Disclosures: Eric A. Liu, DO: Nothing to disclose

Case Description: Our patient with a past medical history of Meckel’s diverticulum, history of small-bowel obstruction, and appendicitis status post appendectomy in 12/2018 presented to the acute care hospital with significant weakness and vomiting. CT imaging of the abdomen showed dilated small bowel concerning for SBO and initial labs demonstrated severe hyponatremia with a serum sodium of 96. On admission, patient had no obvious neurological or motor deficits. Shortly after the correction of severe hyponatremia, the patient developed altered mentation, decreased arousal, and exhibited signs of locked-in syndrome. MRI imaging of the brain demonstrated central pontine myelinolysis (CPM).

Setting: Academic Acute Inpatient Rehabilitation Hospital

Patient: 21-year-old male with central pontine myelinolysis.

Assessment/Results: Initial acute management for CPM included gentle correction of the serum sodium level, hydrocortisone, and IVIG. Locked-in syndrome continued to persist. Plasmapheresis was initiated, which showed immediate improvement in the patient’s command following and ability to move his extremities. He continued to improve functionally with therapy and plasmapheresis. He was transferred to the acute inpatient rehabilitation hospital for an intensive rehabilitation program. After two weeks, he was discharged home at a functional level of supervision for ADLs and close-supervision for transfers and ambulation.

Discussion: Limited case reports discuss using IVIG and plasmapheresis as a viable option in the acute management of CPM. The patients in the other reports were given either IVIG or plasmapheresis. Cases that included patients receiving both IVIG and plasmapheresis were in the setting of post liver transplant. None of the patients presented with a serum sodium level as low as 96.

Conclusion: Outside of supportive therapy, no specific treatment of CPM has been established. Limited reports document the efficacy of using both IVIG and plasmapheresis. This case demonstrates that possibly plasmapheresis and IVIG combined with an intensive rehabilitation program may provide significant improvement in functional outcomes for patients diagnosed with CPM.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/the-use-of-ivig-and-plasmapheresis-in-a-patient-with-central-pontine-myelinolysis-a-case-report/