(311) Don't Be Salty: A Case of Osmotic Demyelination Syndrome From Rapid Sodium Correction

Introduction: Hyponatremia is a common sequelae in patients with advanced cirrhosis. These patients are hypervolemic and experience labile sodium levels due portal hypertension and antidiuretic hormone-driven free water retention. Close monitoring of sodium is crucial in alcohol cirrhosis as they are at high risk for osmotic demyelination syndrome (ODS).

Description: A 49 year old female with a history of decompensated alcoholic cirrhosis and chronic back pack presented for generalized weakness, diarrhea and non-bloody vomiting for three days. Vitals were significant for hypotension and tachycardia, which improved after 2L IV fluids. Labs were significant for hyponatremia (108 mmol/L), hypokalemia, hypomagnesemia, and hypochloremia. She was admitted to the ICU, nephrology was consulted and sodium was monitored every 4 hours. At the 16th hour, her sodium overcorrected to 131 mmol/L and D5W was started. The subsequent sodium levels were 126 mmol/L and 124 mmol/L. After 48 hours, sodium was no longer tightly trended and it eventually normalized over 2-3 days. On day 3, our patient was noted to be confused and agitated, which was thought to be secondary to alcohol withdrawal. On day 6, a rapid response was called for altered mental status. Workup including urine toxicology, blood work, EEG, and CT head were normal. Etiology was thought to be secondary to sedative medications for her back pain. Symptoms did not improve and an MRI brain was obtained on day 12 which revealed central pontine and extrapontine demyelination syndrome.

Discussion: In a nationwide study, 0.02% of inpatient cirrhotic patients developed ODS. Despite its rarity, these patients are high risk and clinicians must have a high index of suspicion for diagnosis. Recognition of ODS remains a challenge as symptoms are typically delayed, nonspecific and can be mistaken for alcohol withdrawal and/or hepatic encephalopathy. ODS should be suspected when confusion, quadriplegia, pseudobulbar palsy or reduced consciousness develops over a period of time following correction of electrolyte abnormalities. Patients with alcohol cirrhosis who develop ODS have increased morbidity and mortality, longer hospital stays, higher medical costs, and are more likely to be discharged to a secondary care facility compared to those without cirrhosis.