Clinical image description

A 54 year old man with past medical history of chronic alcohol abuse, who presented to the ER with sudden onset of hematemesis and altered mental status, visual and auditory hallucinations suggesting a possible delirium tremens. On physical examination the patient was hypotensive and somnolescent. Laboratory studies showed severe hyponatremia, hyperkalemia, and hypomagnesemia; serum electrolytes were gradually adjusted with successive serum levels. After treatment, the patient‘s mental status improved. Four days after electrolytic correction the patient underwent deterioration of his mental status, experiencing mutism and spastic quadriplegia. Brain MRI showed demyelinating lesions at the pons compatible with Central Pontine Myelinolysis (CPM) figures 1, 2 and 3. CPM its rare occurrence of 0,4 to 0,56% of all neurological admissions, MRI based studies show an incidence of 0.3% to 1.1% [1].

This chain of events occurred on this case which on day 3 of hydroelectrolitic adjustment there was an increase of 14 mEq of Na in 24 hours, fulfilling the following 3 conditions described for the development of PM: Blood sodium <120 mEq/L longer than 48 hours, [2] sodium adjustment with hypertonic saline, and hypernatremia during treatment [3].

References

1. Lambeck J, Hieber M, Dreßing A, Niesen W. Central Pontine Myelinosis and Osmotic Demyelination Syndrome. Rev Dtsch Arztebl Int. 2019; 116: 600–606.
2. Khosya S, Meena H. Central pontine myelinolysis. Rev Indian J Med Res. 2013; 137: 993–994.
3. Christopher Luzzio MD, Stephen A Berman MD, PhD, MBA, Howard A Crystal, M D, Francisco Talavera P, PhD. Central Pontine Myelinolysis. 2017.