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LETTER TO EDITOR
Year : 2011  |  Volume : 59  |  Issue : 5  |  Page : 782-783

Central neurogenic hyperventilation due to pontine glioma


1 Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
2 Department of Neurology, Haga Hospital, The Hague, Netherlands
3 Department of Neurology, Reinier de Graaf Hospital, Delft, Netherlands

Date of Submission21-Jun-2011
Date of Decision22-Jun-2011
Date of Acceptance22-Jun-2011
Date of Web Publication22-Oct-2011

Correspondence Address:
H J Gilhuis
Department of Neurology, Reinier de Graaf Hospital, Delft
Netherlands
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.86573

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How to cite this article:
Van Wamelen D J, Hama-Amin A D, Gilhuis H J, De Bruijn S. Central neurogenic hyperventilation due to pontine glioma. Neurol India 2011;59:782-3

How to cite this URL:
Van Wamelen D J, Hama-Amin A D, Gilhuis H J, De Bruijn S. Central neurogenic hyperventilation due to pontine glioma. Neurol India [serial online] 2011 [cited 2019 Nov 18];59:782-3. Available from: http://www.neurologyindia.com/text.asp?2011/59/5/782/86573


Sir,

A 29-year-old otherwise healthy man presented with hyperventilation of at least 6 weeks duration. He also complained of weakness of right arm and leg and persistent occipital headache. The leg weakness used to worsen on walking. On examination, blood pressure was 130/80 mmHg, heart rate 75/min and respiratory rate 28 breaths/min and no dyspnea. Neurologic examination revealed mild right paresis and diminished touch sensation and right extensor plantar response. Gait was slightly wide-based. Arterial blood gas revealed a respiratory alkalosis with pH. 7.50, PCO 2 2.7 kPa (20.3 mmHg), HCO 3 16 mmol/L, PO 2 17.0 kPa (128 mmHg), and SaO 2 99%. Posteroanterior and lateral chest radiographies and an electrocardiogram, as well as routine blood tests, showed no abnormalities. T2-weighted and gadolinium-enhanced magnetic resonance imaging (MRI) showed a low-grade glioma of 3.2 × 2.6 × 1.8 cm in the ventrocaudal pons and rostral medulla oblongata [Figure 1]a and b. With this clinical and laboratory findings the diagnosis of central neurogenic hyperventilation (CNH) was made.
Figure 1: T1-weighted gadolinium-enhanced (a) and T2-weighted (b) MRI, showing tumor mass in the ventrocaudal pons and rostral medulla oblongata (a) with a diameter of 3.2 × 2.6 × 1.6 cm, surrounded by edema (b), suggestive of low-grade glioma

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CNH in conscious patients, defined as the presence of hyperventilation with low arterial PaCO 2 , high arterial PaO 2 , and high arterial pH, persisting during sleep and not due to drug-induced or metabolic causes, is a very rare disorder. [1] Nearly all cases are due to brainstem malignancies, but other causes include bilateral medial thalamic infarction and multiple sclerosis lesions in the brainstem. [2],[3] The mechanisms of CNH is thought to be due to disconnection between pontine and medullary respiratory centers leading to unopposed stimulation of the latter or from acidosis due to lactate production by the tumor mass, activating brainstem chemosensitive respiratory neurons. [1] Although a reduction in respiratory rate in CNH has been achieved by opioid and fentanyl administration, only aggressive treatment, such as radiation or excision of tumor mass, seems to bring about complete remission of CNH. [4],[5],[6]

Our patient was treated with dexamethasone 4 mg four times a day and cranial radiation in dose of 33 times 1.8 Gy, resulting in complete remission of neurologic deficits, including hyperventilation. An arterial blood gas performed after cranial radiation revealed a pH. of 7.47, PCO 2 4.7 kPa (35 mmHg), HCO 3 25 mmol/L, PO 2 11.3 mmol/L (85 mmHg), and SaO 2 98%, values within the normal range. Repeated cerebral MRI showed reduction of pontine tumor mass to 2.0 × 1.8 × 1.6 cm, without significant uptake of gadolinium. He has remained symptom-free during a follow-up at 3 months, after which he returned to his home country. In conclusion, we suggest in case of unexplained hyperventilation, the diagnosis of a brainstem malignancy should be considered.

 
  References Top

1.Tarulli AW, Lim C, Bui JD, Saper CB, Alexander MP. Central neurogenic hyperventilation: A case report and discussion of pathophysiology. Arch Neurol 2005;62:1632-4.  Back to cited text no. 1
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2.Johnston CS, Singh V, Ralston HJ 3rd, Gold WM. Chronic dyspnea and hyperventilation in an awake patient with small subcortical infarcts. Neurology 2001;57;2131-3.  Back to cited text no. 2
    
3.Takahashi M, Tsunemi T, Miyayosi T, Mizusawa H. Reversible central neurogenic hyperventilation in an awake patient with multiple sclerosis. J Neurol. 2007;254:1763-4.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Adachi YU, Sano H, Doi M, Sato S. Central neurogenic hyperventilation treated with intravenous fentanyl followed by transdermal application. J Anesth 2007;21:417-9.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Dubaybo BA, Afridi I, Hussain M. Central neurogenic hyperventilation in invasive laryngeal carcinoma. Chest 1991;99:767-9.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Sakamoto T, Kokubo M, Sasai K, Chin K, Takahashi JA, Nagata Y, et al. Central neurogenic hyperventilation with primary cerebral lymphoma: a case report. Radiat Med 2001;19:209-13.  Back to cited text no. 6
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