of those hinted close contacts.This ODS investigation included four groups of mice: Sham (NN; n = 13), hyponatremic (HN; n = 11), those sacrificed 12 h after a fast restoration of normal natremia (ODS12h; n = 6) and mice sacrificed 48 h afterward, or ODS48 h (n = 9). Out of these, thalamic zones samples included NN (n = 2), HN (n = 2), ODS12h (n = 3) and ODS48h (n = 3).

RESULTS

Ultrastructure illustrated junctions between nerve cell bodies that were immunolabeled with connexin36 (Cx36) with light microscopy and Western blots. These cell's junctions were reminiscent of low resistance junctions characterized in other regions of the CNS with electrophysiology. Contiguous neurons showed neurolemma contacts in intact and damaged tissues according to their location in the ODS zones, at 12 h and 48 h post correction along with other demyelinating alterations. Neurons and ephaptic contact measurements indicated the highest alterations, including nerve cell necrosis in the ODS epicenter and damages decreased toward the outskirts of the demyelinated zone.

CONCLUSION

Ephapses contained C × 36between intact or ODS injured neurons in the thalamus appeared to be resilient beyond the core degraded tissue injuries. These could maintain intercellular ionic and metabolite exchanges between these lesser injured regions and, thus, would partake to some brain plasticity repairs.

Osmotic demyelination syndrome with transient diabetes insipidus in postpartum female: a case report

Osmotic demyelination syndrome (ODS) is a neurological disorder usually after rapid correction of hyponatremia. Only few cases of ODS with hypernatremia and diabetes insipidus (DI) in postpartum state is reported. Postpartum hypernatremia is described as severe hypernatremia in postpartum period and presents as an encephalopathy with rhabdomyolysis with diffuse white matter hyperintensities suggestive of osmotic demyelination.

CASE PRESENTATION

The authors present a case of 29-year-old female who presented with chief complaint of altered sensorium and quadriparesis. Two days prior to onset of symptoms, she underwent caesarean section, was kept on nil per oral and free fluid restriction, after which she had confusion, altered sensorium, and weakness in all four limbs. Sodium level was 170 mEq/l. Urine osmolality and plasma osmolality was 150 and 410 mOsm/kg of water, respectively. MRI showed high signal intensity lesion in pons suggestive of demyelination. She was diagnosed ODS with transient DI and quadriparesis, in postpartum period due to further rise in sodium after free fluid restriction and nil per oral. She was treated with desmopressin, 5% dextrose and 0.9% normal saline, her quadriparesis recovered and desmopressin was tapered and stopped over 45 days and discharged at stable state.

CLINICAL DISCUSSION

ODS can rarely be associated with hypernatremia in postpartum female presenting as quadriparesis and altered sensorium.

CONCLUSION

Clinicians should be familiar of ODS with hypernatremia with transient DI in postpartum period, which is reversible and can be managed by desmopressin and fluid replacement.

Case report: Recovery and sequential imaging of a patient with osmotic demyelination syndrome

A 4-year-old neutered-male Australian Shepherd was presented to an emergency and referral hospital for an acute onset of neurologic signs and abnormal mentation. Seven days prior, the patient had been diagnosed with hypoadrenocorticism and was treated accordingly at another hospital. Based on recent clinical history, the neurologic signs were consistent with thalamic and brainstem deficits and suspected to be caused by osmotic demyelination syndrome secondary to rapid correction of hyponatremia. A brain MRI confirmed lesions consistent with osmotic demyelination syndrome. The patient's clinical signs initially worsened, and he required intensive nursing care with multimodal sedation, close monitoring of electrolytes and tailored fluid therapy. The patient recovered and was discharged on day seven of hospitalization. Four and a half months later, re-evaluation of the patient showed complete resolution of the neurological deficits with a now unremarkable neurological exam, and follow-up MRI revealed still present, yet improved bilateral thalamic lesions. This is the first known veterinary case report of sequential brain imaging of a dog that has recovered from osmotic demyelination syndrome. In humans, patients can have evidence of near to full clinical recovery, yet imaging findings may still be abnormal several months after recovery. This report details similar imaging findings in a canine with improved clinical signs, despite persistent lesions on brain MRI. Prognosis of canines with osmotic demyelination syndrome may be better than previously perceived, despite the severity of clinical signs and brain lesions apparent on MRI.

Refractory Hypernatremia and Osmotic Demyelination Syndrome After Liver Transplantation: A Case Report

Osmotic demyelination syndrome is an uncommon neurologic condition, characterized by noninflammatory demyelination involving the pons and other areas of the central nervous system. As chronic hyponatremia is frequently associated with cirrhosis, patients undergoing liver transplantation are at an increased risk for developing this condition. We report the case of a patient who developed refractory hypernatremia and osmotic demyelination syndrome after liver transplantation. The patient was a 40-year-old man, who underwent liver transplantation for the treatment of cryptogenic cirrhosis, and had a preoperative sodium level of 128 mmol/L. Although there were no intraoperative complications, the patient showed signs of mental confusion and drowsiness in the second postoperative day, and we noticed an increase to 136 mmol/L in his serum sodium. Treatment with 5% dextrose and desmopressin was initiated, but his serum sodium continued to increase steadily, while his neurologic condition gradually worsened. Serum sodium rose to 157 mmol/L, and a magnetic resonance imaging of the brain showed extensive lesions consistent with osmotic demyelination syndrome. The clinical condition of the patient continued to deteriorate until his death 17 days after the transplant. Although the occurrence of this syndrome after liver transplantation is well described, the steady increase in serum sodium despite early treatment, as described in this case, is highly unusual, and highlights the great attention that must be taken with monitoring and control of serum sodium in patients who undergo liver transplant in the context of chronic hyponatremia. This manuscript is compliant with the Helsinki Congress and the Istanbul Declaration.

Case Report: Osmotic Demyelination Syndrome After Transcatheter Aortic Valve Replacement: Case Report and Review of Current Literature

Background

Osmotic demyelination syndrome (ODS) has a low incidence but is a life-threatening neurological disorder whose common cause is rapid overcorrection of chronic hyponatremia. Transcatheter aortic valve replacement (TAVR) is a new and important therapy for patients with aortic valve stenosis. In this article, we discuss the case of a 64-year-old woman who developed ODS after TAVR and provide a literature review.

Case Presentation

A 64-year-old female patient was admitted to the hospital with chest tightness, shortness of breath, and fatigue for 2 months, with worsening of symptoms for 3 days prior to presentation. Auscultation revealed crackles in the lung fields, and systolic murmurs could be easily heard in the aortic area. Echocardiography showed severe aortic stenosis. Chest X-ray showed pulmonary oedema. Laboratory examinations showed that her serum sodium was 135 mmol/L. The patient received a diuretic to relieve her symptoms but showed little benefit. Her symptoms worsened, and her blood pressure dropped. Then, she underwent emergency TAVR under extracorporeal membrane oxygenation (ECMO) support. After the operation, her urine output increased markedly, and serum sodium increased sharply from 140 to 172 mmol/L. An MRI scan showed multiple lesions in the pons suggestive of ODS.

Conclusion

To date, this is the first reported case of a patient who developed ODS after receiving TAVR. In current clinical practice, diuretics are often used in aortic stenosis patients because of pulmonary oedema. After a patient receives TAVR, kidney perfusion pressure quickly returns to normal, and with the residual effect of a high-dose diuretic, balances of fluid volume and electrolyte levels in this phase are quite fragile and must be carefully managed. If a patient has neurological symptoms/signs during this phase, ODS should be considered, and MRI might be necessary.

Case Report: Hindlimb Ataxia Concurrent With Seizures by Presumed Osmotic Demyelination Syndrome in a Dog

A 6-year-old castrated male Chihuahua dog was presented with hindlimb paresis and ataxia. The dog had hyponatremia and was diagnosed as hypoadrenocorticism 10 days before its visit, and the neurologic signs including generalized tonic seizures and hindlimb paresis occurred 3 days after correction of hyponatremia at a referral hospital. Based on history and clinical findings, osmotic demyelination syndrome (ODS) secondary to rapid correction of hyponatremia was highly suspected. After administration of anti-convulsant and supplements, seizures did not occur, and gait was normalized within 2 weeks. Phenobarbital was tapered and finally discontinued after 3 months, and seizure did not recur. The neurologic signs were completely resolved and the dog continued to be free of neurologic or additional clinical signs over the 19-month follow-up period. ODS should be included among the differential diagnoses in case of any acute neurological dysfunction that occurs with episodes of rapid correction of hyponatremia. To the author's knowledge, this is the rare case report of a dog with hypoadrenocorticism and presumed ODS after rapid correction of hyponatremia leading to neurologic signs including seizures and ataxia.

Osmotic demyelination syndrome following slow correction of hyponatraemia

Hyponatraemia is the most common electrolyte disturbance observed in hospital inpatients. We report a 90-year-old woman admitted generally unwell following a fall with marked confusion. Examination revealed a tender suprapubic region, and investigations observed elevated inflammatory markers and bacteriuria. Admission investigations demonstrated a serum sodium of 110 mmol/L with associated serum osmolality 236 mmol/kg and urine osmolality 346 mmol/kg. She was treated for hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone (SIADH) and urosepsis. However, her serum sodium failed to normalise despite fluid restriction, necessitating treatment with demeclocycline and hypertonic saline. Despite slow reversal of hyponatraemia over 1 month, the patient developed generalised seizures with pontine and thalamic changes on MRI consistent with osmotic demyelination syndrome (ODS). This case highlights the risk of ODS, a rare but devastating consequence of hyponatraemia treatment, despite cautious sodium correction.

Osmotic demyelination syndrome improving after immune-modulating treatment: Case report and literature review

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.