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      Acute psychosis with a favorable outcome as a complication of central pontine/extrapontine myelinolysis in a middle aged man

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          Abstract

          Central pontine myelinolysis is a demyelinating condition affecting the pons characterized by an acute progressive quadriplegia, dysarthria, dysphagia, and alterations of consciousness. Pathologic features include prominent demyelination in the central pons with sparing of axons and neurons. This condition is usually associated with systemic disorders such as hyponatremia, chronic alcoholism, liver failure, severe burns, malignant neoplasms, hemorrhagic pancreatitis, hemodialysis, and sepsis. There are limited reports of psychosis in patients with central pontine/extrapontine myelinolysis (CPEM). We have described a case of CPEM with psychosis as a complication which recovered completely with treatment given for short duration using low dose atypical antipsychotic (quetiapine). We also discuss etiopathology and clinical outcome of psychosis in this rare neurological disorder.

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          Most cited references15

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          Pontine and extrapontine myelinolysis.

          Victor M. Victor, D. Wright, R Laureno (1979)
          No coherent theory has been advanced to explain either the particular localization of the myelinolytic lesions of central pontine myelinolysis or their pathogenesis. However, several lines of evidence support the generalization that the centre of the basis pontis has a special susceptibility to a metabolic fault. The constancy of localization of the lesion and its bilateral symmetry are the very attributes that characterize other metabolic (nutritional) disorders, such as the assymmetrical degeneragion of the papillomacular bundles within the optic nerves and tracts in deficiency amblyopia and the specific affection of the paraventricular regions in the Wernicke-Korsakoff syndrome. And clinically, the frequent occurrence of central pontine myelinolysis in a setting of severe metabolic derangement, particularly of the serum sodium, points in the same direction.
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            Clinical and functional outcome and factors predicting prognosis in osmotic demyelination syndrome (central pontine and/or extrapontine myelinolysis) in 25 patients.

            Ashalatha Radhakrishnan, Chandrasekharan Kesavadas, Ramesha Kallakatta … (2011)
            To assess the functional and clinical outcome in a sizeable cohort of patients with osmotic demyelination syndrome (ODS) and to characterise the factors which could predict the final outcome. Twenty five consecutive patients with ODS formed the study cohort. The diagnosis of ODS was based on clinical features with corroborating imaging findings. Two functional scales--Functional Independent Measure (FIM) and Disability Rating Scale (DRS)--were applied to assess the functional status at the time of admission, discharge and last follow-up. Patients who became independent for activities of daily living (ADL) at last follow-up were classified as favourable outcome, and those who died or became dependent for ADL were classified as a poor outcome group respectively. The Fisher exact test and Mann-Whitney U test were used to assess categorical and continuous variables respectively. The mean age at diagnosis was 53 ± 14 years. Five (20%) had central pontine myelinolysis, seven (28%) had extrapontine myelinolysis, and 13 (52%) had both. Hyponatraemia and hypokalaemia were noted in 20 (80%) and 10 (40%) patients respectively. Six (24%) received intravenous methylprednisolone. Eleven (46%) had a favourable outcome at a mean follow-up of 2.2 ± 2.5 years. Hyponatraemia ≤ 115 mEq (p=0.04), associated hypokalaemia (p=0.04) and low Glasgow Coma Scale (GCS) (p=0.008) at presentation were predictive of poor outcome. The mean FIM score at admission (p=0.05) and at discharge (p=0.01), and mean DRS at admission (p=0.05) were predictive of poor outcome. Higher GCS scores, better scores in functional scales in hospital, less severe hyponatraemia and absence of superadded hypokalaemia predicted favourable outcome.
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              Clinical and radiologic correlations of central pontine myelinolysis syndrome.

              A Rabinstein, Jonathan Graff, Jayawant Mandrekar … (2011)
              To characterize clinical and radiologic features of patients with central pontine myelinolysis (CPM) and identify variables that predict outcome. We retrospectively studied patients diagnosed as having CPM identified by a search of Mayo Clinic medical records from January 1, 1999, through December 31, 2010. Diagnosis was made by clinical and radiologic features. Favorable outcome was defined by a modified Rankin Scale score of 2 or lower. Volume of signal abnormality on brain magnetic resonance imaging (MRI) was quantified by a neuroradiologist blinded to outcomes. Wilcoxon rank sum tests were used to assess association between volume of signal abnormality and outcomes at discharge and last follow-up. Of 24 patients, 14 (58%) had only CPM, and 10 (42%) had extrapontine involvement. Hyponatremia was documented in 18 patients (75%), with median sodium nadir of 114 mmol/L. Eighteen patients (75%) had alcoholism, and malnutrition was documented in 12 (50%). Presenting symptoms included encephalopathy (n=18 [75%]), ataxia (n=11 [46%]), dysarthria (n=7 [29%]), eye movement abnormalities (n=6 [25%]), and seizures (n=5 [21%]). Favorable outcome was seen in 15 patients (63%) at last follow-up. Findings on initial brain MRI were normal in 5 patients, but all MRI scans were abnormal with serial imaging. The volume of radiologic signal abnormality was not associated with outcome at discharge or last follow-up (P=.67 and P=.37, respectively). Clinical outcome in patients with CPM is not predicted by the volume of radiologic T2 signal abnormality on MRI or the severity of hyponatremia. Serial brain imaging is of value because a substantial proportion of patients have normal findings on initial MRI.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Midlife Health
                Journal ID (iso-abbrev): J Midlife Health
                Journal ID (publisher-id): JMH
                Title: Journal of Mid-Life Health
                Publisher: Medknow Publications & Media Pvt Ltd (India )
                ISSN (Print): 0976-7800
                ISSN (Electronic): 0976-7819
                Publication date (Print): Jul-Dec 2012
                Volume: 3
                Issue: 2
                Pages: 103-105
                Affiliations
                [1]Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
                Author notes
                Address for Correspondence: Prof. Yatan Pal Singh Balhara, Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India. E-mail: ypsbalhara@ 123456gmail.com
                Article
                Publisher ID: JMH-3-103
                DOI: 10.4103/0976-7800.104475
                PMC ID: 3555017
                PubMed ID: 23372330
                SO-VID: b3d17cd6-0037-4527-843b-83739e61da4c
                Copyright © Copyright: © Journal of Mid-life Health
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Medicine
                Keywords: central pontine myelinolysis,quetiapine,magnetic resonance imaging
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: central pontine myelinolysis, quetiapine, magnetic resonance imaging

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