A 44-Year-Old Alcohol-Dependent Man Who Recovered from Central Pontine Myelinolysis with Supportive Physical Therapy

Abstract

Patient: Male, 44-year-old Final Diagnosis: Central pontine myelinolysis Symptoms: Bulbar paralysis • locked-in syndrome • tetraplegia Medication: — Clinical Procedure: Brain MRI Specialty: Neurology • Rehabilitation Objective: Unusual clinical course Background: Central pontine myelinolysis (CPM) includes symmetric demyelination of the central pons. CPM is a rare neurological disorder that generally develops after rapid correction of hyponatremia in individuals having underlying conditions, such as malnutrition, alcoholism, and severe burns. It can cause severe long-term disabilities. However, there is currently no pharmacotherapy capable of promoting remyelination, a process crucial for recovery from CPM. We present the case of a patient with alcoholism and malnutrition-related CPM, which developed following rapid correction of hyponatremia but then improved remarkably with supportive physical therapy. Case Report: A 44-year-old alcoholic and malnourished man was admitted to an emergency hospital for disorientation due to overdrinking, but later developed bulbar palsy after hyponatremia was unexpectedly, but rapidly, corrected. Axial scans of the diffusion-weighted brain MRI revealed a characteristic lesion known as a piglet sign in the central pons. Based on his underlying conditions, present episode of sodium correction, and MRI finding, the patient was diagnosed as having CPM, which progressively worsened, resulting in locked-in syndrome after 12 days. The patient was then transferred to a long-term care unit and received simple motion exercise daily, but no specific medication. His symptoms gradually improved, achieving discontinuation of tube feeding on day 21, independent walking on day 110, and discharge after 6 months. Conclusions: This report highlights the importance of physical therapy, the potential of which is often underestimated despite its broad benefits for human health, as a readily applicable intervention for patients with CPM. Further understanding of mechanisms underlying exercise-induced myelination should contribute to establishing novel therapies for a wide spectrum of brain disorders.

Physical Exercise Counteracts Aging-Associated White Matter Demyelination Causing Cognitive Decline

“…While pharmacotherapies targeting myelination have not been established yet, recent studies have demonstrated that PE can help myelinate brains [15,[34][35][36], suggesting a novel PE-based mechanism for counteracting cognitive decline in AD. In support of this view, some reports have indicated the therapeutic potential of PE to promote remyelination in demyelinating disorders, such as MS and central pontine myelinolysis [37][38][39][40].…”

Physical activity and the brain myelin content in humans

“…Based on the available literature, it seems that two relatively firm conclusions can be made: (1) an active lifestyle is associated with augmented myelin content in the human brain and (2) with the use of intense aerobic exercise myelin expansion can be achieved in healthy subjects throughout the entire adult lifespan. One small study in patients with Huntington’s disease ( Casella et al, 2020 ) and a case report describing a subject with central pontine myelinolysis ( Tobiume et al, 2022 ) may suggest that even not very intensive but regular physical activity can result in remyelination in the brain areas affected by demyelination. Active life style also seems to be neuroprotective in stroke patients ( Greeley et al, 2022 ).…”

“…The central pontine piglet sign was clearly defined in T2W and T1W images 11 weeks after disease onset. The diagnosis was based on radiological examination (MRI) and clinical signs and symptoms ( Tobiume et al, 2022 ). Rehabilitation was not particularly specific or sophisticated, as no specialized equipment was used (commonly available aids such as a chair, parallel bars, a walker and a cane were applied), but it was regular (about 1 h daily).…”

Case Report: Quantitative Evaluation of Gait Function Following Treatment Progression in a Patient with Central Pontine Myelinolysis

“…Foot rotation Defined as the angle of the foot during walking. It acts as a pivotal criterion for the identification of normal versus abnormal gait patterns 13 .…”