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Dhadwad J, Chitnis A. Extra-pontine Myelinolysis After Rapid Correction of Hyponatremia Responding to Levodopa. Cureus 2024; 16:e52707. [PMID: 38384610 PMCID: PMC10879730 DOI: 10.7759/cureus.52707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
Osmotic demyelinating disease of the central nervous system has two variants: central pontine myelinolysis and extra-pontine myelinolysis (EPM). Up to 10% of cases of osmotic demyelination syndrome are associated with EPM, which mostly affects the thalamus and basal ganglia. It is commonly associated with the rapid correction of hyponatremia. An elderly woman in her 60s presented with complaints of acute gastroenteritis and giddiness and visited the emergency ward. On examination, she was conscious and oriented to time but disoriented to place and person and had slurring of speech with signs of dehydration. Her serum sodium levels were 100 meq/L, and her brain MRI was normal. After shifting her to the intensive care unit, she was treated with 200 ml of 3% NaCl bolus to correct her hyponatremia. On day three, she began developing rigidity in both lower limbs, which progressed to the upper limbs with hyperreflexia and mutism. A brain MRI was done, which showed subtle hyperintensities in the caudate lobe with no other new findings. Her serum aldosterone and cortisol were on the lower side of the normal range. Treatment of tablet levodopa-carbidopa (100/25) combination thrice a day (TDS) led to an improvement in her health condition.
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Affiliation(s)
- Jagannath Dhadwad
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Anish Chitnis
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
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Cullin A, Trom A. Abnormal Presentation of Severe Hyponatremia. Cureus 2023; 15:e50883. [PMID: 38249170 PMCID: PMC10799307 DOI: 10.7759/cureus.50883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Hyponatremia can be a life-threatening condition. Our patient presented alert and oriented, with bilateral upper and lower extremity weakness and gastrointestinal concerns. Labs demonstrated significant hyponatremia at 103 mEq/L, which is inconsistent with her lack of neurological symptoms. It is very rare to have such severe hyponatremia without altered mentation, seizures, or coma. Careful correction of sodium must be completed, and if it is done too quickly, there is a risk of osmotic demyelination syndrome. This makes hyponatremia and its treatment of the utmost importance.
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Affiliation(s)
- Alison Cullin
- Department of Emergency Medicine, Inspira Medical Center Mullica Hill, Mullica Hill, USA
| | - Andrew Trom
- Department of Emergency Medicine, Inspira Medical Center Mullica Hill, Mullica Hill, USA
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Romero Calvo L, Garcia-Blanco MJ, Valenzuela F, Álvarez Granda J. Osmotic Demyelination Syndrome in a Normonatremic Patient Under Treatment With Proton Pump Inhibitors. Cureus 2023; 15:e44472. [PMID: 37791144 PMCID: PMC10544346 DOI: 10.7759/cureus.44472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
A 66-year-old woman was admitted to the emergency department with diarrhea, nausea, and vomiting as well as low-grade fever. She was initially treated with ciprofloxacin and metronidazole with symptomatic improvement and was discharged. One week later, she returned to the emergency department for gait instability, dizziness, and vomiting and had a witnessed generalized tonic-clonic seizure in the hospital. During both admissions, the presence of ionic alterations such as severe hypomagnesemia, hypophosphatemia, and hypokalemia stood out, while sodium levels remained normal. Among her antecedents, she had a hiatal hernia and had been receiving treatment with omeprazole for years.
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Affiliation(s)
- Lidia Romero Calvo
- Internal Medicine, Hospital Central de la Defensa Gomez Ulla, Madrid, ESP
| | - Maria J Garcia-Blanco
- Medicine, Universidad de Alcalá, Alcalá de Henares, ESP
- Internal Medicine, Hospital Central de la Defensa Gomez Ulla, Madrid, ESP
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Jamil M, Salam A, Joseph Benher BM, Rehman S, Jamil J, Suleyman G. A Case of Alcohol Withdrawal-Induced Central and Extrapontine Myelinolysis. Cureus 2023; 15:e41640. [PMID: 37565130 PMCID: PMC10411381 DOI: 10.7759/cureus.41640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2023] [Indexed: 08/12/2023] Open
Abstract
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.
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Affiliation(s)
- Maria Jamil
- Internal Medicine, Henry Ford Health System, Detroit, USA
| | - Abdus Salam
- Internal Medicine, Khyber Teaching Hospital, Peshawar, PAK
| | | | - Sheema Rehman
- Internal Medicine, Henry Ford Health System, Detriot, USA
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Senanayake J, Haji Rahman R, Boucher B, Ali MZ, Madanat S, Hammell C, Chuy F. Multi-Etiological Hyponatremia in Association With Suspected Beer Potomania. Cureus 2023; 15:e36407. [PMID: 37090390 PMCID: PMC10115209 DOI: 10.7759/cureus.36407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
Beer potomania is a unique condition characterized by hyponatremia secondary to excessive beer drinking and low daily solute intake. We report a case of a 41-year-old African American female with multiple comorbidities, notably alcohol use disorder, who was initially treated for hypertensive emergency and was subsequently found to be hyponatremic during the same visit. Beer potomania was suspected as a leading etiology of hyponatremia. This report emphasizes the importance of the proper diagnosis and appropriate management of beer potomania in the setting of concomitant comorbidities. Clinician awareness is crucial in implementing immediate treatment and in the prevention of potentially fatal sequelae such as severe malnutrition and osmotic demyelination syndrome.
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Affiliation(s)
| | | | - Benoit Boucher
- Medicine, Saint James School of Medicine, St. Vincent, VCT
| | | | - Sally Madanat
- Medicine, Washington University of Health and Science, Cleveland, USA
| | - Carly Hammell
- Medicine, Washington University of Health and Science, Cleveland, USA
| | - Francisco Chuy
- Internal Medicine, Weiss Memorial Hospital, Chicago, USA
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Ivanova NI, Tsalta-Mladenov ME, Georgieva DK, Andonova SP. Central Pontine Myelinolysis as a Late Complication After Hyponatremia and COVID-19 Infection. Cureus 2023; 15:e35191. [PMID: 36960247 PMCID: PMC10030256 DOI: 10.7759/cureus.35191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/21/2023] Open
Abstract
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.
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Affiliation(s)
- Nora I Ivanova
- Second Clinic of Neurology With ICU and Stroke Unit, University Hospital "Sveta Marina", Varna, BGR
- Department of Neurology and Neuroscience, Medical University "Prof. Paraskev Stoyanov", Varna, BGR
| | - Mihael E Tsalta-Mladenov
- Second Clinic of Neurology with ICU and Stroke Unit, University Hospital "Sveta Marina", Varna, BGR
- Department of Neurology and Neuroscience, Medical University "Prof. Paraskev Stoyanov", Varna, BGR
| | - Darina K Georgieva
- Second Clinic of Neurology With ICU and Stroke Unit, University Hospital "Sveta Marina", Varna, BGR
- Department of Neurology and Neuroscience, Medical University "Prof. Paraskev Stoyanov", Varna, BGR
| | - Silva P Andonova
- Second Clinic of Neurology With ICU and Stroke Unit, University Hospital "Sveta Marina", Varna, BGR
- Department of Neurology and Neuroscience, Medical University "Prof. Paraskev Stoyanov", Varna, BGR
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