Central Pontine Myelinolysis in Patient with Normal Serum Sodium Levels, System Alcohol Use and Malnutrition- A Case Report

Case Report

Austin J Clin Neurol 2015; 2(9): 1074.

Central Pontine Myelinolysis in Patient with Normal Serum Sodium Levels, System Alcohol Use and Malnutrition- A Case Report

I Staikov¹, Simeonova A¹, Mihnev N¹*, Simeonov G², Davidov K³ and Kirova G4

¹Clinic of Neurology, Tokuda Hospital Sofia, Bulgaria

²Department of Anesthesiology and Intensive care, Tokuda Hospital Sofia, Bulgaria

³Department of Urology, Tokuda Hospital Sofia, Bulgaria

4Clinic of Imaging Diagnostic, Tokuda Hospital Sofia, Bulgaria

*Corresponding author: Nikolay Mihnev, Clinic of Neurology, Tokuda Hospital Sofia, Bulgaria

Received: June 01, 2015; Accepted: August 05, 2015; Published: August 08, 2015

Abstract

Central pontine myelinolysis (CPM) is heterogeneous group of demyelinating conditions with different etiology, pathophysiological mechanisms, clinical presentation and development. The suspectable main reasons for development of pontine myelinolysis syndrome in patients with alcohol use and malnutrition are basically deficiency of thiamine - vitamin B1 and direct toxic effects of acetaldehyde. Role in cell damage plays changes in serum potassium levels and accompanying these conditions magnesium deficiency.

Early and proper diagnosis of pontine myelinolysis syndrome should be based on acute brain stem dysfunction, history and clinical data of serum electrolyte disturbances, alcohol consumption and malnutrition, as well as typical findings of magnetic resonance imaging (MRI).

We present a case of 42 years old female patient with history of long-term alcohol abuse, normal serum sodium levels and malnutrition after ten-day period of confusion and aggressive behavior develops acute bulbar, pseudo bulbar and quadriparetic syndrome, which requires hospitalization in intensive care unit. Several MRI studies were performed and patient was diagnosed with central pontine myelinolysis syndrome as a result of malnutrition and alcohol abuse. In six months complete reversal of neurological symptoms was observed, but MRI findings persist.

Basic etiological reasons were discussed, as well as possible pathophysiological mechanisms, clinical and diagnostic possibilities for patient with CPM syndrome, systemic alcohol abuse, malnutrition and normal serum sodium levels.

Keywords: Pontine myelinolysis; Malnutrition; Alcohol abuse; Thiamine; Oxidative stress

Background

Central pontine myelinolysis (CPM) is heterogeneous group of demyelinating conditions with different etiology, pathophysiological mechanisms, clinical presentation and development [1,2]. For the first time, the condition was described in 1959 by Adams and colleagues in patients with alcohol consumption and/or malnutrition [1,2]. Later in 1976 Tomlinson describes the case of CPM after rapid correction of low serum sodium levels. Since then, several cases of CPM in patients with alcohol consumption, malnutrition, normal serum sodium level are described [1-3]. In the most cases CPM syndrome is associated with alcohol use and insufficient conditions [3].

In etiological aspect it is a multifaceted disease. Factors which may lead to it are quick correction of low serum sodium levels, chronic alcohol use, insufficient conditions, acute electrolyte imbalance accompanying kidney, liver and gastrointestinal processes, endocrine diseases, late pregnancy toxemia, malignant processes, anorexia and other eating disorders [1-6].

Case Report

We present 42 year female patient hospitalized in a clinic of psychiatry within five days, due to ten-day period of confusion, irrational behavior, anxiety and aggression towards her family. On the fifth day of stay in department of psychiatry due to worsening of her condition she had been hospitalized in intensive care unit of Tokuda Hospital Sofia. The patient was in poor general condition, unable to move, non-contact, with no quantitative changes in consciousness. According to her relatives patient has history for systematically consumed alcohol for years and in recent months patient consumed it in unlimited quantities, refused to eat, had reduction in body weight. Without medical and family history or any data for previous treatment. Without history of fever in recent months or experienced acute viral infections in last year.

Upon admission in intensive care unit, the following changes in somatic status were observed: skin and visible mucosa- pale, expressed ulcers in lips corners. Dry scaly skin on the palms and feet, changes in the nails plate bilaterally. Strongly reduced subcutaneous fat with decreased skin elasticity. Neurological examination upon admission showed mydriasis on the right pupil with missing direct and indirect reaction to light, miotic pupil on the left eye with slow reaction to light, missing bilateral convergence and accommodation reactions, missing smooth tracking eye movements, vertical gaze paresis, spontaneously eyes abduction to the right. Patient was unable to show his tongue upon request, missing bilateral pharyngeal reflexes, absent cough reflex. Quadriparеtic syndrome was observed with right-sided upper central monoplegiya, severe left-sided upper monoparesis, and lower central paraplegia. Muscle tone was decreased in the four limbs. Conjunctival and corneal reflex were reserved. Mandibular reflex was exaggerated. Diminished reflexes for upper limbs, missing knee and Achilles reflexes bilaterally, presented bilateral plantar reflexes, absent cutaneus reflexes. Sustained clonus on the left leg. Sensory function and coordination were not possible to be examined. The patient was in consciousness, without pain response, reserved circadian cycle, catheterized, orotracheal intubated. The following examinations and consultations were performed:

Para clinical test

• laboratory tests data for iron deficiency anemia, low serum levels of vitamin B12, low serum levels of protein, albumin, calcium, potassium, normal serum levels of sodium.

• laboratory tests data for iron deficiency anemia, low serum levels of vitamin B12, low serum levels of protein, albumin, calcium, potassium, normal serum levels of sodium.

• Echocardiography: normal valve apparatus, preserved systolic and diastolic function.

• Electroneurography and Electromyography study showed data for polyneuropathy, affecting sensory and motor nerves, mainly axonal form prevailing in the lower limbs. Myogenic changes mainly in proximal muscle groups.

• Electroencephalography: Generally slow activity without epileptiform changes.

• Magnetic resonance imaging (MRI) of the head upon admission - in the area of the pons is visualized formation with size 22 mm/17 mm., isointense in T1 and hyper intense in T2. After application of gadolinium, contrast enhancement in middle of formation was observed, without perifocal edema/Figure 1,2.

Citation: Staikov I, Simeonova A, Mihnev N, Simeonov G, Davidov K and Kirova G. Central Pontine Myelinolysis in Patient with Normal Serum Sodium Levels, System Alcohol Use and Malnutrition- A Case Report. Austin J Clin Neurol 2015; 2(9): 1074. ISSN : 2381-9154