CIRRHOSIS A RARE CAUSE OF CPM

A 74-year-old gentleman with cirrhosis, Type 2 Diabetes Mellitus and peripheral neuropathy developed central pontine Myelinolysis. The man’s history of most recent admissions shows that he was having multiple metabolic disturbances on different occasions like erratic Blood glucose readings, Hyponatremia, hypoalbuminemia, hypokalaemia, and once had hypophosphatemia. He presented to Princess Alexandra Hospital A/E during this admission (November, 2018) with complaint of weakness of legs, slurred speech and progressive dysphagia for 1 week. His Neurological examination mandated the MRI head with focus on posterior fossa lesions. The MRI was reported as having central pontine myelinolysis with rest of brain studies being normal. His further tests on viral serology, infection screening, TSH level, Vitamin B12 level, Folic acid level and autoimmune screening were all normal. Lumbar Puncture reported to be having elevated proteins while xanthochromia screening shown high bilirubin and Oxyhaemoglobin. There were no further evidences to suggest subarachnoid haemorrhage as well. Patient’s CPM was correlated clinically to metabolic disturbances and corrective measures taken for those derangements during recent admissions to hospital and all of these derangements were either directly or indirectly caused by Liver Cirrhosis. Background: A commonly understood cause of central pontine myelinolysis is sudden correction of hyponatremia with fluids which would increase serum osmolality rapidly. In patients with decompensated liver disease and Diabetes few more rare causes need to be considered which put them at risk of CPM. It is well known that Cirrhosis patients are mostly hyponatremic due to multiple pathophysiological phenomena and due to diuretics they consume for ascites management. If these patient undergo osmolar corrections it is vital to consider that osmolality is not only controlled by sodium but also by Glucose, potassium and salbumin which, if are deranged too, they would increase the risk of CPM