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|Year : 2017 | Volume
| Issue : 3 | Page : 674-675
Central pontine myelinolysis associated with hypokalemia in a diabetic patient with sepsis
Sweety V Shinde
Department of Pathology, B.Y.L Nair Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||9-May-2017|
Sweety V Shinde
Building 1, Flat 27, Hajiali Doctor's Quarters, Hajiali, Mahalaxmi, Mumbai - 400 034, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shinde SV. Central pontine myelinolysis associated with hypokalemia in a diabetic patient with sepsis. Neurol India 2017;65:674-5
Central pontine myelinolysis is an osmotic demyelinating disorder. We report a case associated with hypokalemia due to sepsis-induced acute renal failure follwing diabetic Fournier's gangrene. Histopathology needed differentiation from pontine infarct and fixation artifact using the myelin stain, Luxol fast blue.
A 57-year old diabetic patient presented with fever and scrotal blackening suggestive of Fournier's gangrene. Investigations showed leukocytosis 22000 per cumm, BUN 66 mg/dl, creatinine 4 mg/dl, blood sugar 224 mg/dl, and sodium and potassium of 140 and 2.4 mEq/L, respectively. He developed oliguria and altered sensorium. Scrotal swab showed gram positive diplococci. Computed tomography (CT) scan showed a hypodense pontine lesion suggestive of infarction [Figure 1]a. The patient expired following desloughing surgery. Autopsy showed a pontine lesion [Figure 1]b with myelin loss [Figure 2]a and [Figure 2]b, confirming central pontine myelinolysis (CPM).
|Figure 1: (a) Computed tomography scan shows a hypodense circumscribed lesion in the pons (white arrow). (b) Gross appearance shows a 5 × 5 mm soft, pale lesion in basis pontis (black arrow). Typically there is sparing of the periventricular zone|
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|Figure 2: (a) Photomicrograph, hematoxylin and eosin stain, 10 × shows pontine loss of myelin fibres replaced by sheets of foamy macrophages. (b) Photomicrograph, Luxol Fast Blue stain, 40 × shows foamy macrophages with cytoplasmic blue ingested lipid debris. Adjacent viable white matter tract shows intact blue stain (red arrow)|
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Osmotic demyelination affecting pontine or extrapontine sites (thalamus, caudate nucleus, or cerebellum) is associated with rapid correction of hyponatremia, hyperosmolality, and hypokalemia. Underlying disorders include renal failure, diabetes, and septicemia. CPM clinically presents with locked-in syndrome and a hypodense lesion on CT scan. Apparent diffusion coefficient has prognostic value since low value in active CPM normalizes with clinical improvement. Gross and histomorphologic features of CPM are distinct [Table 1]. Our case showed CPM associated with hypokalemia following septic renal failure due to diabetic Fournier's gangrene, similar to the case reported by Shintani et al. Hypokalemic osmotic efflux causes apoptosis of oligodendrocytes with secondary myelinolysis. Loss of osmotic channels aquaporin 1 and 4 can be confirmed by immunohistochemistry.
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[Figure 1], [Figure 2]