Khalid Hamid Changal1, Hameed Raina1, Irfan Yusuf Wani2. 1. Internal Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India. 2. Neurology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India.
Abstract
PURPOSE: This case report demonstrates that if serum sodium is re lowered early in the course of Osmotic demyelination syndrome (ODS), many of its devastating consequences may be avoided. In animal models, initiation of re-lowering within four hours of symptom onset has been associated with better outcomes than initiation within eight to ten hours of symptom onset. As there is no effective therapy for the condition we suggest a trial of re lowering of serum sodium early in its course. CASE REPORT: A 33 years old woman who was on diuretics presented to us with delirium in the form of hypo responsiveness for two to three days after suffering from an acute gastroenteritis. On evaluation she was found to have hyponatremia that was corrected too rapidly and was followed by an initial improvement and later worsening of neurological signs. T2 weighted MRI of the brain showed hyperintense lesions in pons and in extra pontine areas including thalamus and cerebellum. The patient was diagnosed to be suffering from osmotic demyelinating syndrome. Re-lowering of the patient's serum sodium with dextrose 5% and desmopressin was tried along with aggressive supportive treatment. Patient was reassessed after regular intervals and at 6 months post treatment patient has recovered almost completely and is living an independent life. CONCLUSION: Based on the absence of other effective therapies, and the poor prognosis associated with ODS, it is suggested re-lowering the serum sodium to a level that is just below the maximal target value at 48 hours of less than 18 meq/L above the initial serum sodium. Re-lowering therapy should be initiated as quickly as possible after the onset of neurologic symptoms that are attributed to ODS.
PURPOSE: This case report demonstrates that if serum sodium is re lowered early in the course of Osmotic demyelination syndrome (ODS), many of its devastating consequences may be avoided. In animal models, initiation of re-lowering within four hours of symptom onset has been associated with better outcomes than initiation within eight to ten hours of symptom onset. As there is no effective therapy for the condition we suggest a trial of re lowering of serum sodium early in its course. CASE REPORT: A 33 years old woman who was on diuretics presented to us with delirium in the form of hypo responsiveness for two to three days after suffering from an acute gastroenteritis. On evaluation she was found to have hyponatremia that was corrected too rapidly and was followed by an initial improvement and later worsening of neurological signs. T2 weighted MRI of the brain showed hyperintense lesions in pons and in extra pontine areas including thalamus and cerebellum. The patient was diagnosed to be suffering from osmotic demyelinating syndrome. Re-lowering of the patient's serum sodium with dextrose 5% and desmopressin was tried along with aggressive supportive treatment. Patient was reassessed after regular intervals and at 6 months post treatment patient has recovered almost completely and is living an independent life. CONCLUSION: Based on the absence of other effective therapies, and the poor prognosis associated with ODS, it is suggested re-lowering the serum sodium to a level that is just below the maximal target value at 48 hours of less than 18 meq/L above the initial serum sodium. Re-lowering therapy should be initiated as quickly as possible after the onset of neurologic symptoms that are attributed to ODS.