Intravenous Immunoglobulin Use In Treatment Of Central Pontine Myelinolysis: A Case Report (P1.168)

Objective: Not Applicable Background: Central Pontine Myelinolysis (CPM) occurs due to rapid osmotic shifts causing demyelination in central pons due to rapid correction of hyponatremia most likely in the setting of alcoholism, liver/renal dysfunction, malnutrition causing craniopathies, quadriparesis, seizures, and encephalopathy. Symptoms and signs are typically delayed for 2 to 6 days after the sodium shifts, and can lead to permanent neurologic sequelae. Thus far, no specific treatment exists and patients are managed symptomatically. Literature reports indicate favorable outcomes in only 50–67% patients on long term (u003e2 years) follow up. Design/Methods: Our patient is a 50 year old male with hypertension, history of tobacco and alcohol abuse, admitted with severe aortic stenosis, complicated by alcohol withdrawal, pneumonia and acute kidney injury. He was treated with benzodiazepines, broad spectrum antibiotics, and fluid resuscitation. On Hospital Day (HD) 10, he had to be intubated for airway protection due to acute confusion and quadriparesis. His blood work was notable for wide fluctuations in serum sodium, from 131 on admission to 155 on HD7 to 146 on HD10. Otherwise, laboratory evaluation was remarkable only for mildly elevated AST and serum creatinine. MRI brain w/wo contrast 2 days after symptom onset (HD12) showed DWI and FLAIR hyperintensities around central pons bilaterally crossing midline. EEG showed severe generalized slowing. Diagnosis of CPM was made and intravenous immunoglobulin (IVIG) (0.4 g/kg/day for 5 days) was initiated within 4 days of symptom onset, on HD14. Results: After initiation of IVIG, patient showed rapid improvement, first noted in the bilateral upper extremities. By HD20, i.e. 6 days after initiation of IVIG, he was able to be successfully extubated. Prior to discharge he had regained 3–4/5 strength in all extremities. Neuropsychology testing at 1 month follow up after administration of IVIG demonstrated intact cognition. Conclusions: We describe a case of rapid clinical improvement in CPM following treatment with IVIG. In addition to ours, 5 similar cases have been reported, in which beneficial outcomes were demonstrated following prompt initiation of IVIG. One proposed theory of IVIG being able to change the course of CPM would be through reduction of myelinotoxic antibodies, thus promoting remyelination. Disclosure: Dr. Patel has nothing to disclose. Dr. Kaur has nothing to disclose. Dr. Gupta has nothing to disclose. Dr. Ayman has nothing to disclose. Dr. Hays Shapshak has nothing to disclose.