Prolonged Altered Mental Status in a Diabetic Hemodialysis Patient

Abstract

Osmotic demyelination syndrome (ODS) is a demyelinating disorder of the central nervous system. It usually occurs with rapid correction of severe chronic hyponatremia. ODS is rarely seen as a complication of hyperglycemia. Herein, we report a rare presentation of ODS secondary to hyperosmolar hyperglycemic state. A 28-year-old female with type 1 diabetes, hypertension, seizure disorder, and end-stage renal disease on hemodialysis was brought from a shelter with two days of unresponsiveness and developed ODS after hyperosmolar hyperglycemic state in long-standing uncontrolled diabetes with normal serum electrolyte levels.

Occurrence of osmotic demyelination syndrome in diabetes mellitus: A case report and literature review of various etiologies for osmotic demyelination syndrome

“…Occurrence of ODS having complicated DM as its underlying cause is rare, and we could identify only 16 such cases reported in English literature till date. 6 – 21 In a recent case report by Kusumoto et al, 6 malnutrition and severe illness with fluctuations in osmolarity were also considered risk factors for onset of ODS which was ruled out in our case.…”

“…Occurrence of ODS having complicated DM as its underlying cause is rare, and we could identify only 16 such cases reported in English literature till date. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] In a recent case report by Kusumoto et al, 6 malnutrition and severe illness with fluctuations in osmolarity were also considered risk factors for onset of ODS which was ruled out in our case. Demyelination involves region-specific oligodendrocytes, that is, oligodendrocytes of pons, basal ganglia, mesencephalon and deep cortical layers.…”

“… 1 All the 16 patients in our review, including this case, were treated supportively under controlled serum glucose since there is no specific treatment for ODS; however, correction of osmolarity under appropriate correction rate can prevent ODS in case of hyponatremia correction. 1 Two patients 14 , 21 died during the treatment, and others had significant prognosis. Our case presented in healthy state without any neurological deficit in a follow-up after a month of discharge.…”

“…6,7,14–21 Six of these case reports 6,7,14–17 have described that the ODS was caused by rapid correction of serum glucose from hyperglycemic state to normal or hypoglycemic state. Three of these case reports 18,19,21 have stated that the ODS was accompanied by HHS prior to when the patients visited hospitals. Ramineni et al 25 reported ODS in de novo type 2 DM with HHS on presentation suggesting its association even without sodium imbalance and its correction.…”

“…Ramineni et al 25 reported ODS in de novo type 2 DM with HHS on presentation suggesting its association even without sodium imbalance and its correction. Jalalzadeh et al 21 has reported prior history of several hypoglycemic and hyperglycemic states and indicated the fluctuations in serum osmolarity due to corresponding fluctuation in serum glucose concentration as the cause of ODS. Hegazi and Mashankar 20 have indicated severe prolonged hypernatremia secondary to HHS as the cause of ODS.…”