Monday, January 23, 2012

HISTORY LESSON: Story Behind Central Pontine Myelinolysis

Central Pontine Myelinolysis(CPM) is now well established to be associated with over correction of hyponatremia. It is very interesting to note how that came about. Historically, this is a very fascinating story. Here it is in a bulleted summary.

1959: Adams et al described CPM as a potential disorder. They found it in alcoholics and malnourished and chronically ill individuals. They called it "new disease" and no cases reported prior to those years.
1963:  Aleu and Terry noted that perhaps an iatrogenic agents were involved and that it happened predominately in the hospital setting.
1966: More lesions identified and not localized to the Pons.  It became evident by observation that all had chronic conditions such as liver disease, sepsis, burns, and cancer.
1977: Burcar et al identified 15 cases and 12 had hyponatremia. Overall, 61% of cases of CPM were associated with hyponatremia.
1979: Messert et al made the most important observation that CPM was recognized only after the advent of IV fluids therapy in the late 1950s.  ( reminds us of the MRI and gadolinium association )
1979: Kevin Leslie, a pathology resident was doing an autopsy case of CPM in a jaundiced patient.  He noticed a striking green discoloration in the PONS- likely secondary to breakdown of BBB leading to albumin bound bile pigment to get there.  Review of literature confirmed this in many CPM cases.
1979: Scott Venderberg, pathology resident was reviewing a CPM case.  He mentioned; " could this discoloration be due to osmotic stress?".  This bought to light if the correction of the Na was the factor and not the Na itself.
1980-82: 15 cases of CPM with hyponatremia were reviewed and found that all 15 cases had experienced a 20-30meq/L rise in serum sodium in 3-10 days ( mean of 6 days) before CPM developed.
1982: Similar findings were confirmed in rats made hyponatremic and then given hypertonic saline quickly.
1984: patients with hyponatremia for a short period of time( hours to a few days) did not develop CPM but patients with chronic hyponatremia did.

This is a fascinating history and great discovery. This points to a great observation power of these individuals and putting it together and what is now common knowledge in the Nephrology world.

For a complete reference:

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