Extra pontine Osmotic demyelination syndrome

Abstract

The osmotic demyelination syndrome (ODS) has been identified as a complication of the rapid correction of hyponatremia for decades. However, in recent years, a variety of other medical conditions have been associated with the development of ODS, independent of changes in serum sodium which cause a rapid changes in osmolality of the interstitial (extracellular) compartment of the brain leading to dehydration of energy-depleted cells with subsequent axonal damage that occurs in characteristic areas. Slow correction of the serum sodium concentration and additional administration of corticosteroids seems to be a major prevention step in ODS patients. In the current report we aimed to share a rare case which we observed in our hospital. A 65 year old female admitted as altered sensorium with history of vomiting, diarrhea was managed with intravenous fluids for 2 days at a peripheral health centre. Patient was referred to our centre with encephalopathy, evaluated and found to have hyponatremia and hypokalemia rest of biochemical parameters and septic profile were normal. Patient’s electrolyte disturbances were managed as per guidelines but encephalopathy persisted. Supportive treatment was continued and patient was discharged after 2 wks of stay in hospital after gaining full sensorium and neurological functions.

Osmotic Demyelination Syndrome - Evolution of Extrapontine Before Pontine Myelinolysis on Magnetic Resonance Imaging

“…[1] EPM generally occurs contemporaneously with CPM; however, case reports suggesting that it may precede CPM[3] or occur in isolation also exist. [4]…”

Osmotic Demyelination Syndrome following Correction of Hyponatremia by ≤10 mEq/L per Day

“…3,16 One had been given intravenous fluids for gastroenteritis at a peripheral health center for two days and was transferred to the author's hospital for altered consciousness. 16 On admission, despite modest hyponatremia (120 mEq/L) the patient was stuporous and had bilateral Babinski signs. Another, with a SNa of 130 mEq/L on admission, was found to have asymptomatic CPM on a staging MRI for a newly diagnosed aggressive lymphoma.…”

“…At least two of these patients may have developed central pontine myelinolysis (CPM) before admission to the authors' hospitals (3,16). One had been given intravenous fluids for gastroenteritis at a peripheral health center for 2 days and was transferred to the author's hospital for altered consciousness (16). On admission, despite modest hyponatremia (120 mEq/L) the patient was stuporous and had bilateral Babinski signs.…”

“…Nine of the reported patients that we identified had SNa ≥115 mEq/L (115–130 mEq/L), including five with an SNa >120 mEq/L, a level that is seldom associated with ODS (Table 2). At least two of these patients may have developed central pontine myelinolysis (CPM) before admission to the authors’ hospitals (3,16). One had been given intravenous fluids for gastroenteritis at a peripheral health center for 2 days and was transferred to the author’s hospital for altered consciousness (16).…”

“…Etiology of Hyponatremia Treatment of hyponatremia Hu et al 23 Not mentioned by authors NS at 1 lit over 24 h Pradhan et al 17 Not mentioned by authors, presumably from low solute intake NS and salt tablets Macmillan et al 4 Not mentioned by authors Not mentioned by the authors Pradhan et al 17 Salt restriction, persistent vomiting NS, salt tablets, discontinuation of thiazide diuretic and enalapril Zunga et al 16 Not mentioned by authors, presumably from viral gastroenteritis Only mentions 'supportive treatment' without specifics. Orakzai et al 38 Not mentioned by authors No specific therapy given Jahan et al 39 Not mentioned by authors, presumably from non-bloody diarrhea Free water restriction and 'gentle' intravenous fluid repletion with NS Davenport et al 21 SIAD secondary to pneumonia NS Shah et al 3 Not mentioned by authors Salt tablets and NS…”