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Meng H, Wang J, Hou J, Liu R, Zhang M. Case report: Hyponatremia is an initial presentation of Neuromyelitis optica spectrum disorder. Int J Neurosci 2023:1-4. [PMID: 38019130 DOI: 10.1080/00207454.2023.2277666] [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: 11/17/2022] [Accepted: 10/26/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVE Neuromyelitis optica spectrum disorders (NMOSD) is often misdiagnosed or delayed because of the complex and diverse clinical manifestations, especially the atypical initial presentation. Hyponatremia can be an infrequently isolated initial presentation of NMOSD and is associated with hypothalamus involvement. Awareness of this mechanism will help clinicians to identify NMOSD early, treat it in time and improve the prognosis. METHODS We describe a 36-year-old woman who developed repeated hyponatremia and then experienced diplopia. Serum AQP4, MOG, MBP and GFAP antibody were detected, and NMOSD was finally diagnosed. RESULTS She responded well to high-dose glucocorticoids. Sequential treatment with mycophenolate mofetil (MMF) was prescribed. Two-month follow-up revealed full recovery. So far, after 10 months, the patient still has no recurrence. CONCLUSION For young patients, repeated hyponatremia, with or without slight fever, and no evidence of obvious infection, brain magnetic resonance imaging (MRI) and serum AQP4/MOG antibody detection may be useful to determine whether there is a possibility of NMOSD.
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Affiliation(s)
- Huaxing Meng
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jing Wang
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jiaqi Hou
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ruiqin Liu
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Meini Zhang
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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Chung JY, Lee CJ, Bong JB, Shin BS, Ryu HU, Kang HG. Neuromyelitis optica spectrum disorder with herpes simplex viral infection presenting with syndrome of inappropriate antidiuretic hormone: A case report. Medicine (Baltimore) 2023; 102:e35566. [PMID: 37904479 PMCID: PMC10615398 DOI: 10.1097/md.0000000000035566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/11/2023] [Indexed: 11/01/2023] Open
Abstract
RATIONALE Neuromyelitis optica spectrum disorder (NMOSD) is a demyelinating disease that causes lesions in areas with abundant aquaporin-4 (AQP4) channels, including the hypothalamus. Hypothalamic lesions can disrupt antidiuretic hormone regulation, resulting in hyponatremia due to syndrome of inappropriate antidiuretic hormone (SIADH). Various factors can trigger NMOSD, including viral infections. We report the case of a young female patient who presented with hyponatremia due to SIADH and was found to have bilateral hypothalamic lesions along with positive serum herpes simplex virus immunoglobulin M. PATIENT CONCERNS An 18-year old female patient presented with fever and nausea that had persisted for 5 days. Three days after hospitalization, the patient complained of blurred vision, hiccups, and excessive daytime sleepiness. DIAGNOSIS The patient hyponatremia was attributed to SIADH. Magnetic resonance imaging revealed bilateral lesions in the hypothalamus, and serum laboratory tests were positive for herpes simplex virus immunoglobulin M. On the 15th day of admission, the anti-AQP4 antibody test result was positive, leading to the diagnosis of NMOSD. INTERVENTIONS On the initial suspicion of herpes encephalitis, treatment with acyclovir was initiated. However, upon the confirmation of after anti-AQP4 antibody, the patient was additionally treated with a high-dose intravenous steroid for 5 days. OUTCOMES The patient fever, nausea, visual disturbances, and other complaints improved within 1 week of initiating steroid treatment. LESSONS In young patients presenting with hyponatremia and suspected SIADH accompanied by neurological abnormalities, it is crucial to differentiate central nervous system diseases, including NMOSD, which can involve lesions in AQP4-abundant areas, such as the hypothalamus.
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Affiliation(s)
- Ji Yeon Chung
- Department of Neurology, Chosun University Medical School, Gwangju, South Korea
| | - Chang Ju Lee
- Department of Neurology, Chosun University Medical School, Gwangju, South Korea
| | - Jeong Bin Bong
- Department of Neurology, Chosun University Medical School, Gwangju, South Korea
| | - Byoung-Soo Shin
- Department of Neurology and Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, South Korea
- Biomedical Research Institute, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea
| | - Han Uk Ryu
- Department of Neurology and Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, South Korea
- Biomedical Research Institute, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea
| | - Hyun Goo Kang
- Department of Neurology and Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, South Korea
- Biomedical Research Institute, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea
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Akaishi T, Tarasawa K, Matsumoto Y, Sandhya P, Misu T, Fushimi K, Takahashi T, Fujimori J, Ishii T, Fujimori K, Yaegashi N, Nakashima I, Fujihara K, Aoki M. Associations between neuromyelitis optica spectrum disorder, Sjögren's syndrome, and conditions with electrolyte disturbances. J Neurol Sci 2023; 452:120742. [PMID: 37515845 DOI: 10.1016/j.jns.2023.120742] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/20/2023] [Accepted: 07/23/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVE Electrolyte disorders are among the important conditions negatively affecting the disease course of neuromyelitis optica spectrum disorder (NMOSD). Possible mechanisms may include renal tubular acidosis (RTA) accompanying Sjögren's syndrome (SS), syndrome of inappropriate antidiuretic hormone secretion (SIADH), and central diabetes insipidus (DI). Currently, the overlap profiles between these conditions remain uncertain. METHODS This cross-sectional study collected data from the nationwide administrative Diagnosis Procedure Combination (DPC) database and evaluated the overlap profiles. RESULTS Among the 28,285,908 individuals from 1203 DPC-covered hospitals, 8477 had NMOSD, 174108 had SS, 4977 had RTA, 7640 had SIADH, and 24,789 had central DI. Of those with NMOSD, 986 (12%) had SS. The odds ratio (OR) for a diagnosis of NMOSD in those with SS compared with those without was 21 [95% confidence interval (CI), 20-23]. Overlap between NMOSD and SS was seen both in males (OR, 28 [95% CI, 23-33]) and females (OR, 16 [15-17]) and was more prominent in the younger population. Among patients with SS, the prevalence of RTA was lower in patients with NMOSD compared with those without NMOSD. Patients with NMOSD showed a higher prevalence of SIADH (OR, 11 [7.5-17]; p < 0.0001) and DI (OR, 3.7 [2.4-5.3]; p < 0.0001). Comorbid SS in NMOSD was associated with a higher prevalence of DI. CONCLUSIONS Patients with NMOSD are likely to have SS, SIADH, and central DI. RTA in SS does not facilitate the overlap between NMOSD and SS. SS in NMOSD may predispose patients to DI.
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Affiliation(s)
- Tetsuya Akaishi
- Department of Neurology, Tohoku University Graduate School of Medicine, Tohoku University, Sendai, Japan; Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan.
| | - Kunio Tarasawa
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuki Matsumoto
- Department of Neurology, Tohoku University Graduate School of Medicine, Tohoku University, Sendai, Japan
| | | | - Tatsuro Misu
- Department of Neurology, Tohoku University Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Tokyo, Japan
| | - Toshiyuki Takahashi
- Department of Neurology, Tohoku University Graduate School of Medicine, Tohoku University, Sendai, Japan; Department of Neurology, National Hospital Organization Yonezawa National Hospital, Yonezawa, Japan
| | - Juichi Fujimori
- Department of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Tadashi Ishii
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ichiro Nakashima
- Department of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kazuo Fujihara
- Department of Neurology, Fukushima Medical University, Sendai, Japan
| | - Masashi Aoki
- Department of Neurology, Tohoku University Graduate School of Medicine, Tohoku University, Sendai, Japan
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Sen K, DiSabella MT, Harmon J, Strelzik JA, Gropman AL. Gaps in Neurogenetics Education During Child Neurology Residency: Results of a National Survey. J Child Neurol 2022; 37:702-706. [PMID: 35656773 DOI: 10.1177/08830738221106896] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The practice of child neurology has changed significantly in the past two decades as we have integrated genetic testing into our standard of care to achieve precise diagnoses and to guide management of many childhood neurological conditions. Despite this paradigm shift, there appears to be a gap in both clinical exposure to neurogenetic disorders and education provided to residents in ordering and interpreting genetic testing. We therefore conducted a national survey for child neurology trainees in all programs across the United States to delineate their perception of the adequacy of current training and didactics in genetic/neurogenetic disorders. The results revealed knowledge gaps related to ordering and interpreting genetic testing, managing acute metabolic emergencies, and identifying resources for referral of patients to clinical trials. Responders considered their current curriculum in neurogenetics to be insufficient and voted favorably for an educational platform using recorded lectures and interactive sessions.
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Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Developmental Pediatrics, 8404Children's National Hospital, Washington DC, USA
| | - Marc T DiSabella
- Division of Neurology, 8404Children's National Hospital, Washington DC, USA
| | - Jennifer Harmon
- Rare Disease Institute; 8404Children's National Hospital, Washington DC, USA
| | - Jeffrey A Strelzik
- Division of Neurology, 8404Children's National Hospital, Washington DC, USA
| | - Andrea L Gropman
- Division of Neurogenetics and Developmental Pediatrics, 8404Children's National Hospital, Washington DC, USA
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Etemadifar M, Nouri H, Khorvash R, Salari M, Ghafari K, Aghababaee A. Frequency of diencephalic syndrome in NMOSD. Acta Neurol Belg 2021; 122:961-967. [PMID: 34515964 DOI: 10.1007/s13760-021-01792-1] [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: 01/29/2021] [Accepted: 08/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Diencephalic region of the brain harbors sites with a considerable amount of aquaporin-4 expression. Neuromyelitis optica spectrum disorder (NMOSD) primarily involves autoimmune processes against this molecule. However, little is known about the frequency of symptoms of diencephalic involvement in NMOSD patients. OBJECTIVE To investigate the frequency of symptoms of diencephalic involvement in NMOSD patients and describe the associated characteristics in patients presenting such symptoms. MATERIALS AND METHODS This retrospective cohort included 145 NMOSD patients (39 males and 106 females) who visited Isfahan Multiple Sclerosis Center from January 2013 to February 2020 for approximately 61 months. Demographic and clinical information of patients and findings from radiological and serological investigations were retrieved. RESULTS The frequency of diencephalic involvement in NMOSD patients was 3.4% (five cases). Diencephalic syndrome-associated symptoms observed in this cohort consisted of narcolepsy (n = 2; 40%), hypotension (n = 1; 20%), amenorrhea (n = 1; 20%), and syndrome of inappropriate antidiuretic hormone secretion (n = 1; 20%). These manifestations responded well to NMOSD-associated treatments, i.e., rituximab and azathioprine. CONCLUSION Although rarely manifested through symptoms suggestive of diencephalic involvement, NMOSD should be considered when encountering patients with the diencephalic syndrome to identify the primary cause of these manifestations.
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Lin TH, Hsu PC, Sung CC, Fang HH, Tien CH, Hu CF, Wu PW, Yu CH, Ding JJ, Ho SY, Chen SJ. Refractory hyponatremia in neuromyelitis optica in a pediatric patient: A case report. Medicine (Baltimore) 2021; 100:e26231. [PMID: 34398000 PMCID: PMC8294868 DOI: 10.1097/md.0000000000026231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/19/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Neuromyelitis optica spectrum disorders (NMOSD) is a rare autoimmune disease predominantly involving optic nerves and spinal cord, and possible comorbidities including syndrome of inappropriate antidiuretic hormone secretion or urinary complication. We reported a young girl diagnosed with NMOSD presented with refractory hyponatremia, acute urine retention, and general weakness. Clinical symptoms improved gradually after receiving intravenous immunoglobulin, high-dose methylprednisolone, and plasmapheresis. NMOSD should be kept in mind in adolescence with acute urine retention, intermittent fever, and hyponatremia. PATIENT CONCERNS A 15-year-old girl admitted to our hospital due to no urination for 2 days. DIAGNOSIS Aquaporin-4 antibodies were detected showing positive both in serum and cerebrospinal fluid. Long transverse myelitis in cervical and thoracic spinal cord and optic neuritis was revealed in magnetic resonance imaging. INTERVENTIONS Intravenous immunoglobulin 2 g/kg was infused totally in 4 days, and methylprednisolone pulse therapy was subsequently followed in 5 days; followed by 5 courses of plasmapheresis a week later. OUTCOMES Her muscle power, syndrome of inappropriate antidiuretic hormone secretion condition, and urinary function were all improved after immune-modulated treatment course; NMOSD relapsed twice within the first year after diagnosis, however no relapse of NMOSD in the subsequent 1 year. LESSONS To the best of our knowledge, this was the first childhood case of NMO accompanied by refractory hyponatremia in the reported literature. In childhood cases presenting with refractory hyponatremia and limb weakness, NMO or NMOSD should be considered possible diagnoses despite their rarity in pediatric cases.
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Affiliation(s)
- Tai-Han Lin
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
| | - Po-Chang Hsu
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
| | - Chia-Cheng Sung
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
| | - Hung-Hsiang Fang
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
| | - Chiung-Hsi Tien
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, No. 161, Section 6,MinChuan East Road, Neihu, Taipei, Taiwan
| | - Chih-Fen Hu
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, No. 161, Section 6,MinChuan East Road, Neihu, Taipei, Taiwan
| | - Po-Wei Wu
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
| | - Chia-Hsiang Yu
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
| | - Jhao-Jhuang Ding
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
| | - Sheng-Yuan Ho
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
| | - Shyi-Jou Chen
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, No.325, Section 2, Chenggong Rd., Neihu District, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, No. 161, Section 6,MinChuan East Road, Neihu, Taipei, Taiwan
- Department of Microbiology and Immunology, National Defense Medical Center, No. 161, Section 6, MinChuan East Road, Neihu, Taipei, Taiwan
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Iorio R, Papi C. Neuromyelitis optica, aquaporin-4 antibodies, and neuroendocrine disorders. HANDBOOK OF CLINICAL NEUROLOGY 2021; 181:173-186. [PMID: 34238456 DOI: 10.1016/b978-0-12-820683-6.00013-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neuromyelitis optica (NMO) is an autoimmune disorder of the central nervous system that preferentially affects the optic nerve and the spinal cord. In around 80% of NMO patients, autoantibodies binding to aquaporin-4 (AQP4) are detected. AQP4-IgG unifies a spectrum of disorders (NMOSD) that include not only optic neuritis, longitudinally extensive transverse myelitis but also syndromes caused by lesion of the diencephalic region and the circumventricular organs (CVOs). The distinctive immunopathological characteristics of NMOSD lesions, occurring in regions where AQP4 is highly expressed, supports a central role for AQP4-IgG in disease pathogenesis. AQP4 expression is concentrated in CVOs and in the hypothalamus, mainly in the dorsal hypothalamic area, dorsomedial hypothalamic nucleus and suprachiasmatic nucleus. Several neuroendocrine disorders caused by inflammatory lesions involving the diencephalic region have been described in patients with NMOSD, including syndrome of inappropriate antidiuresis, sleep disorders, and other endocrinopathies caused by hypothalamic injury. Focus of this chapter is the involvement of hypothalamus and CVOs in AQP4 autoimmunity.
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Affiliation(s)
- Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudia Papi
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy
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Go S, Kim S, Son HE, Ryu JY, Yang H, Choi SR, Seo JW, Jo YH, Koo JR, Baek SH. Association between copeptin levels and treatment responses to hypertonic saline infusion in patients with symptomatic hyponatremia: a prospective cohort study. Kidney Res Clin Pract 2021; 40:371-382. [PMID: 34233437 PMCID: PMC8476303 DOI: 10.23876/j.krcp.20.233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/28/2021] [Indexed: 11/05/2022] Open
Abstract
Background Copeptin is secreted in equimolar amounts as arginine vasopressin, main hormone regulating body fluid homeostasis. A recent study reported a copeptin-based classification of osmoregulatory defects in syndromes of inappropriate antidiuresis that may aid in prediction of therapeutic success. We investigated usefulness of copeptin for differentiating etiologies of hyponatremia and predicting efficacy and safety of hypertonic saline treatment in hyponatremic patients. Methods We performed a multicenter, prospective cohort study of 100 inpatients with symptomatic hyponatremia (corrected serum sodium [sNa] ≤ 125 mmol/L) treated with hypertonic saline. Copeptin levels were measured at baseline and 24 hours after treatment initiation, and patients were classified as being below or above median of copeptin at baseline or at 24 hours, respectively. Correlations between target, under correction, and overcorrection rates of sNa within 24 hours/24–48 hours and copeptin levels at baseline/24 hours were analyzed. Results Mean sNa and median copeptin levels were 117.9 and 16.9 pmol/L, respectively. Ratio of copeptin-to-urine sodium allowed for an improved differentiation among some (insufficient effective circulatory volume), but not all hyponatremia etiologic subgroups. Patients with below-median copeptin levels at baseline achieved a higher target correction rate in 6/24 hours (odds ratio [OR], 2.97; p = 0.02/OR, 6.21; p = 0.006). Patients with below-median copeptin levels 24 hours after treatment showed a higher overcorrection rate in next 24 hours (OR, 18.00, p = 0.02). Conclusion There is a limited diagnostic utility of copeptin for differential diagnosis of hyponatremia. However, copeptin might be useful for predicting responses to hypertonic saline treatment in hyponatremic patients.
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Affiliation(s)
- Suryeong Go
- Department of Internal Medicine, Armed Forces Yangju Hospital, Yangju, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyung-Eun Son
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Huijin Yang
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Sun Ryoung Choi
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jang-Won Seo
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ja-Ryong Koo
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
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Prasadani TGM, Panditha K, Irugalbandara D. Optic Neuritis Presented as Syndrome of Inappropriate Antidiuretic Hormone Secretion in an 8 Year Old. Case Rep Neurol Med 2021; 2021:6672827. [PMID: 37600468 PMCID: PMC10435311 DOI: 10.1155/2021/6672827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/27/2021] [Accepted: 03/09/2021] [Indexed: 08/22/2023] Open
Abstract
Optic neuritis is a rare demyelinating disorder, which involves the optic nerve. It can be a monophasic self-limiting illness due to postinfectious or postvaccination etiology. It can also be an initial presentation of a relapsing demyelinating disorder such as multiple sclerosis or neuromyelitis optica spectrum of disorders. It is characterized to aquaporin-4 antibody-rich areas in the brain, optic nerve, and spinal cord. The hypothalamus and periventricular area are also rich in specific antibodies and may lead to dysfunction in the hypothalamic-pituitary axis. Antidiuretic hormone (ADH) is synthesized in the hypothalamus and stored in the posterior pituitary and may secrete inappropriately due to this disturbance. This will impair water excretion from the kidney, leading to hyponatremia. When hyponatremia is significant, the patient will present with confusion, agitation, and convulsions. This case report discusses acute symptomatic hyponatremia as the initial presentation of optic neuritis due to syndrome of inappropriate ADH secretion (SIADH).
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Affiliation(s)
- T. G. M. Prasadani
- Pediatric Ward, District General Hospital Avissawella, Avissawella, Colombo, Sri Lanka
| | - Kapila Panditha
- Pediatric Ward, District General Hospital Avissawella, Avissawella, Colombo, Sri Lanka
| | - D. Irugalbandara
- Ophthalmology Unit, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
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Baek SH, Jo YH, Ahn S, Medina-Liabres K, Oh YK, Lee JB, Kim S. Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial. JAMA Intern Med 2021; 181:81-92. [PMID: 33104189 PMCID: PMC7589081 DOI: 10.1001/jamainternmed.2020.5519] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Few high-quality studies have clarified whether hypertonic saline is best administered as slow continuous infusion (SCI) therapy or rapid intermittent bolus (RIB) therapy for symptomatic severe hyponatremia. OBJECTIVE To compare the risk of overcorrection in RIB and SCI with hypertonic saline in patients with symptomatic hyponatremia. DESIGN, SETTING, AND PARTICIPANTS This prospective, investigator-initiated, multicenter, open-label, randomized clinical trial enrolled 178 patients older than 18 years with moderately severe to severe hyponatremia and glucose-corrected serum sodium (sNa) levels of 125 mmol/L or less. Recruitment took place from August 24, 2016, until August 21, 2019, across emergency departments and wards of 3 general hospitals in the Republic of Korea. INTERVENTIONS Either RIB or SCI of hypertonic saline, 3%, for 24 to 48 hours stratified by the severity of clinical symptoms. MAIN OUTCOME AND MEASURES The primary outcome was overcorrection at any given period, defined as increase in the sNa level by greater than 12 or 18 mmol/L within 24 or 48 hours, respectively. Secondary and post hoc outcomes included efficacy and safety of the treatment approaches. The sNa concentrations were measured every 6 hours for 2 days. RESULTS The 178 patients (mean [SD] age, 73.1 [12.2] years; 80 (44.9%) male; mean [SD] sNa concentrations, 118.2 [5.0] mmol/L) were randomly assigned to the RIB group (n = 87) or the SCI group (n = 91). Overcorrection occurred in 15 of 87 (17.2%) and 22 of 91 (24.2%) patients in the RIB and SCI groups, respectively (absolute risk difference, -6.9% [95% CI, -18.8% to 4.9%]; P = .26). The RIB group showed lower incidence of relowering treatment than the SCI group (36 of 87 [41.4%] vs 52 of 91 [57.1%] patients, respectively; absolute risk difference, -15.8% [95% CI, -30.3% to -1.3%]; P = .04; number needed to treat, 6.3). Groups did not differ in terms of efficacy in increasing sNa concentrations nor improving symptoms, but RIB, when compared with SCI, showed better efficacy in achieving target correction rate within 1 hour (intention-to-treat analysis: 28 of 87 (32.2%) vs 16 of 91 (17.6%) patients, respectively; absolute risk difference, 14.6% [95% CI, 2%-27.2%]; P = .02; number needed to treat, 6.8; per-protocol analysis: 21 of 72 (29.2%) vs 12 of 73 (16.4%) patients, respectively; absolute risk difference, 12.7% [95% CI, -0.8% to 26.2%]; P = .07). The statistical significance of the intention-to-treat and per-protocol analyses were similar for all outcomes except for achieving the target correction rate within 1 hour. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that both RIB and SIC therapies of hypertonic saline for treating hyponatremia were effective and safe, with no difference in the overcorrection risk. However, RIB had a lower incidence of therapeutic relowering treatment and tended to have a better efficacy in achieving sNa within 1 hour than SCI. RIB could be suggested as the preferred treatment of symptomatic hyponatremia, which is consistent with the current consensus guidelines. TRIAL REGISTRATION ClinicalTrials.org Identifier: NCT02887469.
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Affiliation(s)
- Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soyeon Ahn
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kristianne Medina-Liabres
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jung Bok Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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11
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Tenembaum S, Yeh EA. Pediatric NMOSD: A Review and Position Statement on Approach to Work-Up and Diagnosis. Front Pediatr 2020; 8:339. [PMID: 32671002 PMCID: PMC7330096 DOI: 10.3389/fped.2020.00339] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/21/2020] [Indexed: 11/13/2022] Open
Abstract
Neuromyelitis Optica Spectrum Disorder (NMOSD) is an inflammatory demyelinating disease of the central nervous system (CNS) primarily affecting the optic nerves and spinal cord, but also involving other regions of the CNS including the area postrema, periaqueductal gray matter, and hypothalamus. Knowledge related to pediatric manifestations of NMOSD has grown in recent years, particularly in light of newer information regarding the importance of not only antibodies to aquaporin 4 (AQP4-IgG) but also myelin oligodendrocyte glycoprotein (MOG-IgG) in children manifesting clinically with this syndrome. In this review, we describe the current state of the knowledge related to clinical manifestations, diagnosis, and chronic therapies for children with NMOSD, with emphasis on literature that has been published in the last 5 years. Following the review, we propose recommendations for the assessment/follow up clinical care, and treatment of this population.
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Affiliation(s)
- Silvia Tenembaum
- Department of Neurology, National Pediatric Hospital Dr. J. Garrahan, Buenos Aires, Argentina
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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12
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Jin S, Long Z, Wang W, Jiang B. Hyponatremia in neuromyelitis optica spectrum disorders: Literature review. Acta Neurol Scand 2018; 138:4-11. [PMID: 29654708 DOI: 10.1111/ane.12938] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 02/03/2023]
Abstract
Hyponatremia is a potentially serious electrolyte abnormality observed in neuromyelitis optica spectrum disorders (NMOSDs), and its most common cause is syndrome of inappropriate antidiuretic hormone secretion (SIADH). Another potential cause of hyponatremia is cerebral salt-wasting syndrome (CSWS), although CSWS has not previously been reported in NMOSDs. Accurate and early differentiation between SIADH and CSWS is difficult. However, the two conditions have important implications for the selection of therapy. Here, we describe two patients with aquaporin-4 antibody (AQP4-Ab)-positive NMOSDs who developed hyponatremia as a result of CSWS and SIADH, respectively. Additionally, we review all previously reported studies of hyponatremia in patients with NMOSDs and propose several potential pathophysiological mechanisms of hyponatremia. In conclusion, NMOSDs accompanied by hyponatremia are not actually rare, but have previously been given little attention. Furthermore, SIADH should not be the only consideration, before the exclusion of rare but significant CSWS.
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Affiliation(s)
- S. Jin
- Department of Neurology; The Second Xiangya Hospital; Central South University; Changsha China
| | - Z. Long
- Department of Neurology; The Second Xiangya Hospital; Central South University; Changsha China
| | - W. Wang
- Department of Neurology; The Second Xiangya Hospital; Central South University; Changsha China
| | - B. Jiang
- Department of Neurology; The Second Xiangya Hospital; Central South University; Changsha China
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13
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Baghbanian SM, Asgari N, Sahraian MA, Moghadasi AN. A comparison of pediatric and adult neuromyelitis optica spectrum disorders: A review of clinical manifestation, diagnosis, and treatment. J Neurol Sci 2018; 388:222-231. [DOI: 10.1016/j.jns.2018.02.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/19/2017] [Accepted: 02/16/2018] [Indexed: 12/12/2022]
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