渗透性脱髓鞘综合征(ODS)是在积极纠正严重低钠血症后出现的临床综合征。长期饮酒,营养不良,和电解质紊乱是促进ODS脱髓鞘的额外危险因素。一名49岁女性,有未经治疗的情绪障碍史,高血压,酒精,以及向急诊科(ED)提交的有三个月全身无力病史的烟草滥用。她也有反复跌倒的病史,行走困难,食物和水摄入不足,黄疸逐渐恶化,和大约在同一时间开始的混乱。她的生命体征正常;一些重要的体检结果是:巩膜黄疸,腹胀,双侧踏板水肿,手颤抖,旋转眼球震颤,轻瘫,1+双侧膝跳,没有双侧踝关节抽动。她有中度低钠血症,轻度低钾血症,具有胆汁淤积型和转氨酶的紊乱肝功能测试,低蛋白血症,氨升高,脂肪酶,保持酒精性肝病和急性胰腺炎。在ED中,她接受了生理盐水输注,在最初的24小时内,她的血清钠仅上升了6mmol/L。她排出腹水并用硫胺素治疗,叶酸,泼尼松,乳果糖,利福昔明,呋塞米,螺内酯,和头孢曲松改善临床和实验室异常。尽管进行了物理治疗,她的下肢无力仍然存在,提示神经评估。腰椎MRI显示为陈旧性压缩性骨折和腰椎管狭窄,而脑MRI结果与渗透性脱髓鞘一致。在出院到康复设施时,她的血清钠为132mmol/L,但她的腿仍然虚弱。虽然罕见,如果存在降低脱髓鞘阈值的其他危险因素,则在中度低钠血症的情况下可能发生ODS。
Osmotic demyelination syndrome (ODS) is a clinical syndrome seen following aggressive correction of severe hyponatremia. Chronic alcohol use, malnutrition, and electrolyte derangement are additional risk factors promoting the demyelination in ODS. A 49-year-old female with a history of untreated mood disorder, hypertension, alcohol, and tobacco abuse presented to the emergency department (ED) with a three-month history of generalized body weakness. She also had a history of recurrent falls, difficulty walking, inadequate food and water intake, progressively worsening jaundice, and confusion which started about the same time. Her vital signs were normal; some of the significant physical examination findings were: sclera icterus, abdominal distension, bilateral pedal edema, hand tremors, rotary nystagmus, paraparesis, 1+ bilateral knee jerk, and absent bilateral ankle jerk. She had moderate hyponatremia, mild hypokalemia, deranged liver function test with a cholestatic pattern and transaminitis, hypoalbuminemia, elevated ammonia, lipase, in keeping with alcoholic liver disease and acute pancreatitis. In the ED, she received a normal saline infusion, and her serum sodium rose by just 6 mmol/L within the first 24 hours. She had drainage of her ascitic fluid and treatment with thiamine, folic acid, prednisone, lactulose, rifaximin, furosemide, spironolactone, and Ceftriaxone with improvement in clinical and laboratory abnormalities. Her lower extremity weakness persisted despite physical therapy, prompting neurologic evaluation. MRI of the lumbar spine showed an old compression fracture and lumbar spinal stenosis, while MRI brain findings were consistent with Osmotic demyelination. At the time of discharge to a rehabilitation facility, her serum sodium was 132 mmol/L, but her leg weakness persisted. Although rare, ODS can occur in the setting of moderate hyponatremia if there are additional risk factors that lower the threshold for demyelination.