Acute Disseminated Encephalomyelitis, Transverse Myelitis and Central Pontine Myelinolysis

by Carlo Raj, MD

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    00:02 Our topic here is acute disseminated encephalomyelitis.

    00:06 So, what does this mean to you? If you take a look at the picture here, were affecting the spinal cord and were affecting the parenchyma, as well of the brain.

    00:13 It’s a monophasic demyelinating disease that most commonly will be following a viral infection or a patient has received immunization.

    00:24 That’s important.

    00:25 It’s got acute disseminated encephalomyelitis.

    00:28 Please look for a viral infection, and then following which may result in a demyelinating disease.

    00:35 Symptoms develop a week or two after the antecedent infection.

    00:40 Diffuse brain involvement: headache, lethargy, coma in some cases.

    00:45 Prognosis: Well, here, recovery typically near complete, thank goodness, because here for the most part, as long as you’re able to properly provide the supportive therapy for the viral infection, then perhaps, this particular issue goes away.

    00:57 Less than one-third, however, will go on to multiple sclerosis in the future.

    01:01 So, keep that in mind as well.

    01:03 We want to think of this of being, perhaps, something like pre-multiple sclerosis, if that helps you.

    01:08 This one's important, pay attention to ADE viral infection.

    01:16 This is transverse myelitis.

    01:18 I’ll give you one clinical pearl.

    01:21 Stay away from the brain in this condition, okay? The reason I say that is if you say myelo-, you’ll notice there’s no encephalo-.

    01:29 In addition, take a look at the schematic here.

    01:32 There’s no brain pictured here on purpose.

    01:35 So, it’s the demyelinating event restricted to the spinal cord.

    01:40 Way back when, when we talked about spinal cord pathology or when you have reviewed it, we talked about transverse myelitis as being a possible cause of trauma to the spinal cord.

    01:51 Here you have it.

    01:52 There’s no evidence of brain lesion.

    01:53 That is the absolute clinical pearl that you want to take out of this.

    01:57 It can be in isolation or associated with autoimmune disorders such as Sjogren's, you have your la, right? What am I talking about? Your SSA, ro and la.

    02:08 SSA is going to be your ro, whereas, SSB will be your la.

    02:14 It’s extremely important when you do autoimmune diseases with Sjogren's.

    02:18 Treated with steroids and plasmapheresis.

    02:22 Why? Because you’re thinking about autoimmune diseases.

    02:25 And can be recurrent This is called transverse myelitis.

    02:28 Look for autoimmune diseases.

    02:30 For the most part, inflammation of the spinal cord with no involvement of the brain.

    02:39 Our next topic.

    02:40 Your patient comes in and, well, was taking carbamazepine.

    02:45 Why? To treat, perhaps, trigeminal neuralgia.

    02:49 It has a side effect.

    02:50 We get labs, and on the labs, this shows that your sodium level is 125.

    02:56 Would you please put together carbamazepine and sodium level that is, what? Decreased.

    03:02 Hyponatremia.

    03:04 That’s your patient that’s coming in with hyponatremia.

    03:06 You want to correct this, you want to correct this unbeknownst to the resident, unbeknownst to the intern.

    03:13 Get all anxious and extremely happy and wanting to correct this.

    03:18 So therefore, too rapidly, corrects the hyponatremia, and in the process, results in a condition called central pontine myelinolysis.

    03:32 What’s happening? Allow the name to speak to you.

    03:35 The pons.

    03:36 You’re in the brain stem.

    03:38 What’s happening in the central portion of the pons? If you take a look at the picture here, it clearly tells you what’s happening.

    03:44 The lesion is in the central portion of pons.

    03:46 What’s happening? Demyelination.

    03:48 Why? Well, there are many theories out there.

    03:51 At this point, what you’re correcting for too rapidly was the hyponatremia.

    03:57 So, what was I trying to say with carbamazepine? Carbamazepine causes side effect of SIADH, syndrome of inappropriate antidiuretic hormone.

    04:07 With too much ADH, what then happens to your sodium levels? Hyponatremia.

    04:12 And if you want to correct it too quickly, there’s every possibility that the patient may suffer from central pontine myelinolysis.

    04:18 That’s unfortunate.

    04:19 This whole thing could have been prevented.

    04:22 And really, the next step of management was to take the patient off the carbamazepine in this particular case.

    04:29 It could be also seen with alcoholics, anything that causes hyponatremia, and there’s rapid correction.

    04:35 It is the basis pontis classically, but it could be other sites as well, keep that in mind.

    04:40 Never, never correct your hyponatremia too rapidly.

    04:44 Presents what? Look at this, look at the manifestations.

    04:48 It’s devastating, it’s tetraplegia, quadriplegia, the patient loses all ability to move.

    04:55 “I’m locked in.” Isn’t that a horrible feeling? You have all your limbs, you’re completely aware but yet, you can’t move anything.

    05:02 Could you imagine how the patient is going to feel? Because, not you, but someone that you know rapidly corrected the hyponatremia.

    05:13 Common presentation.

    05:16 What are you going to find? Acute paralysis, maybe dysarthria, difficulty with speaking, and dysphagia, you’ve knocked out the brain stem.

    05:24 Holy cow! No joke.

    05:25 What happened? Don’t correct the serum sodium to more than 10 units for 24 hours, clear? Memorize that, memorize that, and only then are you permitted to move on.

    About the Lecture

    The lecture Acute Disseminated Encephalomyelitis, Transverse Myelitis and Central Pontine Myelinolysis by Carlo Raj, MD is from the course Multiple Sclerosis. It contains the following chapters:

    • Acute Disseminated Encephalomyelitis
    • Central Pontine Myelinolysis

    Included Quiz Questions

    1. Sjogren's syndrome
    2. Rheumatoid arthritis
    3. Systemic lupus erythematosus
    4. Scleroderma
    5. Wegener's granulomatosis
    1. Acute disseminating encephalomyelitis
    2. Central pontine mylelinosis
    3. Transverse myelitis
    4. Japanese encephalitis
    5. Syringomyelia
    1. Central pontine myelinosis
    2. Transverse myelitis
    3. Acute disseminated encephalomyelitis
    4. Hydrocephalus
    5. Wernicke's encephalopathy

    Author of lecture Acute Disseminated Encephalomyelitis, Transverse Myelitis and Central Pontine Myelinolysis

     Carlo Raj, MD

    Carlo Raj, MD

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    very good learning resource
    By Niamh D. on 31. March 2018 for Acute Disseminated Encephalomyelitis, Transverse Myelitis and Central Pontine Myelinolysis

    this lecture is great, good level of detail and well explained!