Transient athetoid involuntary movement in a patient with chronic renal failure, possibly due to rapid correction of hyponatremia by hemodialysis Hiro

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1 Transient athetoid involuntary movement in a patient with chronic renal failure, possibly due to rapid correction of hyponatremia by hemodialysis Hiroki Sasage, Yoshiki Suzuki, Fumitake Gejyo, Takashi Inuzuka*, Masaaki Arakawa Second Department of Internal Medicine, and Neurology*, Niigata University School of Medicine A 52-years-old woman was admitted for exacerbation of edema and severe azotemia. Her sodium (Na) concentration was as low as 123mEq/l on admission. Treatment with hemodialysis (HD) was started because of the progressing azotemia. Serum Na concentrations were 112 and 131mEq/lat the start and the end of the first HD, respectively. During the second HD 3 days after the first HD, athetoid involuntary movements (IVM) of the right upper and lower extremities suddenly occurred. The IVM tended to improve after interruption of HD but still appeared intermittently. Serum Na concentrations before and after the second HD were 127 and 138 meq/l respectively. The neurological examination revealed saccadic eye movements and increased deep tendon reflexes. IVM disappeared after oral administration of clonazepam the next day, and did not recur even after discontinuing clonazepam on the ninth day. The MRI examination of brain after 40 days, failed to detect any abnormal findings in the pons and elsewhere. No remarkable abnormalities were found in electroencephalograms on the next day and two months later. We suspect that the cause of neurological symptoms in this case was due to the rapid correction of hyponatremia by HD. Since hyponatremia often occurs at the end stage chronic renal failure, the correction of the electrolyte disorder should be made carefully.

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4 1) Norenberg MD, Leslie KO, Robertson AS: Asso ciation between rise in serum sodium and central pontine myelinolysis. Ann Neurol 11: , ) Kleinschmidt-DeMasters BK, Norenberg MD: Rapid correction of hyponatremia causes demyelination: Relation to central pontine myelinolysis. Science 211: , ) Laureno R: Central pontine myelinolysis follow ing rapid correction of hyponatremia. Ann Neurol 13: ,1983 4) Malangone JM, Abuelo JG, Pezzullo JC, Lund K, McGloin CA: Clinical and laboratory features of chronic renal disease at the start of dialysis. Clin Nephrol 31: 77-87, ) Coleman AJ, Arias M, Carter NW, Rector Jr FC, Seldin DW: The mechanism of salt wastage in chronic renal disease. J Clin Invest 45: , ) Abramow M, Cogan E: Clinical aspects and path ophysiology of diuretic-induced hyponatremia. Adv Nephrol 13: 1-28, ) Adams RD, Victor M, Mancall EL: Central pontine myelinolysis. Arch Neurol Psychiat 81: , ) Wright DG, Laureno R, Victor M: Potine and extrapontine myelinolysis. Brain 102: , ) Burcar PJ, Norenberg MD, Yarneil PR: Hyponatremia and central pontine myelinolysis. Neurology (Minneap) 27: , 1977

5 13) McCormick WF, Danneel CM: Central pontine myelinolysis. Arch Intern Med 119: , ) Thompson DS, Hutton JT, Stears JC, Sung JH, Norenberg M: Computerized tomography in the diagnosis of central and extrapontine myelino lysis. Arch Neurol 38: , ) DeWitt LD, Buonanno FS, Kistler JP, Zeffiro T, DeLaPaz RL, Brady TJ, Rosen BR, Pykett IL: Central pontine myelinolysis: Demonstration by nuclear magnetic resonance. Neurology (Clevel and) 34: , ) Endo Y, Qda M, Hara M: Central pontine myelinolysis-a study of 37 cases in 1000 consecu tive autopsies. Acta Neuropathol (Berl) 53: , ) Arieff AI: Hyponatremia, convulsions, respira tory arrest, and permanent brain damage after elective surgery in healthy women. N Engl J Med 314: , 1986

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