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| LETTER TO EDITOR |
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| Year : 2021 | Volume
: 69
| Issue : 1 | Page : 209-210 |
Pituitrin-induced Extrapontine Myelinolysis without Rapid Osmolar Shifts
Jie-Ping Lu1, Cheng-You Wang2, Qi-Qiang Tang1
1 Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
2 Department of Neurology, Tongling People's Hospital, Tongling, Anhui, China
| Date of Submission | 21-Jul-2019 |
| Date of Decision | 04-Nov-2019 |
| Date of Acceptance | 22-Jan-2020 |
| Date of Web Publication | 24-Feb-2021 |
Correspondence Address:
Jie-Ping Lu
Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, NO.17, Lujiang Road, Luyang District, Hefei, Anhui 230001
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.310101
How to cite this article:
Lu JP, Wang CY, Tang QQ. Pituitrin-induced Extrapontine Myelinolysis without Rapid Osmolar Shifts. Neurol India 2021;69:209-10 |
Sir,
The osmotic demyelination syndrome (ODS), an uncommon disorder comprising of central pontine myelinolysis and extrapontine myelinolysis (EPM), is primarily related to the aggressive osmolar correction.[1],[2] In addition to the rapid osmolarshifts, ODS has an increasing risk in patients with alcoholism, malnutrition, liver transplantation, hemodialysis, severe burns, etc.[3] There have been a few reports of ODS caused by the rapid correction of hyponatremia associated with pituitrin/deamino arginine vasopressin.[4],[5],[6],[7] Herein, we describe a patient presenting with encephalopathy and delayed-onset dystonia, but without any preceding rapid osmolar shifts or other common risk factors of ODS following the intravenous administration of pituitrin.
A 37-year-old woman was admitted to neurology department with three days of insomnia, psychiatric symptoms, and gait disorder. Eleven days earlier, the patient had begun to receive continuously the intravenous injection of pituitrin at a rate of 1.5 U/h via a pump for eight consecutive days because of hemoptysis. During that period, she did not suffer from hyponatremia or rapid osmolar shifts. The patient had no history of poisoning, alcoholism, or malnutrition. Physical examination revealed restlessness, normal orientation, and festinating gait. There was no muscle weakness, abnormal muscle tension, or sensory disturbance. Blood tests showed serum sodium 135 mmol/L. Other serum electrolyte concentrations and ceruloplasmin levels were also within a normal range. Liver and renal function tests showed no abnormality. The slit-lamp examination found no Kayser–Fleischer ring of the cornea. Brain magnetic resonance imaging revealed bilateral caudate nuclei and putamina of low T1 and high T2 signaling, which were consistent with EPM [Figure 1]. The patient received corticosteroid therapy and her clinical conditions improved gradually. She developed delayed-onset dystonia consisting of oromandibular dystonia and spasmodic torticollis 3.5 months later. We treated her with trihexyphenidyl, baclofen, and clonazepam, and she partially responded to this drug treatment. | Figure 1: Brain magnetic resonance imaging showed symmetrical lesions in the basal ganglia. (a) Axial T1-weighted image showed bilaterally symmetrical hypointense areas in the caudate nuclei and putamina (red arrow). (b) Axial T2-weighted image showed bilaterally symmetrical hyperintense areas in the caudate nuclei and putamina (red arrow)
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Pituitrin, extracted from the posterior pituitary, consists of oxytocin and vasopressin. It is often used in the treatment of gastrointestinal and pulmonary hemorrhage due to its vasoconstrictive properties. Hyponatremia is a rare adverse event of vasopressin administration, and attention should be drawn especially when high-dose therapy is used.[8] Patients may develop ODS in case of the rapid correction of hyponatremia induced by vasopressin.[4] Our patient did not experience any rapid osmolar shifts. She also had no other common risk factors for EPM, whereas she received intravenous pituitrin before the onset of neurological symptoms. Therefore, the use of pituitrin was considered as the most probable cause of EPM.
The basal ganglia lack collateral circulation and are susceptible to ischemia. Müller et al. found that therapeutic level arginine vasopressin might significantly reduce the cardiac output and carotid blood flow by increased vascular resistance.[9] Another experimental observation showed arginine vasopressin reduced cerebral blood flow and increased cerebrovascular resistance due to vasoconstriction via activation of vasopressin V1 receptors.[10] Therefore, the pathogenesis of EPM in our case was postulated to be owing to basal ganglion ischemia resulted from the cerebral hypoperfusion associated with pituitrin administration, but the exact mechanism needs to be further studied. In summary, clinicians should be aware that EPM may still occur in patients who receive pituitrin even without rapid osmolar shifts.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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