Letter to the Editor
Potomania and osmotic imbalance: Permanent cortical visual impairment due to extrapontine myelinolysis
Potomanía y desequilibrio osmótico: Ceguera cortical definitiva por mielinólisis extrapontina
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Domínguez, N. Laguarde, E. Pinkala, S.E. González" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R.O." "apellidos" => "Domínguez" "email" => array:1 [ 0 => "dominguezraulo@yahoo.com.ar" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Laguarde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Pinkala" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "S.E." "apellidos" => "González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Neurología, Hospital Sirio Libanés, Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina Interna, Hospital Sirio Libanés, Buenos Aires, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Potomanía y desequilibrio osmótico: Ceguera cortical definitiva por mielinólisis extrapontina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 832 "Ancho" => 900 "Tamanyo" => 100174 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">FLAIR Brain MRI. Axial slice showing bilateral extensive hyperintense cortical and subcortical lesions (white arrows) in both occipital lobes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Potomania or psychogenic polydipsia is characterised by excessive drinking of liquids, such as water (polydipsia) or alcohol (dipsomania). Excessive drinking may lead to hyponatraemia (HNa) even in patients presenting no organic, metabolic, or toxic diseases.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Central pontine myelinolysis (PM) and extrapontine myelinolysis (EPM) have numerous manifestations and affect different areas (generally symmetrical areas). Myelinolysis is mainly caused by hyponatraemia and the means used to correct it; to a lesser extent, it may be caused by association with hypokalaemia. We present the case of a woman aged 72 who was admitted to the hospital in a coma 3<span class="elsevierStyleHsp" style=""></span>hours after its onset. Coma was preceded by disorientation and progressive stupor developing in the preceding 6<span class="elsevierStyleHsp" style=""></span>hours. The patient presented decreased muscle tone in all limbs, deep tendon areflexia, lack of Babinski sign, and bilateral plantar reflex due to pain. The oculocephalic, corneal, and photomotor reflexes were present. The Glasgow coma scale score was 6/15. Studies showed no renal, cardiac, or hormonal disorders. The patient had a history of non-alcoholic potomania in the preceding 6 months (water intake of 4 to 6 litres daily). She was in psychotherapy and undergoing treatment with quetiapine (50<span class="elsevierStyleHsp" style=""></span>mg/day). This treatment was beneficial for 5 months, after which potomania appeared again. Blood tests revealed hyponatraemia of 111<span class="elsevierStyleHsp" style=""></span>mM/L and hypokalaemia of 2.2<span class="elsevierStyleHsp" style=""></span>mM/L. The rest of the results were anodyne. The ECG showed sinus rhythm, a heart rate of 85 beats per minute, ST segment deviation, and flat T wave. The computed tomography (CT) performed in the first 12<span class="elsevierStyleHsp" style=""></span>hours yielded normal results. Natraemia was corrected at a rate of 9<span class="elsevierStyleHsp" style=""></span>mM/L/day; kalaemia was corrected by administering 5<span class="elsevierStyleHsp" style=""></span>mM/h of potassium chloride intravenously. The patient awoke 48<span class="elsevierStyleHsp" style=""></span>hours later with a confusional state, flexor withdrawal reflex in all 4 limbs, and purposeless hand movements. The Glasgow coma scale score was 12/15. At this time, natraemia was 127<span class="elsevierStyleHsp" style=""></span>mM/L and kalaemia, 3.7<span class="elsevierStyleHsp" style=""></span>mM/L. Doctors suspected bilateral vision loss since stimulating visual fields with rapid, nearby movements elicited no blink reflex. The brain MRI carried out on the third day of hospitalisation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed occipital lesions. There were no changes in the pons or the cerebral/cerebellar hemispheres. Blood test showed normal results on the 10th day after admission. Another brain MRI showed similar changes and the angiography of the neck vessels and intracranial arteries yielded normal results. In the fourth week of hospitalisation, the patient presented no cognitive decline, but cortical blindness had not abated. She was lucid and aware of her visual impairment. There are 2 main causes of hyponatraemia: net increase in water (total sodium remains normal), and sodium loss. Although the mechanisms often coexist, one is frequently predominant. In our case, psychogenic polydipsia triggered dilutional hyponatraemia; researchers found no primary diseases inducing potomania or hyponatraemia. PM is suspected when the patient presents severe manifestations (disorientation, stupor and coma, tetraparesis) or a history of malnutrition, alcoholism, or polydipsia. Myelinolysis is due to oligodendrocyte death, which is favoured by the predominance of proapoptotic factors.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> EPM presents similar pathological changes characterised by predominantly extrapyramidal manifestations, such as parkinsonism, dystonia, dyskinesias, and spasmodic dysphonia. According to a recent publication, EPM lesions are symmetrically arranged and located in the basal ganglia.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We did not find any reports of osmotic myelinolysis with definitive amaurosis in the posterior half of the brain. The literature includes only one case of blindness due to optic nerve atrophy and one other case of transient vision loss due to osmotic changes resulting from an altered ammonium cycle.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> In cases of dipsomania, excessive beer intake may trigger hyponatraemia,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which is sometimes accompanied by PM<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>; likewise, alcohol withdrawal syndrome may cause PM and EPM without associated hyponatraemia.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In cases of asymptomatic normovolaemic hyponatraemia, guidelines suggest that correction should not exceed 10 to 12<span class="elsevierStyleHsp" style=""></span>mM/L per day.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The presence of PM and EPM associated with hyponatraemia is a formidable cause of death and disability. This letter points out a new sequela of EPM, stressing that potomania is a risk factor that can be modified to prevent the consequences described here.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Domínguez RO, Laguarde N, Pinkala E, González SE. Potomanía y desequilibrio osmótico: Ceguera cortical definitiva por mielinólisis extrapontina. Neurología. 2013;28:449–450.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 832 "Ancho" => 900 "Tamanyo" => 100174 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">FLAIR Brain MRI. Axial slice showing bilateral extensive hyperintense cortical and subcortical lesions (white arrows) in both occipital lobes.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Psychogenic polydipsia with hyponatremia: report of eleven cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 0 | 9 |
| 2024 October | 36 | 13 | 49 |
| 2024 September | 55 | 23 | 78 |
| 2024 August | 46 | 14 | 60 |
| 2024 July | 53 | 7 | 60 |
| 2024 June | 75 | 4 | 79 |
| 2024 May | 106 | 6 | 112 |
| 2024 April | 53 | 4 | 57 |
| 2024 March | 68 | 7 | 75 |
| 2024 February | 76 | 7 | 83 |
| 2024 January | 125 | 6 | 131 |
| 2023 December | 114 | 11 | 125 |
| 2023 November | 175 | 17 | 192 |
| 2023 October | 139 | 9 | 148 |
| 2023 September | 56 | 3 | 59 |
| 2023 August | 74 | 8 | 82 |
| 2023 July | 84 | 5 | 89 |
| 2023 June | 82 | 7 | 89 |
| 2023 May | 114 | 21 | 135 |
| 2023 April | 86 | 2 | 88 |
| 2023 March | 79 | 6 | 85 |
| 2023 February | 66 | 6 | 72 |
| 2023 January | 74 | 11 | 85 |
| 2022 December | 63 | 6 | 69 |
| 2022 November | 83 | 13 | 96 |
| 2022 October | 91 | 26 | 117 |
| 2022 September | 67 | 13 | 80 |
| 2022 August | 83 | 12 | 95 |
| 2022 July | 67 | 10 | 77 |
| 2022 June | 62 | 12 | 74 |
| 2022 May | 90 | 19 | 109 |
| 2022 April | 74 | 9 | 83 |
| 2022 March | 78 | 12 | 90 |
| 2022 February | 81 | 11 | 92 |
| 2022 January | 130 | 16 | 146 |
| 2021 December | 74 | 13 | 87 |
| 2021 November | 94 | 16 | 110 |
| 2021 October | 99 | 13 | 112 |
| 2021 September | 123 | 15 | 138 |
| 2021 August | 97 | 14 | 111 |
| 2021 July | 70 | 8 | 78 |
| 2021 June | 103 | 18 | 121 |
| 2021 May | 72 | 16 | 88 |
| 2021 April | 110 | 22 | 132 |
| 2021 March | 95 | 26 | 121 |
| 2021 February | 63 | 15 | 78 |
| 2021 January | 76 | 26 | 102 |
| 2020 December | 63 | 13 | 76 |
| 2020 November | 47 | 9 | 56 |
| 2020 October | 38 | 8 | 46 |
| 2020 September | 33 | 7 | 40 |
| 2020 August | 70 | 18 | 88 |
| 2020 July | 24 | 15 | 39 |
| 2020 June | 35 | 6 | 41 |
| 2020 May | 29 | 16 | 45 |
| 2020 April | 22 | 4 | 26 |
| 2020 March | 54 | 12 | 66 |
| 2020 February | 31 | 16 | 47 |
| 2020 January | 24 | 8 | 32 |
| 2019 December | 35 | 11 | 46 |
| 2019 November | 29 | 13 | 42 |
| 2019 October | 30 | 8 | 38 |
| 2019 September | 40 | 1 | 41 |
| 2019 August | 34 | 6 | 40 |
| 2019 July | 39 | 14 | 53 |
| 2019 June | 89 | 29 | 118 |
| 2019 May | 241 | 36 | 277 |
| 2019 April | 83 | 23 | 106 |
| 2019 March | 20 | 12 | 32 |
| 2019 February | 28 | 9 | 37 |
| 2019 January | 24 | 7 | 31 |
| 2018 December | 17 | 16 | 33 |
| 2018 November | 30 | 7 | 37 |
| 2018 October | 37 | 4 | 41 |
| 2018 September | 34 | 7 | 41 |
| 2018 August | 14 | 7 | 21 |
| 2018 July | 10 | 8 | 18 |
| 2018 June | 17 | 7 | 24 |
| 2018 May | 25 | 10 | 35 |
| 2018 April | 16 | 4 | 20 |
| 2018 March | 10 | 2 | 12 |
| 2018 February | 8 | 2 | 10 |
| 2018 January | 14 | 0 | 14 |
| 2017 December | 12 | 3 | 15 |
| 2017 November | 24 | 3 | 27 |
| 2017 October | 30 | 5 | 35 |
| 2017 September | 27 | 5 | 32 |
| 2017 August | 22 | 14 | 36 |
| 2017 July | 12 | 2 | 14 |
| 2017 June | 26 | 20 | 46 |
| 2017 May | 35 | 11 | 46 |
| 2017 April | 26 | 5 | 31 |
| 2017 March | 29 | 19 | 48 |
| 2017 February | 38 | 5 | 43 |
| 2017 January | 23 | 1 | 24 |
| 2016 December | 25 | 11 | 36 |
| 2016 November | 38 | 4 | 42 |
| 2016 October | 56 | 10 | 66 |
| 2016 September | 119 | 11 | 130 |
| 2016 August | 71 | 13 | 84 |
| 2016 July | 21 | 1 | 22 |
| 2016 June | 39 | 9 | 48 |
| 2016 May | 38 | 17 | 55 |
| 2016 April | 31 | 9 | 40 |
| 2016 March | 31 | 25 | 56 |
| 2016 February | 27 | 16 | 43 |
| 2016 January | 21 | 16 | 37 |
| 2015 December | 23 | 12 | 35 |
| 2015 November | 23 | 16 | 39 |
| 2015 October | 55 | 21 | 76 |
| 2015 September | 37 | 10 | 47 |
| 2015 August | 53 | 7 | 60 |
| 2015 July | 33 | 7 | 40 |
| 2015 June | 23 | 5 | 28 |
| 2015 May | 43 | 14 | 57 |
| 2015 April | 39 | 13 | 52 |
| 2015 March | 20 | 14 | 34 |
| 2015 February | 17 | 14 | 31 |
| 2015 January | 34 | 9 | 43 |
| 2014 December | 33 | 9 | 42 |
| 2014 November | 13 | 3 | 16 |
| 2014 October | 18 | 5 | 23 |
| 2014 September | 35 | 3 | 38 |
| 2014 August | 29 | 6 | 35 |
| 2014 July | 52 | 7 | 59 |
| 2014 June | 8 | 1 | 9 |
| 2014 May | 25 | 2 | 27 |
| 2014 April | 13 | 1 | 14 |
| 2014 March | 19 | 6 | 25 |
| 2014 February | 12 | 2 | 14 |
| 2014 January | 18 | 2 | 20 |
| 2013 December | 19 | 5 | 24 |
| 2013 November | 34 | 15 | 49 |
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