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NEUROIMAGES
Year : 2017  |  Volume : 65  |  Issue : 3  |  Page : 674-675

Central pontine myelinolysis associated with hypokalemia in a diabetic patient with sepsis


Department of Pathology, B.Y.L Nair Hospital, Mumbai, Maharashtra, India

Date of Web Publication9-May-2017

Correspondence Address:
Sweety V Shinde
Building 1, Flat 27, Hajiali Doctor's Quarters, Hajiali, Mahalaxmi, Mumbai - 400 034, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_1092_16

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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

How to cite this URL:
Shinde SV. Central pontine myelinolysis associated with hypokalemia in a diabetic patient with sepsis. Neurol India [serial online] 2017 [cited 2019 Dec 15];65:674-5. Available from: http://www.neurologyindia.com/text.asp?2017/65/3/674/205885


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.[1] Apparent diffusion coefficient has prognostic value since low value in active CPM normalizes with clinical improvement.[2] Gross and histomorphologic features of CPM are distinct [Table 1].[3] 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.[4] Hypokalemic osmotic efflux causes apoptosis of oligodendrocytes with secondary myelinolysis.[1] Loss of osmotic channels aquaporin 1 and 4 can be confirmed by immunohistochemistry.[5]
Table 1: Differentiating CPM from mimics

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Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Martin RJ. Central pontine and extrapontine myelinolysis: The osmotic demyelination syndromes. J Neurol Neurosurg Psychiatry 2004;75:22-8.  Back to cited text no. 1
    
2.
Dervisoglu E, Yegenaga I, Anik Y, Sengul E, Turgut T. Diffusion magnetic resonance imaging may provide prognostic information in osmotic demyelination syndrome: Report of a case. Acta Radiol 2006;47:208-12.  Back to cited text no. 2
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3.
Metabolic diseases. In: Esiri M, Perl D, editors. Oppenheimer's Diagnostic Neuropathology. 3rd ed. London: Hodder Arnold Education; 2006. p. 435-7.  Back to cited text no. 3
    
4.
Shintani M, Yamashita M, Nakano A, Aotani D, Maeda K, Yamamoto T, et al. Central pontine and extrapontine myelinolysis associated with type 2 diabetic patient with hypokalemia. Diabetes Res Clin Pract 2005;68:75-80.  Back to cited text no. 4
[PUBMED]    
5.
Popescu BF, Bunyan RF, Guo Y, Parisi JE, Lennon VA, Lucchinetti CF. Evidence of aquaporin involvement in human central pontine myelinolysis. Acta Neuropathol Commun 2013;1:40.  Back to cited text no. 5
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