Parkinsonism and dystonia in central pontine and extrapontine myelinolysis

Abstract

Parkinsonism as well as dystonic signs are rarely seen in central pontine myelinolysis and extrapontine myelinolysis. A 51 year old woman developed central pontine myelinolysis and extrapontine myelinolysis with parkinsonism after severe vomiting which followed alcohol and drug intake, even though marked hyponatraemia had been corrected gradually over six days. Parkinsonism resolved four months after onset, but she then exhibited persistent retrocollis, spasmodic dysphonia, and focal dystonia of her left hand. Although the medical literature documents three similar patients, this patient is diVerent as dystonic symptoms only developed four months after parkinsonian signs had resolved. (J Neurol Neurosurg Psychiatry 1998;65:119-121) Keywords: central pontine myelinolysis; extrapontine myelinolysis; parkinsonism; dystonia Central pontine myelinolysis is a well defined syndrome characterised by various degrees of tetraparesis and brain stem symptoms as a sequel of rapid correction of electrolyte disturbances, hyponatraemia in particular. In more severe cases, additional demyelination may occur in extrapontine locations, giving rise to parkinsonian signs and symptoms. Tomita et al recently reported on a patient with extrapontine myelinolysis, exhibiting symptoms of parkinsonism and dystonia in his fingers.1 Here we report a case in which parkinsonism and dystonia occurred sequentially within a period of four months and speculate that preclinical damage due to regular alcohol intake might have predisposed our patient to develop dystonic signs only after parkinsonism had subsided. Case reportA 51 year old female patient with a history of repeated alcohol and drug misuse was admitted with severe and persisting vomiting after alcohol and drug intake. She became increasingly weak and drowsy and was only able to take a few assisted steps. Gastroscopy showed haemorrhagic gastritis and duodenitis. The admission values for serum sodium, chloride, and potassium were 93 mmol/l, 58 mmol/l, and T2 weighted images show a symmetric signal increase in the central pons region, putamen, caput nuclei caudati, and lateral thalamus.

Catatonia and Parkinsonism due to extrapontine myelinolysis following rapid correction of hyponatremia

“…However, occasional reports of Parkinsonism as the most prominent clinical feature in extrapontine myelinolysis with or without central pontine involvement have been published in recent years [3,5,9,11,13]. To our knowledge, catatonia was reported in only one case [2].…”

“…Later on, few similar cases were reported in adults [5,11,13,14] and rarely in children [9]. Rapid correction of hyponatremia preceded by days to weeks the onset of the parkinsonian syndrome [3,13].…”

Alcoholic Case of Central Pontine Myelinolysis with Mainly Cerebellar Signs

“…According to the fi ndings in the literature, CPM is usually related to rapid correction of hyponatremia [2,3,6] . However, at least 2 alcoholic cases reported as CPM were presented as normonatremic [4,5] , and in 1 study none of the 3 alcoholic cases with severe hyponatremia developed CPM [7] .…”

Mielinólise pontina central e extra-pontina em paciente alcoolista sem distúrbios hidro-eletrolíticos: relato de caso

“…Em 1993, Karp e Laureno 12 descreveram a persistência dos sintomas de disfunção bulbar e tetraparesia espástica como sequelas frequentes. A longo prazo, alguns pacientes apresentaram mudanças de comportamento, alterações cognitivas e distúrbios do movimento 22 . O presente relato mostra um paciente com MPC/MEP com boa recuperação clínica, não se podendo fazer qualquer ilação acerca do uso de pulsoterapia com corticosteróides.…”