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Washington University Experience | MYELIN (NON-IMMUNE MEDIATED) | Central Pontine Myelinolysis (CPM) | 9A0 Case 9 History
Case 9 History ---- This patient was a 77 year old man with a past medical history significant for Parkinson’s Disease, diabetes mellitus, coronary artery disease, sick sinus syndrome s/p pacemaker, atrial fibrillation, and lung adenocarcinoma, S/P resection. He was admitted to our hospital for an “acute abdomen” presentation and underwent a small bowel resection for transmural ischemic necrosis on 1/4/2002. His postoperative course was complicated by recurrent atrial fibrillation prompting amiodarone and heparin therapy and right empyema and LLQ abdominal abscess that were drained and treated with antibiotics. Meanwhile, he began to demonstrate increased dyskinesias during "on" periods and poor mobility, including poor PO intake, during the "off" periods. He was then transferred to Neurology on 1/21/02, and continued with motor fluctuations and dyskinesias despite optimization of medical therapy. On 2/3/02, he was found unresponsive with a respiratory acidosis and was intubated and transferred to the surgery ICU. He developed right atrial thrombus and bilateral Pseudomonas and ORSA pneumonia, and was transferred to MICU for further treatment. By 2/20/02, he was noted to have disabling dyskinesias and severe motor fluctuations with dose failures and short duration of benefit. On 3/19, he received bilateral implantations of electronic stimulators to the subthalamic nuclei to control his Parkinsonian symptoms. Postoperatively, he was noted to be at baseline mental status: alert and oriented (A+O) x3, following commands, and mouthing words. However, the next day, he began experiencing visual hallucinations. Stimulator use allowed eventual termination of all medical therapy for PD, but he developed confusion, agitation, irritability, delusions and psychosis. Thiamine replacement was used because of nystagmus. His mental status returned to near baseline at the end of April. His parkinsonian symptoms were dramatically improved with intermittent mild dyskinesias. However, he continued to have intermittent atrial fibrillation and flutter. Acute renal insufficiency with hyperkalemia thought secondary to acute tubular necrosis prompted initiation of hemodialysis that was continued until 5/22 when his renal insufficiency resolved. Very mild hyponatremia occurred on 5/15 and returned to normal on 5/18, and mild hypernatremia was noted from 6/1 to 6/7. On 5/6, he was awake, attentive, and was able to follow commands perfectly and walk with assistance. However, on 5/17, he had an episode of jerking movements with decreased consciousness. For the next days, he continued with fluctuating levels of consciousness, but consistent good grips and bilateral lower extremity weakness without a sensory level. On 6/5, he developed an episode of severe hypoglycemia (<30 mg/dL), and had abnormal eye movements, upper extremity stiffening and internal rotation and jerking. Due to his poor prognosis and expressed wishes, mechanical ventilation was withdrawn and he expired on 6/18/22 (his hospital day #165).
