Central pontine myelinolysis laboratory findings
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]
Overview
Laboratory Findings
Laboratory findings consistent with the diagnosis of central pontine myelinolysis include:[1]
- Hypoosmotic hyponatremia
- The rapid correction of hyponatremia is the cause of central pontine myelinolysis.
- The Common causes of hyponatremia include:
- Etiologies of SIAD:
Conditions | |
---|---|
Malignant disorders | Carcinoma: Lung ( small cell carcinoma, mesothelioma), oropharynx, stomach, duodenum, pancreas, ureter, bladder, prostate, endometrium, thymoma
Lymphomas Sarcomas: Ewing's sarcoma Olfactory neuroblastoma |
Pulmonary diseases | Infections: Bacterial pneumonia, viral pneumonia, pulmonary abscess, tuberculosis, aspergillosis
Others: Asthma, cystic fibrosis, respiratory failure, emphysema, COPD, positive-pressure ventilation |
CNS disorders | Infections: Encephalitis, meningitis, brain abscess, RMSF, AIDS, malaria
Vascular and SOP: Subarachnoid hemorrhage, stroke, brain tumors, head trauma Others: Hydrocephalus, cavernous sinus thrombosis, Multiple sclerosis, Guillain–Barré syndrome, Shy–Drager syndrome, delirium tremens, acute intermittent porphyria, chronic psychosis, pituitary stalk section, transsphenoidal adenomectomy |
Other causes | Hereditary: Gain-of-function mutation of V2 receptors
Idiopathic Transient: Exercise, general anesthesia, nausea, pain, stress |
- Causes of acute hyponatremia:
Etiology |
---|
|
( Etiologies that cause hyperacute and acute hyponatremia are applicable to each category interchangeably depending on the onset of symptoms)
- Causes of Hyponatremia based upon Serum Osmolality:
Classification | Serum Osmolality | Etiology |
---|---|---|
Hypertonic or Isotonic Hyponatremia | > 295 mOsm/kg | Hyperglycemia‡, Mannitol, Glycine, Maltose, severe azotemia |
Isotonic Hyponatremia
(Pseudohyponatremia) |
275 – 295 mOsm/kg | Lab/blood draw error, Post TURP (bladder irrigation with osmotic solutions),
intravenous immunoglobulin (IVIg), Hyperlipidemia ( triglyceride, cholesterol ), hyper paraproteinemia (monoclonal gammopathy of undetermined significance (MGUS), multiple myeloma), |
Hypotonic Hyponatremia | < 275 mOsm/kg | Glycerol, Sorbitol, Etiology depends upon volume status (Hypervolemic/ Euvolemic/ Hypovolemic) |
Alcohol, Urea, Ethylen glycol are ineffective osmoles, cause hyperosmolar isotonic serum but not hyponatremia. |
‡ Hyperglycemia causes osmotic diuresis results in a rise in serum sodium concentration, on the other hand it leads to extracellular shift of water due to osmotic gradient which causes relative hyponatremia , depends on which effect is stronger, there would be hypertonicity or hypotonicity[2].
- Causes of Hyponatremia based on volume status [3] :
Volume status | Sodium status | Causes |
---|---|---|
Hypovolemic
Hyponatremia[4] |
|
bicarbonaturia ( renal tubular acidosis, metabolic alkalosis), osmotic diuresis, diuretic use, cerebral salt-wasting syndrome (Stroke ,SAH ,↑ brain natriuretic peptide and ↑ renal sodium loss )
|
Hypervolemic
Hyponatremia |
|
(due to relatively higher water versus salt intake and poor excretion), nephrotic syndrome
|
Euvolemic
Hyponatremia |
|
postoperative nausea, pain, stress, neoplasia (common), trauma, pregnancy) , nephrogenic SIAD (Gain-of-function mutation of v2 receptors)
(caused by a low intake of solutes with relatively high fluid intake)
|
† Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors
- Drugs which cause hyponatremia:
Drug Mechanisms [5] | Drug Classification |
---|---|
Increase ADH secretion | Antidepressants:Tricyclic antidepressants ( Amitryptiline,
Protriptyline, Desipramine),Selective serotonin reuptake inhibitors, Antipsychotic drugs: Phenothiazines (Thioridazine, Trifluoperazine), Antiepileptic drugs: Carbamazepine, Oxcarbazepine, Sodium valproate Anticancer agents: Vinca alkaloids (Vincristine, Vinblastine), Platinum compounds (Cisplatin, Carboplatin) Alkylating agents: Intravenous Cyclophosphamide, Melphalan, Ifosfamide Miscellaneous: Methotrexate, Interferon, Levamisole, Pentostatin, Monoclonal antibodies, MDMA, Nicotine Opiates |
Increase ADH effect | Antiepileptic drugs: Carbamazepine, Lamotrigine
Antidiabetic drugs: Chlorpropamide, Tolbutamide Anticancer agents: Alkylating agents (Intravenous cyclophosphamide) NSAIDS |
Drugs affecting water and sodium homeostasis | Diuretics: Thiazides, Indapamide, Amiloride, Loop diuretics |
Reset omostat ‡ | Antidepressants: Venlafaxine
Antiepileptic drugs: Carbamazepine |
Vasopressin analogues | Desmopressin, oxytocin, terlipressin, vasopressin |
‡ Altered sensitivity to serum osmolality by the hypothalamic osmoreceptors
Causes by Organ System
Causes in Alphabetical Order
References
- ↑ Burgetova A, Vaneckova M, Seidl Z, Dolezal O (2008). "Osmotic demyelination syndrome (central pontine and extrapontine myelinolysis with coagulative necrosis of the putamina and cortical laminar necrosis). A case report and review of the literature". Neuroradiol J. 21 (4): 521–6. doi:10.1177/197140090802100409. PMID 24256958.
- ↑ A. I. Arieff & H. J. Carroll (1972). "Nonketotic hyperosmolar coma with hyperglycemia: clinical features, pathophysiology, renal function, acid-base balance, plasma-cerebrospinal fluid equilibria and the effects of therapy in 37 cases". Medicine. 51 (2): 73–94. PMID 5013637. Unknown parameter
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ignored (help) - ↑ Guillaumin, Julien; DiBartola, Stephen P. (2017). "A Quick Reference on Hyponatremia". Veterinary Clinics of North America: Small Animal Practice. 47 (2): 213–217. doi:10.1016/j.cvsm.2016.10.003. ISSN 0195-5616.
- ↑ Rondon-Berrios, Helbert; Agaba, Emmanuel I.; Tzamaloukas, Antonios H. (2014). "Hyponatremia: pathophysiology, classification, manifestations and management". International Urology and Nephrology. 46 (11): 2153–2165. doi:10.1007/s11255-014-0839-2. ISSN 0301-1623.
- ↑ Liamis, George; Milionis, Haralampos; Elisaf, Moses (2008). "A Review of Drug-Induced Hyponatremia". American Journal of Kidney Diseases. 52 (1): 144–153. doi:10.1053/j.ajkd.2008.03.004. ISSN 0272-6386.