Acute psychosis with a favorable outcome as a complication of central pontine/extrapontine myelinolysis in a middle aged man

Abstract

Central pontine myelinolysis is a demyelinating condition affecting the pons characterized by an acute progressive quadriplegia, dysarthria, dysphagia, and alterations of consciousness. Pathologic features include prominent demyelination in the central pons with sparing of axons and neurons. This condition is usually associated with systemic disorders such as hyponatremia, chronic alcoholism, liver failure, severe burns, malignant neoplasms, hemorrhagic pancreatitis, hemodialysis, and sepsis. There are limited reports of psychosis in patients with central pontine/extrapontine myelinolysis (CPEM). We have described a case of CPEM with psychosis as a complication which recovered completely with treatment given for short duration using low dose atypical antipsychotic (quetiapine). We also discuss etiopathology and clinical outcome of psychosis in this rare neurological disorder.

Acute Psychosis as Main Manifestation of Central Pontine Myelinolysis

“…However, several case series and reports have demonstrated that some patients can recover with dependency, independency, or completely [6, 20, 27, 28]. Several case reports have shown reversibility of psychiatric symptoms in CPM with atypical antipsychotic medications [6, 11, 29]; hence, it is recommended that psychiatric manifestations in CPM should be treated with atypical antipsychotics and mood stabilizers, once the patient is neurologically stable. Nevertheless, Vermetten et al have reported that while significant neurologic deficits may be fully reversible, neuropsychological deficits may remain longer after neurological recovery and may even be permanent [4].…”

“…In some patients, parkinsonian features, behavioral manifestations, and neuropsychological symptoms can also be present [2–5]. Pathophysiology of CPM consists of osmotic demyelination in the central pons with relative sparing of axons and neurons and is commonly associated with chronic alcoholism, liver failure, severe burns, malignant neoplasms, hemorrhagic pancreatitis, hemodialysis, and sepsis [6–8]. Rapid correction of hyponatremia has been proven as one of the most common and important etiologic factors [9, 10].…”

“…Rapid correction of hyponatremia has been proven as one of the most common and important etiologic factors [9, 10]. Although central pontine and extrapontine myelinolysis can present with behavioral and neuropsychiatric manifestations, there is limited literature available describing behavioral manifestations (personality changes, labile affect, disinhibition, poor judgment, paranoid delusions, emotional lability, delirium, hallucinations, and catatonia) in patients with CPM without any focal neurological deficits [3–6, 11–13]. Diffusion-weighted MRI (DWI) characteristically shows restricted diffusion in the central pons, and Positron Emission Tomography (PET) scan has been demonstrated to detect central pons hypermetabolism in patients with CPM [14–18].…”

Pontine myelinolysis with an uncommon manifestation of hallucination: a case report

“…The lesion can extend into the tegmentum, and cranial nerve injuries can happen 3 . Mutism, parkinsonism, dystonia, and catatonia can be atypical manifestations 4 .…”

Central Pontine/Extrapontine Myelinolysis Presenting with Manic and Catatonic Symptoms

“…Besides neurological symptoms, CPM may also present with neuropsychiatric symptoms such as personality changes, inappropriate affect, emotional lability, disinhibition, catatonia, psychosis, and delirium, as described in some reports. [234] None of the previous reports have suggested an occurrence of prominent manic symptoms followed by catatonia in patients with central pontine/extrapontine myelinolysis (CPEM). We describe a unique case of an elderly man with such a presentation after rapidly corrected hyponatremia.…”