Images in Clinical Medicine

Central Pontine Myelinolysis

John D. Fleming, M.B., B.S., and Suresh Babu, M.B., B.S.

N Engl J Med 2008; 359:e29December 4, 2008

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Article

A 26-year-old man with a history of chronic alcohol abuse presented with dysarthria, lethargy, and horizontal nystagmus. Results of a clinical examination and blood tests were otherwise normal, including a serum sodium level of 137 mmol per liter and serum osmolality of 287 mOsm per kilogram. Over the next 5 days, spastic quadriparesis and pseudobulbar palsy developed. Magnetic resonance imaging of the brain revealed central pontine myelinolysis with a well-defined lesion in the pons of low T₁-signal intensity (Panel A, arrow) and high T₂-signal intensity (Panel B, arrow). There was sparing of the ventral lateral and cortical spinal tracts and no space-occupying effect or distortion of the adjacent fourth ventricle. Central pontine myelinolysis is a noninflammatory, demyelinating condition commonly associated with the rapid correction of hyponatremia. However, it was originally described in those with chronic alcoholism and in malnourished persons. There is no specific treatment for central pontine myelinolysis, and this patient had no clinical improvement 6 months later.

John D. Fleming, M.B., B.S.
Suresh Babu, M.B., B.S.
Queen Alexandra Hospital, Cosham, Portsmouth PO6 3LY,, United Kingdom
jdfleming@gmail.com