Central Pontine Myelinolysis in Pregnancy: A Case of Rare Occurrence.

Sami Ullah Khan,Abdullah Abdullah,Dawood Misbah,Muhammad Saqib Saeed,Muhammad Idrees

doi:10.7759/cureus.20281

Abstract

Central pontine myelinolysis is a non-inflammatory neurologic deficit and can have a wide array of clinical features, predisposing risk factors as well as different patterns of onset along with a big difference in prognosis ranging from asymptomatic cases to encephalopathy and also mortality. Apart from the common risk factors like hyponatremia and sudden correction of electrolyte imbalances, sometimes, the least prevalent risk factors such as pregnancy seem to link with the central pontine myelinolysis. Mostly its onset is sudden after the inciting factors. However, it is also likely to have cases of central pontine myelinolysis with gradual onset of clinical features. The purpose of the case report is to highlight the link between pregnancy and central pontine myelinolysis. The slow onset of clinical features in pregnancy-linked central pontine myelinolysis can also be considered. The patient in the case report presented with gradual onset clinical features of osmotic demyelination syndrome during the last months of pregnancy and immediately postpartum. All the possible predisposing risk factors for central pontine myelinolysis were ruled out through history, physical examination, and relevant investigations. The case study of the patient hypothesized that: (1) pregnancy should be considered as a risk factor for central pontine myelinolysis in pregnant and postpartum patients presenting with clinical features of the disease, (2) clinical features of central pontine myelinolysis in pregnancy can have a more gradual onset of symptoms compared to other causes of central pontine myelinolysis. Although, this case report signifies a relationship between pregnancy and osmotic demyelination syndrome. However, further studies should be done to develop a causal relationship and preventive measures for the condition.

Highlights

Central pontine myelinolysis (CPM) is a major subset of a group of disorders called osmotic demyelination syndrome (ODS), in which damage to different parts of the brain occurs, predominantly the white matter pontine tracts [1]
Hyponatremia results in decreased serum tonicity, which causes cerebral edema through osmosis, the brain has several regulatory mechanisms to tackle this, such as removal of water from brain cells into the cerebrospinal fluid (CSF), efflux of organic osmolytes, and removal of intracellular solutes and water through ion channels to reduce brain swelling. When these corrective mechanisms are coupled with rapid therapeutic correction of hyponatremia, it renders the brain’s capacity to recapture lost osmolytes and leads to dehydration of brain tissue and demyelination of the white matter, especially the astrocytes [1]
CPM has a biphasic presentation, initially with seizures secondary to hyponatremia which resolve with correction of the imbalance, and with a wide range of symptoms depending on the area involved which may include dysarthria, dysphagia, quadriparesis, pseudobulbar palsy, and pseudocoma referred to as "locked-in syndrome"

Summary

Introduction

Central pontine myelinolysis (CPM) is a major subset of a group of disorders called osmotic demyelination syndrome (ODS), in which damage to different parts of the brain occurs, predominantly the white matter pontine tracts [1]. Hyponatremia results in decreased serum tonicity, which causes cerebral edema through osmosis, the brain has several regulatory mechanisms to tackle this, such as removal of water from brain cells into the cerebrospinal fluid (CSF), efflux of organic osmolytes, and removal of intracellular solutes and water through ion channels to reduce brain swelling When these corrective mechanisms are coupled with rapid therapeutic correction of hyponatremia, it renders the brain’s capacity to recapture lost osmolytes and leads to dehydration of brain tissue and demyelination of the white matter, especially the astrocytes [1]. The chief diagnostic tool remains to be magnetic resonance imaging (MRI) [3] Both the causes and presentations of CPM were atypical in many of the case reports. A 25-year-old, 12 days post-natal female patient presented to accidents and emergency department with loss of consciousness On inquiry, her husband said that she was fine a month ago when she started developing dysarthria which was gradual in onset, progressive with no aggravating and relieving factors.

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