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Murao S, Kiuchi T, Hasegawa M, Yoshikawa R. Pontine lesion in hyperglycemic crises: Relevance to osmotic demyelination syndrome and posterior reversible encephalopathy syndrome. J Diabetes Investig 2022; 14:486-488. [PMID: 36458523 PMCID: PMC9951566 DOI: 10.1111/jdi.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 12/03/2022] Open
Abstract
We herein describe a case of type 1 diabetes that presented with a pontine lesion during two hyperglycemic crises accompanied by marked fluctuations in serum osmotic pressure and blood pressure. Magnetic resonance imaging showed swollen pons with osmotic demyelination syndrome characteristics accompanying cytotoxic edema at the first crisis. The involvement of vasogenic edema was also assumed in the second crisis. Neurological symptoms were milder than magnetic resonance imaging findings. The patient recovered after 7 days without sequelae in both crises. Based on these findings, a pontine lesion needs to be considered in patients with poorly controlled diabetes showing rapid metabolic and blood pressure changes, as observed in hyperglycemic crises. Cytotoxic edema leading to osmotic demyelination syndrome and vasogenic edema caused by vascular endothelial cell damage might both be involved in the pathogenesis of a pontine lesion.
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Affiliation(s)
- Satoshi Murao
- Department of Metabolism and EndocrinologyTakamatsu HospitalKagawaJapan
| | | | - Momoka Hasegawa
- Department of Metabolism and EndocrinologyTakamatsu HospitalKagawaJapan
| | - Ritsuko Yoshikawa
- Department of Metabolism and EndocrinologyTakamatsu HospitalKagawaJapan
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2
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Di Agostino S, Costanzo AA, Andreone P, Maurantonio M. Central pontine myelinolysis secondary to glycemic variability in type 1 diabetes: a case report and a systematic review of the literature. EXPLORATION OF MEDICINE 2021. [DOI: 10.37349/emed.2021.00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Central pontine myelinolysis (CPM) is a rare manifestation of osmotic demyelination syndrome (ODS) which involves the pons and causes significant morbidity and mortality. CPM usually occurs in the setting of rapid correction of severe chronic hyponatremia. A rare case of CPM due to hyperglycemia in a 27-year-old man with type 1 diabetes is reported. During the patient’s hospitalization, his plasma glucose level showed a wide variability ranging from 38 mg/dL to 530 mg/dL, while plasma sodium level was constantly normal. At computed tomography (CT) scans, areas of hypodensity with a hyperdense ring were identified in the anterior part of the pons. At magnetic resonance imaging (MRI) scan, pontine abnormalities compatible with CPM were observed. According to laboratory tests, we concluded that CPM resulted from rapid and wide shifts in osmolar gradient owing to variability in plasma glucose levels. While universally recognized in several clinical settings, CPM is rarely observed in diabetic patients. Our report supports the notion that hyperosmolarity per se plays a key role in the pathogenesis of CPM, which may occur independently of sodium abnormalities.
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Affiliation(s)
- Stefania Di Agostino
- Division of Metabolic Internal Medicine, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Arianna A.C. Costanzo
- Division of Metabolic Internal Medicine, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Pietro Andreone
- Department of Internal Medicine, General, Emergency and Post-Acute, Division of Metabolic Internal Medicine, University Hospital of Modena, 41126 Modena, Italy
| | - Mauro Maurantonio
- Department of Internal Medicine, General, Emergency and Post-Acute, Division of Metabolic Internal Medicine, University Hospital of Modena, 41126 Modena, Italy
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Jalalzadeh M, Chaudhari A, Baumstein D. Prolonged Altered Mental Status in a Diabetic Hemodialysis Patient. Cureus 2021; 13:e13132. [PMID: 33728148 PMCID: PMC7936650 DOI: 10.7759/cureus.13132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Osmotic demyelination syndrome (ODS) is a demyelinating disorder of the central nervous system. It usually occurs with rapid correction of severe chronic hyponatremia. ODS is rarely seen as a complication of hyperglycemia. Herein, we report a rare presentation of ODS secondary to hyperosmolar hyperglycemic state. A 28-year-old female with type 1 diabetes, hypertension, seizure disorder, and end-stage renal disease on hemodialysis was brought from a shelter with two days of unresponsiveness and developed ODS after hyperosmolar hyperglycemic state in long-standing uncontrolled diabetes with normal serum electrolyte levels.
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Affiliation(s)
- Mojgan Jalalzadeh
- Internal Medicine/Nephrology, Metropolitan Hospital Center, New York Medical College, New York, USA
| | - Ashok Chaudhari
- Internal Medicine/Nephrology, Metropolitan Hospital Center, New York Medical College, New York, USA
| | - Donald Baumstein
- Internal Medicine/Nephrology, Metropolitan Hospital Center, New York Medical College, New York, USA
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Shimizu Y, Kozawa J, Hayakawa T, Sakai Y, Kimura T, Kitamura T, Murase S, Tanaka H, Maeda N, Otsuki M, Matsuoka T, Mochizuki H, Iwahashi H, Shimomura I. Asymptomatic Pontine Lesion and Diabetic Amyotrophy after Rapid Improvement of Poor Glycemic Control in a Patient with Type 1 Diabetes. Intern Med 2019; 58:3433-3439. [PMID: 31391398 PMCID: PMC6928506 DOI: 10.2169/internalmedicine.2835-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We herein report a 28-year-old woman with type 1 diabetes with an asymptomatic pontine lesion and diabetic amyotrophy. She had suffered from diabetes from 10 years old. Treatment in a hospital reduced the hemoglobin A1c level from 14.2% to 7.2% for approximately 2 months. She suffered from acute-onset pain and weakness of the lower limb muscles without central nervous system manifestations. Magnetic resonance imaging showed high-intensity lesions at the brainstem and lower limb muscles on T2-weighted images. These findings and symptoms gradually resolved. Rapid treatment of poor glycemic control might increase the risk of asymptomatic pontine lesions and diabetic amyotrophy.
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Affiliation(s)
- Yuri Shimizu
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Junji Kozawa
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Tomoaki Hayakawa
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Yasuha Sakai
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Takekazu Kimura
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Tetsuhiro Kitamura
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Sho Murase
- Department of Neurology, Graduate School of Medicine, Osaka University, Japan
| | - Hisashi Tanaka
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka University, Japan
| | - Norikazu Maeda
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
- Department of Metabolism and Atherosclerosis, Graduate School of Medicine, Osaka University, Japan
| | - Michio Otsuki
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Takaaki Matsuoka
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Hideki Mochizuki
- Department of Neurology, Graduate School of Medicine, Osaka University, Japan
| | - Hiromi Iwahashi
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
- Department of Diabetes Care Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Japan
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5
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Talluri S, Charumathi R, Khan M, Kissell K. Atypical presentation of central pontine myelinolysis in hyperglycemia. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170064. [PMID: 28924482 PMCID: PMC5592705 DOI: 10.1530/edm-17-0064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 07/06/2017] [Indexed: 12/25/2022] Open
Abstract
Central pontine myelinolysis (CPM) usually occurs with rapid correction of severe chronic hyponatremia. Despite the pronounced fluctuations in serum osmolality, CPM is rarely seen in diabetics. This is a case report of CPM associated with hyperglycemia. A 45-year-old non-smoking and non-alcoholic African American male with past medical history of type 2 diabetes, hypertension, stage V chronic kidney disease and hypothyroidism presented with a two-week history of intermittent episodes of gait imbalance, slurred speech and inappropriate laughter. Physical examination including complete neurological assessment and fundoscopic examination were unremarkable. Laboratory evaluation was significant for serum sodium: 140 mmol/L, potassium: 3.9 mmol/L, serum glucose: 178 mg/dL and serum osmolality: 317 mosmol/kg. His ambulatory blood sugars fluctuated between 100 and 600 mg/dL in the six weeks prior to presentation, without any significant or rapid changes in his corrected serum sodium or other electrolyte levels. MRI brain demonstrated a symmetric lesion in the central pons with increased signal intensity on T2- and diffusion-weighted images. After neurological consultation and MRI confirmation, the patient was diagnosed with CPM secondary to hyperosmolar hyperglycemia. Eight-week follow-up with neurology was notable for near-complete resolution of symptoms. This case report highlights the importance of adequate blood glucose control in diabetics. Physicians should be aware of complications like CPM, which can present atypically in diabetics and is only diagnosed in the presence of a high index of clinical suspicion. LEARNING POINTS Despite the pronounced fluctuations in serum osmolality, central pontine myelinolysis (CPM) is rarely seen in diabetics. This case report of CPM associated with hyperglycemia highlights the importance of adequate blood glucose control in diabetics.Physicians should be aware of complications like CPM in diabetics.CPM can present atypically in diabetics and is only diagnosed in the presence of a high index of clinical suspicion.
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Affiliation(s)
| | | | | | - Kerri Kissell
- Endocrinology, Guthrie Robert Packer Hospital, Sayre, Pennsylvania, USA
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Sharma C, Kumawat BL, Panchal M, Shah M. Osmotic demyelination syndrome in type 1 diabetes in the absence of dyselectrolytaemia: an overlooked complication? BMJ Case Rep 2017; 2017:bcr-2016-219148. [PMID: 28500261 DOI: 10.1136/bcr-2016-219148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Central pontine myelinolysis (CPM) is a demyelinating disorder of central nervous system which involves central portion of the pons and sometimes extrapontine areas also. It is commonly reported in settings of hyponatraemia or its rapid correction, but in the last few years it has also been reported in patients with diabetes in the absence of electrolyte disturbances or correction of serum osmolality. Here we report a case of a 20-year-old female patient, with a known history of type 1 diabetes mellitus, who presented with acute onset spastic quadriparesis with dysarthria and mild ataxia which evolved over 2 weeks. Her MRI brain showed well-defined, bilateral symmetric hyperintense lesion involving central pons showing area of diffusion restriction which was consistent with CPM. Patient was treated conservatively and improved over a period of few weeks. To diagnose more number of cases, we should not overlook CPM in patients with diabetes.
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Affiliation(s)
- Chandramohan Sharma
- Department of Neurology, Sawai Mansingh Medical College and Hospital, Jaipur, Rajasthan, India
| | - Banshi Lal Kumawat
- Department of Neurology, Sawai Mansingh Medical College and Hospital, Jaipur, Rajasthan, India
| | - Maulik Panchal
- Department of Neurology, Sawai Mansingh Medical College and Hospital, Jaipur, Rajasthan, India
| | - Mohit Shah
- Department of Neurology, Sawai Mansingh Medical College and Hospital, Jaipur, Rajasthan, India
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Kishimoto Y, Ikeda K, Murata K, Kawabe K, Hirayama T, Iwasaki Y. Rapid development of central pontine myelinolysis after recovery from Wernicke encephalopathy: a non-alcoholic case without hyponatremia. Intern Med 2012; 51:1599-603. [PMID: 22728498 DOI: 10.2169/internalmedicine.51.7498] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a non-alcoholic diabetic patient with central pontine myelinolysis (CPM) and Wernicke encephalopathy (WE). A 69-year-old man developed consciousness disturbance after parenteral hyperalimentation for liver abscess and sepsis. Neurological examination revealed drowsiness and no articulation. MRI disclosed T2-hyperintense lesions in the dorsal medulla oblongata and dentate nuclei, and symmetric enhancement in the inferior colliculus. Thiamine treatment (1,000 mg/day, div) attenuated neurological deficits. Seven days later, WE-related lesions were markedly regressed and a central pontine T2-hyperintensity lesion appeared. Serum sodium levels were normal. Physicians should pay more attention to rapid development of normonatremic CPM under thiamine supplementation in non-alcoholic WE patients.
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Affiliation(s)
- Yuui Kishimoto
- Department of Gastroenterology, Toho University Omori Medical Center, Japan
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8
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Central pontine and extrapontine myelinolysis associated with acute hepatic dysfunction. Neurol Sci 2011; 33:673-6. [DOI: 10.1007/s10072-011-0838-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 10/21/2011] [Indexed: 10/15/2022]
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Lupato A, Fazio P, Fainardi E, Cesnik E, Casetta I, Granieri E. A case of asymptomatic pontine myelinolysis. Neurol Sci 2010; 31:361-4. [PMID: 20148277 DOI: 10.1007/s10072-009-0215-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 12/28/2009] [Indexed: 10/19/2022]
Abstract
Central pontine myelinolysis is an acquired, non-inflammatory demyelinating lesion usually localized in the brainstem pons basis; it usually affects patients with a history of chronic alcoholism, malnutrition or dysionemia. The exact pathogenesis of myelinolysis is still unclear. A 69-year-old Caucasian male presented intensive headache and underwent cranial MRI that showed the typical feature of central pontine myelinolysis. Neurological valuation was negative. Other examinations included extensive blood tests, electroencephalogram and multimodal evoked potentials which all gave normal results. Alcohol abuse and malabsorption syndrome were excluded. The medical history revealed a continuative use of anti-depressive drugs and exposure to glue for years. Our patient may represent one of the rare cases of asymptomatic CPM. The actual reason why he presented this lesion is not clear, but we discuss the possible role in the etiopathogenesis of his chronic use of anti-depressive drugs and the exposure to glue and chemical agents.
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Affiliation(s)
- Angelica Lupato
- Section of Neurology, Department of Medical and Surgical Sciences of Communication and Behaviour, Ferrara University, Ferrara, Italy.
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