Table 3.

Characteristics of patients admitted to Geisinger system hospitals with an initial serum sodium <120 mEq/L and osmotic demyelination on magnetic resonance imaging

PatientHospitalInitial Serum; Urine Sodium, mEq/LHyponatremia EtiologyOsmotic Demyelination Risk FactorsInitial TreatmentUrine Output over the First 24 h, mlCorrection >8 mEq/L before MRI (Maximum over 24 h); Actions taken to Slow RiseNeurologic Signs before MRINephrology ConsultTiming of MRI after Initial Na+Site(s) InvolvedOutcome
Patients with incident osmotic demyelination occurring after admission
 Patient 1: 39-yr-old man with alcoholism, presented with pneumonia and encephalopathyAcademic centerSerum 110; urine 46aHypovolemia, beer potomaniaHypokalemia, alcohol use disorder, malnutrition3% Saline3900Yes (12 mEq/L), on day 1; D5W givenUpper extremity spasticity, mutism, encephalopathyYes18 d laterCentral ponsWheelchair bound 1 yr, no neurologic deficits at 4 yrb; alcohol cessation
 Patient 2: 52-yr-old woman with alcoholism, HTN, depression on sertraline presented with lethargyTransfer from OSH to academic centerSerum 98; urine 25Hypovolemia, beer potomania, thiazideHypokalemia, malnutrition, alcohol use disorder0.9% SalineNot documentedYes (11 mEq/L), on day 1; D5W givenHyper-reflexia, ataxia, bilateral lower extremity weakness, confusionYes7 d laterCentral ponsNo neurologic deficits at 3 mob; alcohol cessation
 Patient 3: 52-yr-old woman with alcoholism, depression on mirtazapine presented with seizures and hypotensionNonacademic hospitalSerum 107; urine 52aHypovolemia, beer potomaniaAlcohol use disorder3% Saline, 0.9% saline4300Yes (22 mEq/L), on day 1Lower extremity hyporeflexia, recurrent seizuresNo3 d laterCentral ponsNo neurologic deficits at 2 yrb; ongoing alcohol abuse
 Patient 4: 58-yr-old woman with alcoholism, spinal stenosis, HTN, prior hyponatremia on salt tablets presented with seizure, inebriationNonacademic hospitalSerum 112; urine 114cBeer potomania, thiazideAlcohol use disorder0.9% Saline1100 in an 8-h period, then not documentedYes (15 mEq/L), on day 1Ataxia, lower extremity hyporeflexia, seizureYes14 mo laterCentral ponsGait dysfunction, recurrent episodes of severe hyponatremia and alcohol intoxication; died 4 yr later from sepsis and hepatic encephalopathy
 Patient 5: 38-yr-old man with alcoholism, HTN on thiazide, depression on fluoxetine presented with unsteadiness and acute pancreatitisNonacademic hospitalSerum 113Hypovolemia, beer potomaniaHypokalemia, alcohol use disorder0.9% Saline2300Yes (16 mEq/L), on day 2Decreased visual acuity, hyper-reflexia, ataxiaNo11 d laterCentral pons, bilateral frontal, parieto-occipital, cerebellum, basal ganglia, and external capsulesNo neurologic deficits at 6 mob; ongoing alcohol abuse
 Patient 6: 59-yr-old woman with multiple sclerosis, RA, HTN on thiazide, bipolar disorder on quetiapine and mirtazapine presented with encephalopathy, hypotension, and blurred visionAcademic centerSerum 117; urine <20Hypovolemia, thiazideHypokalemia, malnutrition0.9% Saline3690Yes (13 mEq/L), on day 1; D5W, desmopressinAphasia, lower extremity weaknessYes124 d laterCentral pons, bilateral cerebral white matter, not seen on prior MRI before rapid correctionDeath at 1 yr from septic shock due to clostridium difficile colitis
 Patient 7: 36-yr-old woman with alcoholism presented with shortness of breath, severe anemiaTransfer from OSH to academic centerSerum 115; urine <10HypervolemicHypokalemia, malnutrition, alcohol use disorder, end stage liver disease (MELD score 29)0.9% Saline, 3% saline515Yes (9 mEq/L), on day 3Seizure, generalized weaknessYes18 d laterCentral pons, bilateral thalamus, subinsular regionsLost to follow-up
 Patient 8: 69-yr-old woman with diffuse large B cell lymphoma, prior hyponatremia presented with shortness of breath, malignant pleural effusionAcademic centerSerum 118HypovolemiaPrior hyponatremia0.9% Saline175No (7 mEq/L) but sodium 105 and 132 mEq/L in prior month at OSH without documentation of timingEncephalopathy, seizureNo14 d laterCentral pons, bilateral basal gangliaNo neurologic deficitsb
Patient with osmotic demyelination occurring before hospitalization with severe hyponatremia
 Patient 9: 32-yr-old man with depression, heavy alcohol use presented with 5 d of dysarthria and ataxia; also reported salt craving and high salt intake in the 2 wk before presentationTransfer from OSH to academic centerSerum 118; urine <10Hypovolemia, beer potomaniaHypokalemia, alcohol use disorder, malnutrition0.9% Saline977No (7 mEq/L); D5WcAtaxia, dysarthria, dysmetria, intention tremor, opsoclonusYes<24 h laterCentral pons, cerebellumLost to follow-up
  • MRI, magnetic resonance imaging; Na+, sodium; D5W, dextrose 5% in water; HTN, hypertension; OSH, outside hospital; RA, rheumatoid arthritis; MELD, model for end stage liver disease.

  • a Checked after receiving 3% saline.

  • b Per follow-up progress notes.

  • c On salt tablets as outpatient.