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.

A Case of Alcohol Withdrawal-Induced Central and Extrapontine Myelinolysis

A 40-year-old female with a history of chronic alcohol use disorder presented with an acute intractable left-sided headache for three days and progressively worsening unsteady gait requiring a wheelchair to ambulate. The patient had a history of chronic alcoholism since 2019 but reported abstinence since September 2021. One month after quitting alcohol, she experienced a sudden deterioration in bilateral extremity neuropathy, forgetfulness, difficulty writing, and severe mood swings, which continued to worsen until her presentation in July 2022. Laboratory tests, including complete blood count and electrolyte levels, were within normal ranges. A previous MRI performed during the investigation for alcoholic neuropathy a few months before she quit drinking showed no abnormalities. However, a subsequent MRI during work-up for the current acute symptoms revealed significant signal abnormalities involving the central pons, bilateral cerebral peduncles, and medullary pyramids, consistent with chronic central pontine myelinolysis (CPM) with extrapontine myelinolysis (EPM) extending into the peduncles. The patient received treatment with folate and multivitamins and was scheduled for outpatient follow-up with physical therapy for rehabilitation. This case highlights CPM as a consequence of alcohol withdrawal and emphasizes the importance of timely diagnosis and appropriate management in such patients.

Rapid Correction of Hyponatremia With Isotonic Saline Leading to Central Pontine Myelinolysis

Central pontine myelinolysis (CPM) is a part of the spectrum of osmotic demyelination syndrome (ODS), which is a rare demyelinating disorder due to the rapid correction of low serum sodium. It affects the neurons of the pons but may also involve other extra-pontine sites. The disease is characterized by a wide variety of clinical features ranging from dysarthria, dysphagia, bulbar palsy, quadriplegia, and behavioral and psychiatric disturbances. We present a case of a young female who developed CPM due to rapid sodium correction after vomiting. She presented with quadriplegia and locked-in syndrome. The diagnosis is on the basis of clinical and radiographic features. Magnetic resonance imaging (MRI) of the brain is superior to computed tomography (CT) in detecting changes. It shows hyperintensities on T2-weighted images that are classically known as the trident sign in the region of the pons. The patient was managed supportively, and the family was counseled regarding the poor prognosis of the disease. Unfortunately, she met a fatal fate due to a complication of CPM that is aspiration pneumonia. It is, therefore, imperative to create more awareness regarding the disease, and measures should be taken for its prevention that includes correction of low sodium levels not greater than 10 mmol/L/day.

Osmotic Demyelination After Rapid Correction of Hyperosmolar Hyperglycemia

Osmotic demyelination syndrome (ODS) is seen due to an overt rise in serum osmolality, most often during rapid correction of chronic hyponatremia. We present the case of a 52-year-old patient who presented with polydipsia, polyuria, and elevated blood glucose with rapid correction of glucose levels under five hours and developed dysarthria, left-sided neglect, and unresponsiveness to light touch and pain in the left extremities on the second day of hospitalization. MRI revealed restricted diffusion in the central pons, extending into extrapontine areas suggestive of ODS. Our case highlights the importance of cautious correction of serum hyperglycemia and monitoring serum sodium levels in patients with a hyperosmolar hyperglycemic state (HHS).

Central Pontine Myelinolysis as a Late Complication After Hyponatremia and COVID-19 Infection

Osmotic demyelination syndrome (ODS) is a rare but serious condition that is hypothesized to be a result of rapid correction of hyponatremia, with a catastrophic prognosis. The foci of demyelination may occur in either the pontine area or within the white matter of the cerebral hemispheres, which denotes a specific clinical presentation. We present the case of a post-COVID-19 patient who was diagnosed with ODS with typical clinical and radiological characteristics of both forms: central pontine myelinolysis and extrapontine myelinolysis. The clinical assessment of ODS encompasses a variety of differential diagnoses, including stroke, neuroinfection, neoplasia, and other demyelinating diseases. A specific characteristic of ODS is the delayed clinical manifestation after the hyponatremic state. Furthermore, it is noteworthy that there might be discrepancies between the clinical manifestations and the neuroimaging findings. The association between COVID-19 and ODS is unclear at the moment, although it can possibly be explained by the viral infection through multiple mechanisms such as renal dysfunction, diarrhea, or vomiting. ODS should be considered in cases of hyponatremia and neurological deterioration during the course of COVID-19 infection. Despite the fact that early detection and treatment of this syndrome can reduce the risk of short-term mortality and long-term disability, they do not guarantee complete recovery.