Electrolyte Blood Press.  2015 Jun;13(1):30-36. 10.5049/EBP.2015.13.1.30.

A Case of Osmotic Demyelination Presenting with Severe Hypernatremia

• Han MJ
• Kim DH
• Kim YH
• Yang IM
• Park JH
• Hong MK

• KMID: 2052340
• DOI: http://doi.org/10.5049/EBP.2015.13.1.30

Abstract

Osmotic demyelination syndrome is a demyelinating disorder associated with rapid correction of hyponatremia. But, it rarely occurs in acute hypernatremia, and it leads to permanent neurologic symptoms and is associated with high mortality. A 44-year-old woman treated with alternative medicine was admitted with a history of drowsy mental status. Severe hypernatremia (197mEq/L) with hyperosmolality (415mOsm/kgH2O) was evident initially and magnetic resonance imaging revealed a high signal intensity lesion in the pons, consistent with central pontine myelinolysis. She was treated with 0.45% saline and 5% dextrose water and intravenous corticosteroids. Serum sodium normalized and her clinical course gradually improved. Brain lesion of myelinolysis also improved in a follow-up imaging study. This is the first report of a successful treatment of hypernatremia caused by iatrogenic salt intake, and it confirms the importance of adequate fluid supplementation in severe hypernatremia.

Keyword

Hypernatremia; Osmotic demyelination syndrome; Magnetic resonance imaging

MeSH Terms

Adrenal Cortex Hormones
Adult
Brain
Complementary Therapies
Demyelinating Diseases*
Female
Follow-Up Studies
Glucose
Humans
Hypernatremia*
Hyponatremia
Magnetic Resonance Imaging
Mortality
Myelinolysis, Central Pontine
Neurologic Manifestations
Pons
Sodium
Water
Adrenal Cortex Hormones
Glucose
Sodium
Water

Figure

• 

  Fig. 1 Clinical course of the patient. The upper graph shows the changes in serum sodium and osmolality. The lower part shows the serum creatine phosphokinase level. Brain magnetic resonance imaging was performed on day 6.

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  Fig. 2 Initial MRI shows multifocal diffusion restriction in bilateral pons and bilateral thalami on DWI (B and E) and low signal intensity lesion in the same portion on ADC maps (C and F). There were very subtle high signal intensity lesions in bilateral central pons on the FLAIR images (A and D). ADC: apparent diffusion coefficient, DWI: diffusion-weighted image, FLAIR: fluid-attenuated inversion recovery, MRI: magnetic resonance image.

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  Fig. 3 Follow-up MRI performed on hospital day 30 shows symmetric high signal intensity changes in the lateral pons and bilateral thalami on coronal T2-weighted image (A). Previously noted diffusion restriction in bilateral pons and bilateral thalami had resolved on ADC maps (D and G) and diffusion restriction in bilateral central mid-pons, upper pons, and bilateral thalami had disappeared on DWI (B, C, and F).

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