Central Pontine Myelinolysis Nrog Carbamazepine-Induced Syndrome Ntawm Qhov Tsis Tsim Nyog Antidiuretic Hormone Thiab Nws Kev Tswj Xyuas: Ib Daim Ntawv Qhia Txog Cov Ntaub Ntawv thiab Phau Ntawv Ntsuam Xyuas

Abstract

Kev kho mob hnyav ntawm hyper lossis hypoosmolar mob tuaj yeem ua rau osmotic demyelination syndrome. Peb piav qhia txog cov xwm txheej ntawm tus txiv neej muaj hnub nyoog 53- xyoo uas tau pib siv carbamazepine los kho kev puas siab puas ntsws bipolar thiab tom qab ntawd tau kuaj pom tias muaj carbamazepine-induced syndrome ntawm tsis tsim nyog antidiuretic hormone secretion.

Nyem rau cistanche deserticola vs tubulosa rau testosterone

Tus neeg mob lub siab lub ntsws maj mam txhim kho thaum lub hyponatremia raug kho siv 3 feem pua ​​​​ntawm cov saline ib txwm thiab txhawb kev kho. Tus neeg mob tau nthuav tawm mus rau qhov chaw kho mob sab nraud nrog kev tsis meej pem thiab hloov pauv sensorium. Lub paj hlwb suav tomography tau pom qhov txawv ntawm lub paj hlwb atrophy thiab periventricular ischemia demyelination alterations, thiab magnetic resonance imaging pom ib qho kev txhim kho hauv lub hlwb uas suav nrog cov pons, qhia txog kev hloov pauv osmotic demyelination.

Kev txhawb nqa cua thiab kev txhawb nqa tau pib, thiab hyponatremia tau kho. Txawm hais tias tus neeg mob ua tau zoo nrog kev kho mob, nws qhov kev cia siab tseem tsis txaus ntseeg, yog li nws raug xa mus tsev nrog cov lus qhia ua raws.

Taw qhia

Osmotic demyelination syndromes, such as central pontine myelinolysis (CPM), cause damage to several brain regions, most frequently the pons. The fundamental pathophysiology is not hyponatremia per se but rather the quick correction (>12 mEq / L tshaj 24 teev) ntawm hyponatremia [1]. CPM kuj tuaj yeem tshwm sim hauv me me hyponatremia nrog kev kho tus nqi qeeb. Txawm li cas los xij, nws feem ntau tshwm sim thaum kho cov ntshav sodium qib siab tshaj 12 mEq / L / hnub [2].

Nws yog ib qho tseem ceeb uas yuav tau txiav txim siab ntxiv qhov sib txawv, xws li kab mob siab ntev, ntshav qab zib, thiab cawv. Txawm hais tias muaj ntau qhov kev nthuav qhia tau raug sau tseg, cov neeg mob feem ntau tuaj nrog cov tsos mob ntawm lub paj hlwb sai sai thiab hloov pauv ntawm lub hlwb, dysphagia, thiab dysarthria [2-4]. Tus kab mob no kis tau sai thiab feem ntau ua rau tuag taus. Kev ntsuas yog siv los xyuas kom meej qhov kev kuaj mob thiab kev sib nqus resonance imaging (MRI) yog qhov pom zoo imaging modality li dawb teeb meem hyperintensity, piv rau xam tomography (CT), thiab hypoattenuation yog pom nyob rau ntawm T2- hnyav MRI [3,4. ].

Kev kho mob hauv qab yog ua ke nrog kev txhawb nqa raws li kev tswj hwm. Cov kev tshawb fawb tsis ntev los no tau nthuav tawm qhov kev cia siab zoo dua, nrog rau qhov txiaj ntsig zoo ntawm kwv yees li 33-50 feem pua ​​​​ntawm cov neeg mob. Hauv qhov sib piv, cov kev tshawb fawb tau ua ua ntej nruab nrab -1980s pom qhov kev tuag ntawm 90-100 feem pua ​​. Nyob ib ncig ntawm 24-39 feem pua ​​​​ntawm cov neeg mob tau txais kev daws teeb meem, thiab 16-34 feem pua ​​​​ntawm cov neeg mob muaj kev ywj pheej hauv txhua yam haujlwm ntawm kev ua neej nyob txhua hnub [5-7].

Hauv qhov sib piv, nyob ib ncig ntawm 33-55 feem pua ​​​​ntawm cov neeg mob yuav tsis xav tau kev saib xyuas, xav tau kev kho mob thaum kawg, lossis dhau mus. Hyponatremia nrog concurrent hypokalemia, 114 mmol / L ntawm hyponatremia hnyav, thiab kev ceeb toom poob qis yog qhov qhia tau tias tsis zoo. Txawm hais tias ncua kev loj hlob ntawm osmotic demyelination syndrome, qhov kev hloov pauv ntawm hyponatremia maj mam, thiab cov tsos mob hnyav, CPM ua rau qhov teeb meem no tshwj xeeb.

Tsis tas li ntawd, qhov nyuaj ntawm kev ceev faj thiab kev soj ntsuam yog nce ntxiv los ntawm qhov tshwm sim ntawm kev puas siab puas ntsws sib npaug.

Case Presentation

Ib tug txiv neej muaj hnub nyoog 53- xyoo raug coj mus rau lub chaw saib xyuas xwm txheej ceev nrog cov lus tsis txaus siab ntawm qhov tso zis ntau zaus, ua rau tsis muaj zog rau ib hlis, kiv taub hau, thiab hloov tus cwj pwm rau peb hnub dhau los. Nws keeb kwm kev kho mob yav dhau los tau nthuav tawm cov kab mob subdural hematoma uas nws tau ua rau lub cev tsis muaj zog craniectomy peb xyoos rov qab thiab keeb kwm ntawm kev puas siab puas ntsws bipolar rau 20 xyoo dhau los. Nws tau ua raws li nws cov tshuaj uas suav nrog carbamazepine 300 mg ob zaug ib hnub thiab lorazepam 2 mg ib hnub ib zaug.

Ntawm kev kuaj lub cev, ntshav siab yog 114/76 mmHg, pulse rate yog 84/feeb, thiab SpO2 yog 97 feem pua ​​​​ntawm chav cua. Nws zoo li daj ntseg, icterus tam sim no tsis muaj pedal edema, thiab nws Glasgow Coma Scale (GCS) qhab nia yog 13/15. Kev kuaj mob nyob rau hauv cov kev txwv ib txwm muaj. Nws tsis muaj keeb kwm ua npaws, dysuria, nocturia, lossis hematuria. Cov kab mob biochemical tsis tu ncua ntawm kev nkag mus tau muaj nyob rau hauv Table 1. Txhua qhov kev tshawb nrhiav tau pom tias muaj kev mob hyponatremia, thiab ntshav osmolality qis dua 275 mOsm / kg.

Ua kom tiav urinalysis qhia cov zis siab sodium (39 mEq / L) thiab cov zis osmolality (111 mOsm / kg). Endocrine thiab kev puas siab puas ntsws kev xav tau tau txais. Tom qab kev koom ua ke cov tsos mob thiab kev tshawb nrhiav hauv chaw kuaj mob, kev kuaj mob ib ntus ntawm cov tshuaj tiv thaiv kab mob ntawm cov tshuaj tsis tsim nyog antidiuretic hormone (SIADH) tau tsim.

Tam sim ntawd, carbamazepine raug txiav tawm, thiab nws tau raug tswj hwm rau qhov mob hnyav hyponatremia tshaj li 24 teev siv 3 feem pua ​​​​cov saline ib txwm nyob ntawm tus nqi ntawm 0.5 mEq / L ib teev thiab txhawb kev kho mob. Nws teb tau zoo rau kev kho mob, thiab qhov tsis txaus electrolyte tau raug kho kom zoo, raws li qhia hauv Table 1. Nws raug tso tawm hnub thib tsib ntawm kev nkag mus rau hauv tsev kho mob tom qab txhim kho nws cov tsos mob. Nws cov tshuaj kho puas siab puas ntsws kuj tau hloov mus rau ntsiav tshuaj haloperidol 2.5 mg ob zaug ib hnub, melatonin 10 mg ib hnub ib zaug, thiab quetiapine 25 mg raws li xav tau.

Tom qab ob lub lis piam tom qab, nws tau nthuav tawm dua nrog kev tsis meej pem thiab hloov pauv, ua raws li kev hais lus tsis txaus ntseeg thiab taug kev nyuaj. Kev kuaj mob qhia tau tias hyperreflexia, hypertonicity nyob rau hauv tag nrho cov ceg, nystagmus, thiab ophthalmoplegia. Nws tau txais mus rau hauv chav saib xyuas mob hnyav thiab intubated vim GCS tsis zoo thiab muaj kev pheej hmoo siab ntxiv. Nws tau txais CT lub hlwb, uas qhia txog gliosis nyob rau hauv txoj cai frontal thiab sab laug parietal cheeb tsam thiab diffuse cerebral atrophy nrog periventricular ischemic demyelination pauv (Figures 1A, 1B). MRI qhia txog kev txhim kho qhov mob hauv lub hlwb, suav nrog cov pons, qhia txog kev hloov pauv osmotic demyelination (Daim duab 2).

Nws tau txais kev txhawb nqa kev tswj hwm, thiab qhov tsis txaus electrolyte raug kho. Muaj ntau txoj hauv kev tau txais kev pom zoo hauv kev saib xyuas tus neeg mob uas muaj ntau yam tshwj xeeb. Nws thiaj li teb rau kev kho mob thiab tau paub txog hnub xya; Txawm li cas los xij, rigidity thiab hyperreflexia txuas ntxiv mus. Nws raug tso tawm ntawm lub voj voog txuas ntxiv ntawm kev kho lub cev nrog kev ua raws li niaj zaus.

Kev sib tham

CPM yog ib qho kev hloov pauv hauv kev kho mob demyelinating mob [8]. Extrapontine myelinolysis (EPM) los yog lub hauv paus thiab extrapontine myelinolysis yog ob nqe lus siv los piav txog tus mob thaum de-myelination raug pom sab nraum lub pons [9]. Qhov hnyav ntawm tus kab mob no tuaj yeem yog los ntawm kev kuaj pom asymptomatic ntawm kev kuaj pom mus rau coma lossis tuag. Ib qho kev sib xyaw ua ke ntawm cov tsos mob neuropsychiatric xws li lub siab lub ntsws, kev ua kom tsis muaj zog, thiab lwm yam cwj pwm txawv yuav raug pom.

Cov tsos mob neurologic ntawm CPM muaj xws li qaug dab peg, tsis meej pem, gait instability, thiab dysarthria [10]. Feem ntau ua rau CPM yog kev kho sai ntawm hyponatremia hauv cov neeg mob uas ua rau muaj kev ntxhov siab ntawm electrolyte, xws li cawv, kev tiv thaiv kab mob tom qab hloov pauv, kev noj zaub mov tsis zoo nrog cov kab mob hauv qab, kab mob plab hnyuv nrog mob electrolyte abnormalities, SIADH, kab mob raum, thiab kev siv siab. kev ua si [11,12].

Mob hyponatremia (48-teev txoj kev loj hlob) feem ntau ua rau muaj kev nthuav qhia tus neeg mob hnyav dua li mob hyponatremia (ntau tshaj 48- teev kev loj hlob). Tseem, mob hyponatremia tuaj yeem qhia tau tias muaj kev pheej hmoo siab dua rau CPM vim yog cov txheej txheem them nyiaj uas cuam tshuam nrog kev poob, uas ua rau cov neeg mob muaj kev pheej hmoo siab dua rau kev txhim kho CPM [13].

Dej txav los ntawm kev ncig mus rau hauv lub hlwb thaum lub sij hawm mob ntawm hyponatremia, ua rau lub hlwb hlwb nthuav [14]. Cov hlwb hauv hlwb sai plam inorganic osmolytes kom rov qab ntim ntawm tes hauv cov lus teb rau hyponatremia. Lub hlwb tuaj yeem ceev ceev khaws cov electrolytes kom rov qab mus rau qhov qub osmotic equilibrium yog tias qhov xwm txheej hyponatremic raug kho thaum lub sijhawm mob hnyav. Tsuas yog cov neeg mob uas muaj kev phom sij tshaj plaws, xws li cov poj niam cev xeeb tub thiab cov neeg mob hypoxemia, yuav muaj feem cuam tshuam los ntawm lub hlwb raug mob vim qhov ntim poob thiab deranged metabolites.

Yog hais tias lub xeev hyponatremic tseem, lub hlwb hlwb yuav tsum tau tshem tawm cov organic osmolytes (xws li taurine thiab glutamine) thiab electrolytes kom tag nrho rov qab mus rau lub cev ntim. Piv nrog rau electrolytes, cov organic osmolytes txav deb dua maj mam los ntawm intracellular mus rau extracellular ntim [5]. Rau lub hlwb kom nyob rau hauv osmotic equilibrium nrog cov ntshav, lub intracellular osmolality ntawm lub hlwb hlwb yuav tsum tsis tshua muaj nyob rau hauv lub mob hyponatremia mob thaum lub hlwb cell ntim yog ib txwm [9].

Hyponatremia yuav tsum tau kho maj mam muab lub hlwb lub sij hawm txaus kom tau txais ob qho tib si inorganic thiab organic osmolytes. Ntshav-hlwb teeb meem kev ua haujlwm tej zaum yuav raug cuam tshuam los ntawm osmotic kev ntxhov siab los ntawm kev kho sai ntawm kev mob hyponatremia, uas yuav qhia tau tias kev xoob ntawm vascular endothelial hlwb 'txoj kev sib txuas [6].

Cov txheej txheem no tuaj yeem muab cov tshuaj tsis zoo (cov txheej txheem ntxiv) nkag mus rau myelin. Nws kuj tau pom zoo tias cov vascular endothelial hlwb tso tawm lwm yam tshuaj, xws li plasminogen activators thiab cytokines, nyob rau hauv osmotic kev nyuaj siab uas tuaj yeem ua mob myelin. Lwm qhov kev piav qhia yog tias myelin degradation tshwm sim los ntawm impaired potassium siphoning, uas tsis ntev los no tau npaj rau lwm yam kab mob demyelinating. Qhov no tau txhawb nqa los ntawm kev tshawb pom ntawm cov qauv zoo li Rosenthal fibers hauv perivascular astrocytes [15].

Hyponatremia yog ib qho kev mob tshwm sim ntawm ntau cov tshuaj neuropsychiatric. Kwv yees li ntawm 10-25 feem pua ​​​​ntawm cov neeg uas muaj kev puas siab puas ntsws tsis tu ncua tuaj yeem muaj thawj polydipsia, uas ua rau muaj kev pheej hmoo ntawm hyponatremia thiab kev tuag ntxov [16]. Carbamazepine, serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, opioids, thiab polypharmacy nrog ntau cov tshuaj tiv thaiv kev puas siab puas ntsws yog cov chav kawm thawj cov tshuaj siv niaj hnub hauv neuropsychiatry qhov twg hyponatremia yog ib qho kev mob tshwm sim lossis qhia tshwm sim tom qab siv [17].

Lwm cov tshuaj nquag sau tseg uas ua rau muaj kev pheej hmoo ntawm hyponatremia suav nrog ntsev-poob diuretics, haus luam yeeb, tshuaj tsis-steroidal anti-inflammatory, thiab acetaminophen [16,17]. Kev soj ntsuam xyuas kom meej thiab nkag siab txog cov kua dej thiab cov electrolyte sib npaug yog qhov tsim nyog los txiav txim siab seb puas yuav pib kho hyponatremia nrog saline ib txwm lossis ntau qeeb nrog hypertonic 3 feem pua ​​​​ntawm saline rau lub sijhawm luv. Hauv kev mob hnyav hyponatremia (sodium<120 mEq/L) with neurologic symptoms, a hypertonic solution of 3% saline should be administered. 

Yog tias tsis muaj cov tsos mob ntawm neurologic, lub hom phiaj tseem ceeb yuav tsum yog qhov qeeb ntawm kev kho sodium nrog cov kua dej hauv cov hlab ntsha kom ua tiav tus nqi uas tsis pub tshaj {{0}} mEq/L ib 24 teev. Thaum lub sij hawm infusion ntawm cov kua, nws yog ib qho tseem ceeb los saib xyuas cov qib sodium hauv cov ntshav txhua plaub mus rau rau teev. Cov qib sodium tuaj yeem saib xyuas ib teev yog tias muaj kev cuam tshuam loj heev hauv sodium. Lub hom phiaj tseem ceeb tshaj plaws yog los kho cov ntshav sodium ntawm qhov nrawm uas tsis pub tshaj 0.5 mEq / teev [9,12].

Cov qib sodium hauv cov ntshav yuav tsum tau kuaj xyuas thoob plaws hauv theem stabilization. Vim tias vasopressin tseem ceeb heev rau kev tswj hwm qhov sib npaug ntawm ntsev thiab dej, conivaptan, vasopressin V1A / V2 receptor antagonist, tuaj yeem pab kho mob euvolemic hyponatremia [3,15]. Tom qab CPM, kev kho tshiab rau cov neeg mob tej zaum yuav tshwm sim. Nws tau raug pom tias plasmapheresis thiab txhaj tshuaj immunoglobulin intravenously txhim kho cov txiaj ntsig. Cov tshuaj steroids, cov tshuaj kho mob tshwj xeeb rau cov tsos mob neurologic lossis neuropsychiatric, thiab kev kho mob hlwb lossis kev coj tus cwj pwm, yog tias muaj kev puas siab puas ntsws polydipsia, yog cov kev kho mob ntxiv.

Cov lus xaus

CPM nrog carbamazepine-induced SIADH yog qhov tsis tshua muaj tshwm sim, nrog kev mob siab thiab kev tuag. CPM tseem yog ib qho mob rau cov kws kho mob hlwb kom paub txog, tshwj xeeb yog siv ntau yam tshuaj neuropsychiatric siv, tshwj xeeb tshaj yog carbamazepine, thiab cov kab mob puas siab puas ntsws uas hyponatremia yog ib qho kev pheej hmoo thiab yuav tsum tau saib xyuas cov ntshav electrolytes. Kev tiv thaiv yog qhov tseem ceeb vim tias kev kho tam sim no tsis tshua muaj txiaj ntsig zoo.

Refrences

1 Lamotte G: Central pontine myelinolysis theem nrab rau kev kho sai ntawm hyponatremia keeb kwm kev xav nrog kws kho mob Robert Laureno. Neurol Sci. Xyoo 2021, 42:3479-83. 10.1007/s10072-021-05301-3

2. Singh TD, Fugate JE, Rabinstein AA: Central pontine thiab extrapontine myelinolysis: kev tshuaj xyuas zoo. Eur J Neurol. Xyoo 2014, 21:1443-50. 10.1111/ib.12571

3. Lambeck J, Hieber M, Dreßing A, Niesen WD: Central pontine melanosis thiab osmotic demyelination syndrome. Dtsch Arztebl Int. Xyoo 2019, 116:600-6. 10.3238.2019.0600

4. King JD, Rosner MH: Osmotic demyelination syndrome. Am J Med Sci. 2 010, 339:561-7. 10.1097/MAJ.0b013e3181d3cd78

5. Alleman AM: Osmotic demyelination syndrome: central pontine myelinolysis thiab extrapontine myelinolysis. Semin Ultrasound CT MR. Xyoo 2014, 35:153-9. 10.1053/j.sult.2013.09. 009 6. Graff-Radford J, Fugate JE, Kaufmann TJ, Mandrekar JN, Rabinstein AA: Clinical thiab radiologic correlations of central pontine myelinolysis syndrome. Mayo Clin Proc. 2011, 86:1063-7. 10.4065/mcp.2011.0239

7. Tan AH, Lim SY, Ng RX: Osmotic demyelination syndrome nrog kev hloov pauv hloov pauv. JAMA Neurol. Xyoo 2018, 75:888-9. 10.1001/jamaneurol.2018.0983

8. Bose P: Central pontine myelinolysis thiab osmotic demyelination syndromes: qhov qhib thiab kaw? Acta Neurol Belg: koj puas xav tau ntau tus thwjtim? Xyoo 2021, 121:849-58. 10.1007/s13760-021-01634-0

9. Kleinschmidt-Demasters BK, Rojiani AM, Filley CM: Central thiab extrapontine myelinolysis: ces ... thiab tam sim no. J Neuropathol Exp Neurol. Xyoo 2006, 65:1-11.

10.1097/01.jnen.0000196131.72302 68 10. Seok JI, Lee DK, Kang MG, Park JH: Neuropsychological tshawb pom ntawm extrapontine myelinolysis yam tsis muaj central pontine myelinolysis. Behav Neurol. Xyoo 2007, 18:131-4. 10.1155/2007/980643

11. Norenberg MD: Central pontine myelinolysis: keeb kwm thiab kev xav txog kev siv tshuab. Metab Brain Dis. Xyoo 2010, 25:97-106. 10.1007/s11011-010-9175-0

12. Peri A: Kev tswj ntawm hyponatremia: ua rau, kev kho mob, kev kuaj mob sib txawv thiab kev kho mob. Tus kws tshaj lij Rev Endocrinol Metab. Xyoo 2019, 14:13-21. 10.1080/17446651.2019.1556095 PAB

13. Odier C, Nguyen DK, Panisset M: Central pontine thiab extrapontine myelinolysis: los ntawm qaug dab peg thiab lwm yam tshwm sim rau kev txawj ntse prognosis. J Neurol. Xyoo 2010, 257:1176-80. 10.1007/s00415-010-5486-7

14. Pasantes-Morales H, Cruz-Rangel S: Kev tswj lub hlwb ntim: osmolytes thiab aquaporin foundations. Neuroscience. Xyoo 2010, 168:871-84. 10.1016/j.neuroscience.2009.11.074

15. Lohrberg M, Winkler A, Franz J, et al.: Tsis muaj astrocytes cuam tshuam parenchymal oligodendrocyte precursor hlwb los ntawm kev ncav cuag lub xeev myelinating hauv osmolyte-induced demyelination. Acta Neuropathol Sib Tham. Peb Hlis 2020, 8:224. 10.1186/s40478-020-01105-2

16. Crosland L, Longcroft-Wheaton G, Fraser J, Pob zeb A: Antidepressants, thiazide diuretics, thiab cawv: central pontine myelinolysis tos kom tshwm sim? Br J Hosp Med (Lond). Xyoo 2009, 70:296-7. 10.12968/hmed.2009.70.5.42237

17. Saner FH, Koeppen S, Meyer M, et al.: Kev kho mob ntawm central pontine myelinolysis nrog plasmapheresis thiab immunoglobulins hauv daim siab hloov neeg mob. Transpl Int. Xyoo 2008, 21:390-1. 10.1111/j.1432-2277.2007.00608.x