An Unexpected Case of Osmotic Demyelination Syndrome (ODS)

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Introduction: ODS is a neurological condition characterized by altered mentation, extrapyramidal symptoms, and pseudobulbar palsy in response to a rapid increase in serum osmolality. Classically ODS was been described after rapid correction of severe, chronic hyponatremia but can occur with slower rates of correction in high-risk patients, as described herein. Case Description: A 44-year-old man with alcoholism presented with a sodium of 115meq/L. Normal saline was administered and his sodium corrected to 123meq/L over the initial 24 hours. His sodium corrected slowly over the next 5 days to normal range, never exceeding 8 meq/L per day. On day 5, he developed nystagmus, cogwheeling rigidity, hallucinations and aspirations. Brain MRI revealed abnormalities in the central pons (fig. 1), and a diagnosis of ODS was made. D5W and desmopressin were administered, lowering the sodium from 142meq/L to 131meq/L over 2 days, where it was maintained for 24 hours. No clinical improvement resulted and neurological sx progressed. The sodium was then allowed to rise slowly to normal over 2 days, shown in fig. 2. By discharge the patient had moderate improvement in speech and swallowing. Discussion: This case of ODS was unusual in that it occurred despite modest hyponatremia, which corrected at only 8meq / day. ODS can occur despite slow sodium correction in the context of risk factors such as alcoholism. Therapeutic relowering of sodium resulted in no improvement, possibly because relowering was not pursued until MRI confirmation, leading to a delay of 72 hours from symptom onset.MRI brain (DWI sequence) demontrating restricted diffusion in the central pons (arrow).

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