Case Of Central Pontine Myelinolysis Research Articles

Analysis of central pontine myelinolysis in HIV-infected patients

Aim: to conduct a clinical and epidemiological analysis of cases of central pontine myelinolysis (CPM) in HIV-infected patients. Materials and methods. Four patients hospitalized in the infectious diseases department of No. 1 Clinic of the South Ural State Medical University were under dynamic observation. Results and its discussion. Four patients hospitalized in the infectious diseases department of Clinic No. 1 of the South Ural State Medical University were under dynamic observation. Patient management was carried out in accordance with current clinical recommendations for the provision of medical care to patients with HIV infection with a set of clinical and laboratory methods, including examination of lumbar puncture, its cytological and biochemical composition, determination of DNA of cytomegalovirus (CMV) and Epstein-Barr viruses (EBV) herpes simplex types 1 and 2, T. gondii, Cr. Neoformans, M. Tuberculosis, Cryptococcus neoformans, the presence of pathogens of bacterial infections. All patients underwent magnetic resonance imaging (MRI) of the brain. Conclusion. The process of demyelination of the central nervous system develops regardless of the level of CD4 lymphocytes and HIV viral load. The main method for verifying the diagnosis is MRI of the brain

Central Pontine Myelinolysis in a Patient with Hepatosplenic T Cell Lymphoma and Hemophagocytic Lymphohistiocytosis (P6-4.007)

<h3>Objective:</h3> To discuss a rare case of central pontine myelinolysis (CPM) in a patient with hepatosplenic T cell lymphoma (HSTL) and hemophagocytic lymphohistiocytosis (HLH). <h3>Background:</h3> HSTL is a rare disease characterized by infiltration of mature T cells within the sinusoids of the spleen, liver, and bone marrow. Hyponatremia prior to orthotopic liver transplant for liver failure has previously been identified as a risk factor for the development of CPM due to possible disruption of astrocyte metabolism and impaired capacity to regulate osmotic changes leading to secondary dysfunction of the blood brain barrier. CPM has also previously been discovered in EBV positive HLH. <h3>Design/Methods:</h3> We conducted a case report and literature review with PubMed search terms: 1) “central pontine myelinolysis,” “hyponatremia,” and “liver” 2) “central pontine myelinolysis,” “hemophagocytic lymphohistiocytosis,” and “hemophagocytic syndrome” 3) “central pontine myelinolysis” and “hepatosplenic T cell lymphoma.” <h3>Results:</h3> A 20-year-old EBV negative male presented with fever, splenomegaly, and blurry vision with bilateral retinal hemorrhages. Workup was significant for pancytopenia, mild hypovolemic hyponatremia secondary to emesis (initially 132 mmol/L), triglycerides 377, INR 1.2, ALT 55, and ALP 402. HSTL and HLH were confirmed on bone marrow biopsy. He was found to have subclinical CPM on MRI brain without contrast which resolved on 2 month follow-up imaging after 3 rounds of ifosfamide, carboplatin, and etoposide (ICE) intrathecal chemotherapy. We found no prior literature describing HSTL and CPM, 22 articles regarding CPM and liver transplant, and 1 article describing CPM and HLH. <h3>Conclusions:</h3> CPM should be considered as a neurologic complication in patients with HSTL and HLH. We report such a case, despite only mild levels of hyponatremia, the absence of liver failure, and negative EBV status. Future research should explore the connection between these factors to further our understanding of osmotic regulation of the blood brain barrier leading to CPM. <b>Disclosure:</b> Dr. Avila has nothing to disclose. Mr. AW has nothing to disclose. Dr. Danziger has nothing to disclose. Dr. Kim has nothing to disclose. Dr. Tan has nothing to disclose. Dr. Schlick has nothing to disclose.

Central Pontine Myelinolysis as a Result of Ideally Corrected Hyponatremia in a Post-Covid Patient

Central pontine myelinolysis (CPM) is a non-inflammatory neurological condition with various clinical features and onset patterns and also with a very wide prognostic spectrum ranging from asymptomatic cases to encephalopathy and mortality. In this case report we, aim to present the first case of central pontine myelinolysis as a result of an optimally corrected hyponatremia in a post-COVID-19 patient our knowledge while assessing the clinical and radiological findings.

A Case of Central Pontine Myelinolysis Caused by Hyperbilirubinemia in Hepatic Encephalopathy without Significant Osmotic Stress

A Case of Central Pontine Myelinolysis Caused by Hyperbilirubinemia in Hepatic Encephalopathy without Significant Osmotic Stress

Central Pontine Myelinolysis in a Child: Clinical Case

Background. Central pontine myelinolysis (CPM) is limited symmetric non-inflammatory demyelination in the middle part of pontine. This disease is based on electrolyte balance disorders. Although CPM was firstly described in adults, but it can also occur in children. Every new case of CPM in children has undeniable interest and high scientific and practical significance due to its low incidence. Clinical case description. The child, 7 years old, had acute development, lethargy, multiple vomiting, subfebrile fever, pains in epigastric region. It has happened after drinking an unknown herb growing in the yard and previously covered with the insecticide "Akarin", according to the mother. The child was hospitalized in the pediatric department at the place of residence. The patient developed strabismus, swallowing disorder, and muscle weakness on infusion therapy. Biochemical blood test has shown hypokalemia and hyponatremia. Head MRI has shown symmetrical focal lesion of heterogeneous structure in pontine. Conclusion. Distinctive feature of this case is the development of CPM in a child on the ongoing therapy of hypokalemia and hyponatremia. The timely provision of qualified medical care has favoured the child's recovery.

Central pontine myelinolysis secondary to glycemic variability in type 1 diabetes: a case report and a systematic review of the literature

Central pontine myelinolysis (CPM) is a rare manifestation of osmotic demyelination syndrome (ODS) which involves the pons and causes significant morbidity and mortality. CPM usually occurs in the setting of rapid correction of severe chronic hyponatremia. A rare case of CPM due to hyperglycemia in a 27-year-old man with type 1 diabetes is reported. During the patient’s hospitalization, his plasma glucose level showed a wide variability ranging from 38 mg/dL to 530 mg/dL, while plasma sodium level was constantly normal. At computed tomography (CT) scans, areas of hypodensity with a hyperdense ring were identified in the anterior part of the pons. At magnetic resonance imaging (MRI) scan, pontine abnormalities compatible with CPM were observed. According to laboratory tests, we concluded that CPM resulted from rapid and wide shifts in osmolar gradient owing to variability in plasma glucose levels. While universally recognized in several clinical settings, CPM is rarely observed in diabetic patients. Our report supports the notion that hyperosmolarity per se plays a key role in the pathogenesis of CPM, which may occur independently of sodium abnormalities.

Diabetes Induced Osmotic Demyelination of the Pons in a Patient on Peritoneal Dialysis

Introduction: Osmotic demyelination of the pons as a result of uncontrolled diabetes is a rare event. Here we present a unique case of central pontine myelinolysis in a patient with poorly controlled type 2 diabetes mellitus in the setting of peritoneal dialysis.Clinical Case: A 48-year-old male with a history of insulin-dependent diabetes mellitus, hypertension, non-ischemic cardiomyopathy, and end-stage renal disease, treated with peritoneal dialysis, presented to the hospital for slurred speech, inability to walk, and persistent hyperglycemia for 3 days. Approximately 2 years prior to admission, peritoneal dialysis was initiated for ESRD and poor cardiac function. The patient’s outpatient pharmacologic regimen was 30 units of glargine daily and glimepiride. On physical exam, there was evidence of aphasia, dysarthria, and muscle weakness (2/5 in bilateral upper and lower extremities) without muscle rigidity. Deep tendon reflexes were absent in the lower extremities, but sensation to light touch was intact throughout. On admission, the patient was found to be in a hyperosmolar hyperglycemic state without ketosis. Initial lab tests were significant for serum sodium: 138mmol/L (n=134–145 mmol/L), serum sodium corrected for hyperglycemia: 143 mmol/L, serum glucose: 419mg/dL (n=75–99 mg/dL), beta-hydroxybutyrate 2.1 mg/dL (n<4.4 mg/dL), and serum osmolality: 330mosmol/kg (n=275–305 mosmol/kg). Urinalysis showed glucosuria without ketonuria. The cerebrospinal fluid analysis showed protein 57, glucose 109, and WBC 3. Lab studies for meningitis/encephalitis panel were negative. During his 2 years of dialysis, his HbA1C increased from 7.6% to 14.3% (n<5.6%). CT brain without contrast showed midline hypoattenuation of the inferior pons without edema. Magnetic resonance imaging without contrast of the brain demonstrated a lobulated lesion in the pons measuring 1–2 cm that shows T2 hyperintensity without surrounding edema. He was then diagnosed with central pontine myelinolysis in the setting of chronic glycemic changes.Conclusion: Osmotic demyelination of the pons is typically associated with rapid correction of hyponatremia. We describe osmotic demyelination of the pons as a result of poorly controlled diabetes with normal sodium. To our knowledge, this is the first report of this event in association with worsening diabetes after the initiation of peritoneal dialysis.

Central pontine myelinolysis in the presence of SARS-CoV-2 infection (clinical observations)

Osmotic demyelinating syndrome (ODS) is a severe complication that occurs due to rapid correction of hyponatremia. Central pontine myelinolysis (CPM), in which a focus of demyelination occurs in the pontine region, and extrapontine myelinolysis (EPM), in which foci of demyelination appear in the white matter of the cerebral hemispheres, can be distinguished as a part of this syndrome. We describe two clinical cases of CPM that developed due to hyponatremia and hypokalemia in patients with SARS-CoV-2 infection (COVID-19). Differential diagnosis included acute disseminated encephalomyelitis, infectious encephalitis, and brain tumor. In both cases, a significant recovery of the lost functions was noted. The pathogenetic mechanisms of CPM development in patients with COVID-19 are discussed. ODS development in COVID- 19 necessitates strict control and correction of electrolyte disturbances in this category of patients in accordance with existing recommendations, which can reduce the risk of CPM.

A Case of Central Pontine Myelinolysis due to Severe Acute Prolonged Hyponatremia in Our County Hospital

Background: Central pontine myelinolysis (CPM)is unique and rare clinical entity. It could be a neurological complication of prolonged hyponatraemia. Many predisposing risk factors (chronic alcoholism, malnutrition, malignancy) may aggravate the development of CPM. CPM usually have a poor or even fatal outcome. However, CPM does not inevitably have a bad prognosis, and could occur with proper restoration of normal serum sodium concentrations. Case Summary: Here, we presented a case of a 48-year-oldfemale. She used to drink alcohol. She presented to Our Lady’s Hospital/Navan with a history of four days feeling unwell, confused diarrhea, vomiting and by investigations, she had severe hyponatraemia. She was managed optimally in the ICU with close monitoring of her urea and electrolytes. Unfortunately, she got progressive neurological deficits (lower limbs weakness, and slurred speech) irrespective of gentle treatment of hyponatremia in intensive care unit. After Neurological and radiological input from Dublin institute, CPM confirmed under background of alcoholism and malnutrition. Following the diagnosis of CPM, she was discharged home after been rehabilitated with physiotherapy with ongoing recovery.

Continuous hemodialysis with citrate anticoagulation and standard dialysate for managing acute kidney injury in patients with moderate to severe hyponatremia-A retrospective study.

The safety of continuous veno-venous hemodialysis (CVVHD) with citrate-calcium anticoagulation for acute kidney injury (AKI) with coincident hyponatremia remains unclear. We aimed to explore the feasibility of CVVHD with standard dialysate and citrate-calcium anticoagulation in hyponatremic critically ill AKI patients. Thirty-seven of the 493 critically ill AKI patients requiring CVVHD and admitted to our intensive care unit during a 10-year period had hyponatremia (<130mmol/L) and were included in this retrospective study. All patients received CVVHD with citrate-calcium anticoagulation and standard commercial dialysate and plasma sodium concentrations were frequently controlled until death or CVVHD discontinuation. Clinical data, mortalities and cases of central pontine myelinolysis within one-year follow-up were recorded. Median plasma sodium concentration was 127 (IQR 124-129)mmol/L at CVVHD initiation. CVVHD duration was median 3 (IQR 1.5-5.5)days and the mean daily sodium load of the trisodium citrate solution during the first 3days of CVVHD was 1754 (SD 730)mmol. The plasma sodium concentration increased a median 8 (IQR 5-10)mmol/L during the first 24hours of CVVHD and excessively high plasma sodium correction (>8mmol/L/24h) was observed in 18 (48.6%) patients. However, increased mortality in association to rapid plasma sodium correction was not observed in this study. CVVHD using standard citrate-calcium anticoagulation effectively increased plasma sodium concentration in this study. However, excessively high plasma sodium correction was observed in half of the patients and the sodium load provided by the standard citrate anticoagulation solutions was substantial.

Equimolar doses of hypertonic agents (saline or mannitol) in the treatment of intracranial hypertension after severe traumatic brain injury.

Background:Mannitol and hypertonic saline (HTS) are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their efficacy on the ICP has not been evaluated rigorously.Objective:To evaluate the efficacy of repeated bolus dosing of HTS and mannitol in similar osmotic burdens to treat intracranial hypertension (ICH) in patients with severe TBI.Methods:The authors used an alternating treatment protocol to evaluate the efficacy of HTS with that of mannitol given for ICH episodes in patients treated for severe TBI at their hospital during 2017 to 2019. Doses of similar osmotic burdens (20% mannitol, 2 ml/kg, or 10% HTS, 0.63 ml/kg, administered as a bolus via a central venous catheter, infused over 15 minutes) were given alternately to the individual patient with severe TBI during ICH episodes. The choice of osmotic agents for the treatment of the initial ICH episode was determined on a randomized basis; osmotic agents were alternated for every subsequent ICH episode in each individual patient. intracranial pressure (ICP), mean arterial pressure (MAP), and cerebral perfusion pressure (CPP) were continuously monitored between the beginning of each osmotherapy and the return of ICP to 20 mm Hg. The duration of the effect of ICP reduction (between the beginning of osmotherapy and the return of ICP to 20 mm Hg), the maximum reduction of ICP and its time was recorded after each dose. Serum sodium and plasma osmolality were measured before, 0.5 hours and 3 hours after each dose. Adverse effects such as central pontine myelinolysis (CPM), severe fluctuations of serum sodium and plasma osmolality were assessed to evaluate the safety of repeated dosing of HTS and mannitol.Results:Eighty three patients with severe TBI were assessed, including 437 ICH episodes, receiving 236 doses of HTS and 221 doses of mannitol totally. There was no significant difference between equimolar HTS and mannitol boluses on the magnitude of ICP reduction, the duration of effect, and the time to lowest ICP achieved (P > .05). The proportion of efficacious boluses was higher for HTS than for mannitol, although which showed a slight difference (p = 0.207), as was the increase in serum sodium (P = .038). The serum osmolality increased immediately after osmotherapy with a significant difference (P = .017). No cases of CPM were detected.Conclusion:Repeat bolus dosing of 10% HTS and 20% mannitol appears to be significantly and similarly effective for treating ICH in patients with severe TBI. The proportion of efficacious doses of HTS on ICP reduction may be slightly higher than mannitol.

Real-World Effectiveness and Tolerability of Tolvaptan in Patients With Heart Failure - Final Results of the Samsca Post-Marketing Surveillance in Heart Failure (SMILE) Study.

In Japan, tolvaptan is indicated for patients with heart failure and volume overload who have inadequate response to other diuretics. In contrast to the USA and Europe, tolvaptan can be used in Japan in patients with normal sodium levels.Methods and Results:In this multicenter, non-interventional, post-marketing surveillance study, prospective data from 3,349 patients treated with tolvaptan over a 5-year period were analyzed to identify benefits and risks. By Day 2 of treatment, 76.9% of evaluable patients had an increase in baseline 24-h urine volume (tolvaptan responders). Mean change in body weight was similar between 7.5 mg and 15 mg dosage groups (-3.6±3.9 kg and -3.7±4.0 kg, respectively). Improvement or disappearance rates for congestive symptoms from baseline to Day 14 ranged from 77.7% for lower limb edema to 51.1% for 3rd sound. Adverse drug reactions were reported in 18.1% of patients, most frequently thirst (8.4%). No case of central pontine myelinolysis was reported. All-cause mortality was significantly lower in patients with improved sodium concentration and increased 24-h urine volume. The effectiveness and safety of tolvaptan in real-world clinical settings was confirmed in this large-scale analysis. The 7.5-mg dose was equally as effective as the 15-mg dose and had a better safety profile. Improvements in all-cause mortality were suggested in tolvaptan responders.

A case of chronic asymptomatic central pontine myelinolysis with histological evidence of remyelination

Central pontine myelinolysis (CPM) is a neurological demyelinating disease of the pons. Although usually associated with rapid correction of hyponatremia, CPM may occur despite normonatremia, is often associated with chronic alcoholism and may be asymptomatic. Histological confirmation of asymptomatic CPM is rare. We describe an unusual post-mortem case of extensive but asymptomatic CPM in a chronic alcoholic patient with normonatremia. The affected part of the pons contained thinly myelinated axons with appearances supporting remyelination. We suggest that remyelination may account for the subclinical nature of this patient's CPM.

Temporal evolution of the trident and piglet signs of osmotic demyelination syndrome

Central pontine myelinolysis (CPM) is a potentially-devastating complication of rapid osmolar shifts, classically attributed to overlyaggressive correction of chronic hyponatremia. Magnetic resonance imaging (MRI) allowed earlier diagnosis of CPM, but most importantly, it has revealed that the odds of good functional recovery are surprisingly high. A trident shaped pontine lesion is a typical finding in CPM (the trident sign). The “piglet sign” is a much less well-known radiologic finding in CPM. Due to the rarity of CPM, very little has been published on the evolution of these MRI findings. We present a case of CPM in an alcoholic young man, and describe the temporal evolution of both the trident and piglet signs on MRI in CPM.

A CASE OF CENTRAL PONTINE POLIOMYELITIS IN A YOUNG WOMAN WITH ACUTE PANCREATITIS

The article analyzes a case of central pontine myelinolysis in a young woman with acute pancreatitis and describes the principal causes, clinical features, diagnostic procedures, treatment, and the disease outcome.

A Rare Case of Central Pontine Myelinolysis in Overcorrection of Hyponatremia with Total Parenteral Nutrition in Pregnancy.

A 42-year-old high risk pregnant female presented with hyponatremia from multiple causes and was treated with total parenteral nutrition. She developed acute hypernatremia due to the stage of pregnancy and other comorbidities. All the mechanisms of hyponatremia and hypernatremia were summarized here in our case report. This case has picture (graph) representation of parameters that led to changes in serum sodium and radiological findings of central pontine myelinolysis on MRI. In conclusion we present a complicated case serum sodium changes during pregnancy and pathophysiological effects on serum sodium changes during pregnancy.

CENTRAL PONTINE MYELINOLYSIS AFTER ORTHOTOPIC LIVER TRANSPLANTATION (TWO CASE REPORTS)

Central pontine myelinolysis (CPM) is the rare, but extremely severe complication after orthotopic liver trans- plantation. The reason for CPM is currently not precisely de fi ned. However, the rapid correction of hyponatremia is considered as the main etiological factor. In this paper we present two clinical cases of CPM in patients under- went orthotopic liver transplantation. We also discuss the pathophysiology, epidemiology, clinical presentation, treatment options and preventive measures of CPM.

Safety and Efficacy of Repeated Doses of 14.6 or 23.4 % Hypertonic Saline for Refractory Intracranial Hypertension

The efficacy of administering single bolus doses of 14.6 or 23.4 % hypertonic saline (HTS) to treat refractory intracranial hypertension has been demonstrated in the literature and has emerged as an important therapeutic option in treating these patients. However, many institutions lack experience with this therapy and there are few published studies evaluating the safety of repeated bolus dosing of HTS. A retrospective review of patients admitted between January 2008 and July 2012 was conducted to evaluate the use of repeated dosing of HTS in patients with refractory intracranial hypertension. The primary objective was to evaluate the safety of repeated dosing of HTS assessed by documented adverse effects such as central pontine myelinolysis (CPM) and severe fluctuations in serum sodium concentrations. Secondary objectives were to evaluate the efficacy of repeated dosing HTS in reducing intracranial pressure (ICP) and to compare the dose-response relationship of 14.6 and 23.4 % doses. Fifty-five patients were included for evaluation, each receiving an average of 8.9 (range 2-61) doses of HTS. A statistically significant increase in mean serum sodium concentration occurred with the administration of HTS (p < 0.0001). No cases of CPM were identified. The use of HTS was found to be effective based on decreases in ICP after administration (p < 0.0001, mean ICP reduction: 10.1 mmHg, range 3-23.6 mmHg). The efficacy of 23.4 % saline in decreasing ICP was not found to be significantly different than 14.6 % saline (p = 0.23). Repeat bolus dosing of 14.6 or 23.4 % HTS appears to be relatively safe and effective for treating refractory intracranial hypertension assuming there is frequent electrolyte monitoring and concomitant fluid management.

Central pontine myelinolysis in advanced HIV infection with tuberculosis and multicentric Castleman's disease

We present a case of central pontine myelinolysis (CPM) in a patient with advanced HIV infection and miliary tuberculosis. While hospitalized the patient developed an unusual ataxic variant of CPM with full clinical recovery. Follow-up imaging revealed resolution of pontine lesions. To our knowledge, this is the first report of a clinical and radiological recovery from CPM in advanced HIV disease. Our report extends our knowledge of neurological presentations in patients with advanced HIV infection. It highlights the importance of considering CPM in patients with advanced HIV disease presenting with an ataxic syndrome, even in the absence of an electrolyte derangement.

診断に難渋した橋中心髄鞘崩壊症の一例

診断に難渋した橋中心髄鞘崩壊症の一例