JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
REFERENCES
that the hyponatremia be corrected slowly to allow sufficient time for the brain-cells to reacquire both electrolytes and organic osmolytes. Osmotic stress due to rapid correction of chronic hyponatremia sometimes impairs blood–brain barrier function, suggesting a loosening of the tight junctions between vascular endothelial cells possibly allowing an injurious substance access to myelin. 3 The typical clinical presentation involves a biphasic course with initial encephalopathy that may improve but then followed by severe deterioration manifested by dysarthria, dysphagia, oculomotor dysfunction and variable degrees of quadriparesis. MRI is very sensitive for detecting CPM when highly suspected. Diagnosis is made on clinical suspicion based on the patient’s presentation and history, and MRI. 4
1. Nejtek, V. A., Schneider, P., & Hurd, C. L. (2012). A case of mistaken identity: Alcohol withdrawal, schizophrenia, or central pontine myelinolysis? Neuropsychiatric Disease and Treatment , 49. doi:10.2147/ndt.s27634 2. Singh, T. D., Fugate, J. E., & Rabinstein, A. A. (2014). Central pontine and extrapontine myelinolysis: A systematic review. European Journal of Neurology , 21(12), 1443-1450. doi:10.1111/ene.12571 3. Hurley, R. A., Filley, C. M., &Taber, K. H. (2011). Central PontineMyelinolysis: A Metabolic Disorder of Myelin. Journal of Neuropsychiatry J Neuropsychiatry Clin Neurosci , 23(4). doi:10.1176/appi.neuropsych.23.4.369 4. Martin, R. J. (2004). Central pontine and extrapontine myelinolysis: The osmotic demyelination syndromes. Journal of Neurology, Neurosurgery & Psychiatry , 75(Suppl_3), Iii22-Iii28. doi:10.1136/jnnp.2004.045906 5. Norenberg, M. D., Leslie, K. O., & Robertson, A. S. (1982). Association between rise in serum sodium and central pontine myelinolysis. Annals of Neurology Ann Neurol ., 11(2), 128-135. doi:10.1002/ana.410110204 6. Penders, T. M., Stanciu, C. N., Ganpat, P., & Ingersoll, J. A. (2015). Psychogenic polydipsia, hyponatremia and osmotic myelinolysis. Case Reports, 2015 (Jan27 2). doi:10.1136/bcr-2014-207508 7. Sohn, M. K., & Nam, J. H. (2014). Locked-in Syndrome due to Central Pontine Myelinolysis: Case Report. Annals of RehabilitationMedicine , 38(5), 702–706. http://doi.org/10.5535/arm.2014.38.5.702
CONCLUSION
It is important to recognize central pontine myelinolysis early on and take measures to manage the sequelae to avoid an unfavorable prognosis. In a patient with schizophrenia, it may be difficult to recognize certain symptoms, especially when the patient’s baseline is unknown. In this case, the agitation as well as poor attention and concentration clouded the picture from the internal medicine perspective. The subsequent psychiatric consultation suggested an underlying medical condition playing a role and the CPM was discovered. It is important to emphasize that the appropriate correction of hyponatremia does not rule out the possibility of central pontine myelinolysis. This case also demonstrated the importance of interdisciplinary effort in approaching a patient with such complex issues. Clinicians should be aware of the potential for hyponatremia resulting from compulsive water drinking to cause myelinolysis with delayed development of cognitive and gait symptoms. CPM should be on the differential for patients with conditions pre-disposing them to osmotic myelinolysis such as severe hyponatremia. The morbidity and mortality of CPM may be reduced by early recognition and appropriate supportive care. 2 Take home points:
Carine Nzodom, MD, is affiliated with the Department of Psychiatry, Louisiana State University Health Sciences Center, Baton Rouge, LA.
1. It is important to keep CPM on the differential in patient with hyponatremia
2. Appropriate correction of hyponatremia does not rule out CPM
3. Understanding the pathophysiology of CPM helps with treatment
4. A Multidisciplinary approach is important in treating patients with multiple comorbidities
J La State Med Soc VOL 170 MARCH/APRIL 2018 45
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