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A case of mistaken identity: alcohol withdrawal, schizophrenia, or central pontine myelinolysis?

Authors Schneider P, Nejtek VA, Hurd

Received 25 October 2011

Accepted for publication 25 November 2011

Published 1 February 2012 Volume 2012:8 Pages 49—54

DOI https://doi.org/10.2147/NDT.S27634

Review by Single-blind

Peer reviewer comments 3


Paul Schneider1, Vicki A Nejtek2,3, Cheryl Hurd2,3
1Green Oaks Behavioral Health Care Services, Dallas, 2University of North Texas Health Science Center, Fort Worth, 3John Peter Smith Health Network, Fort Worth, Texas, USA

Abstract: Demyelination is a hallmark of central pontine myelinolysis (CPM). Neuropsychiatric manifestations of this condition include weakness, quadriplegia, pseudobulbar palsy, mood changes, psychosis, and cognitive disturbances. These psychiatric symptoms are also associated with schizophrenia and alcohol withdrawal. Thus, it is clinically relevant to differentiate between CPM, schizophrenia, and alcohol withdrawal as the treatment and prognostic outcomes for each diagnosis are distinct. We present a series of events that led to a misdiagnosis of a patient admitted to the medical emergency center presenting with confusion, psychomotor agitation, and delirium who was first diagnosed with schizophrenia and alcohol withdrawal by emergency medical physicians and later discovered by the psychiatric consult team to have CPM. With a thorough psychiatric evaluation, a review of the laboratory results first showing mild hyponatremia (127 mmol/L), subsequent hypernatremia (154 mmol/L), and magnetic resonance brain imaging, psychiatrists concluded that CPM was the primary diagnosis underlying the observed neuropsychopathology. This patient has mild impairments in mood, cognition, and motor skills that remain 12 months after her emergency-center admission. This case report reminds emergency clinicians that abnormal sodium metabolism can have long-term and devastating psychopathological and neurological consequences. Differentiating between CPM, schizophrenia, and alcohol withdrawal using neuroimaging techniques and preventing the risks for CPM using slow sodium correction are paramount.

Keywords: MRI, alcohol, schizophrenia, central pontine myelinolysis, hyponatremia

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