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Washington University Experience | MYELIN (NON-IMMUNE MEDIATED) | Central Pontine Myelinolysis (CPM) | 4A0 Case 4 History

4A0 Case 4 History
Case 4 History ---- The patient was a 59 year old woman with a 14 year history of hypertension and a 6 year history of adult onset diabetes mellitus, treated with Diabinase. The patient presented on 9/25/86 with a 3 day history of lethargy, anorexia, generalized weakness as well as slurred speech. Clinical exam suggested dehydration as demonstrated by dry mucous membranes and poor skin turgor. Labs showed a serum sodium of 105, serum potassium of 2.5, chloride of 58, glucose of 181, and pH on an ABG of 7.51. She was admitted for hypotonic hypovolemic hyponatremia and was initially treated with D5 half normal saline intravenously. However on the morning of 9/26 her serum sodium was still 108. She was then treated with 8 liters of 3.5% normal saline and vasopressin 10 units per hour over the next 16 hours, which raised her serum sodium to 137 by the morning of 9/27. A CT exam of the head was performed which was interpreted showing enlargement of the sella turcica. She was transferred to BH for evaluation of possible pituitary tumor on 9/27. In the BH ER she had orthostatic changes in her blood pressure and to be drowsy with slurred speech in the absence of other abnormalities in her neuro exam. Her labs were notable for a serum sodium of 147, potassium 2.9, calcium 7.6, and a phosphate of 0.8. On 9/28 she was noted to have deteriorated neurologically with a right facial droop, right hemiparesis, and a right Babinski sign. Later in the day she was noted to have developed left sided weakness, left gaze preference, and to have unintelligible speech. She was transferred to the RICU. Head CT was performed on 9/28 but showed no abnormalities except for some fluid around the sella turcica. She continued to deteriorate such that on 9/29 she had flaccid quadriparesis, bilateral facial weakness, and gaze palsies. A lumbar puncture was performed but was essentially unremarkable. She was transferred to the Neurology ICU on 10/1 at which time she had no spontaneous movements, no response to pain, and no speech. She exhibited ongoing SIADH which was treated with fluid restriction. She began to spike fevers on 10/3 and the clinical impression was aspiration pneumonia, which was treated with penicillin. On 10/4 she began to have both left and right sided focal seizures, often involving the face, which were treated with Dilantin and phenobarbital. A repeat LP at this time again was unremarkable. On 10/7 an EEG was performed which was abnormal due to diffuse slow activity with possible left temporal suppression. This was consistent with a bilateral disorder and suggested more than the central pons area was involved. From 10/11 through 10/16 she received prednisone 50 mg BID, but no improvement was noted. On 10/14 an MRI scan of the head was performed which showed diffuse cerebral atrophy. No abnormality was seen in the brainstem, cerebellum, or cerebral hemisphere; however, a questionable area on the T2 weighted image suggested the lower part of the pons might be involved. She continued to spike fevers; a urine culture on 10/19 grew greater than 100,000 colonies per ml of E. coli. Her neuro exam showed the persistence of ocular motion on doll's eyes maneuvers and of sluggish pupillary response to light as well as gagging during oral suctioning. On 10/25 she suffered a cardiopulmonary arrest and was pronounced dead.



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