A 35-year-old diabetic woman presented with altered consciousness for 12 days. She had a history of vomiting and abdominal pain. Examinations revealed she was disoriented with hypertonia and exaggerated reflexes. Investigations showed hyponatremia that had since corrected. MRI brain showed changes consistent with osmotic demyelination syndrome. She was diagnosed with diabetes, osmotic demyelination from hyponatremia, and erosive gastritis. She was treated with insulin, omeprazole, rehabilitation and discharged with advice to follow up in neurology.

1. Dr. Md Rashedul Islam
FCPS, MRCP(UK)
Registrar, Neurology, BIRDEM

2. A 35 years old diabetic right handed lady hailing
from Mirpur, Dhaka got admitted in BIRDEM
General Hospital on 12th
November,14
with the complaints of-
• Altered level of consciousness for 12 days

3. According to the statement of the patient,
she was reasonably well 12 days back. Then
she developed altered level of consciousness
which was gradual on onset associated with
confusion, drowsiness, behavioral changes,
difficulty in swallowing & vomiting. It was
not associated with fever, headache, loss of
consciousness & convulsion.

4. H/O Present illness
On detailed query she gives history of
vomiting for 15 days which was projectile,
containing undigested food materials. It was
not mixed with blood or bile. It was
associated with upper abdominal pain which
was burning in nature, mild in severity
without any radiation. With the above
complaints she was admitted in NIKDU &
investigated.

5. H/O Present illness
CT Scan of brain was done in NIKDU which was
normal. Routine blood test was done which
showed hyponatremia. She was diagnosed as a
case of DMT2 & electrolyte imbalance there &
subsequently transferred to Neurology,
BIRDEM for further management & treatment.

6. CT Scan of Brain

7. H/O past illness:
Nothing contributory
Socioeconomic history:
She belongs to a middle class family
Personal history:
She is non alcoholic, non smoker

8. Family history:
Nothing significant
Treatment history:
Tab. Metformin
Table salt
I/V 0.9%NaCl during admission in NIKDU

9. General examination:
Appearance: ill looking, vacant look, NG
tube in situ
Built: average
Decubitus: on choice
Anaemia
Jaundice
Cyanosis
Oedema
Dehydration
Clubbing
Koilonychia
Leukonychia
Absent

11. General examination:
Neck vein: not engorged
Thyroid: not enlarged
Lymph node: not palpable
Skin pigmentation & body hair distribution: normal
Pulse: 86 b/min
BP: 130/80 mmHg
Temp:98 F
RR: 16 breaths/min

12. • Higher psychic function : Disoriented,
apathetic, decreased responsiveness to external
stimuli.
• Speech: Could not be assessed
• Cranial nerves : Could not be assessed properly.
• Fundus: Normal
• GCS: 8/15
NERVOUS SYSTEM EXAMINATION

13. Muscle Rt. UL Lt. UL Rt. LL Lt. LL
Bulk Normal Normal Normal Normal
Tone Increased Increas
ed
Increased Increased
Power Could not
be assessed
properly
Involuntary
movement
Absent Absent Absent Absent
MOTOR FUNCTION:

14. Reflex B T S K A Abd Plantar
Right ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ Abse
nt
Extensor
Left ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑
Abse
nt
Extensor

15. Sensory system:
Pain Temp Touch Vibratio
n
Position
sense
Right upper
limb
Could not be assessed properly
Right lower
limb
Left upper
limb
Left lower
limb

16. • Sign of Meningeal irritation - Absent
• Cerebellar sign : Could not be assessed properly
• Gait: Could not be assessed properly

17. Systemic examinations
Other systemic examination was normal

18. A 35 years old diabetic right handed lady got
admitted in BIRDEM General hospital with
the complaints of altered level of
consciousness for 12 days which was gradual
on onset associated with confusion,
drowsiness, behavioral changes, difficulty in
swallowing & vomiting. It was not associated
with fever, headache, loss of consciousness &
convulsion.
Salient feature

19. Salient feature
She also gives history of vomiting for 15 days
which was projectile, containing undigested
food materials. It was not mixed with blood or
bile. It was associated with upper abdominal
pain which was burning in nature, mild in
severity without any radiation.

20. Salient feature
On examination ,she was ill looking, NG tube
in situ Disoriented, apathetic, decreased
responsiveness to external stimuli, GCS 8/15,
generalized hypertonia, exaggerated deep
tendon reflexes including bilateral extensor
planter responses. Other systemic examination
was normal

21. PROVISIONAL DIAGNOSIS
• Diabetes Mellitus Type 2
• Pseudo bulbar palsy due to brainstem
stroke
• Electrolyte imbalance

22. DIFFERENTIAL DIAGNOSIS
• Osmotic demyelination syndrome due to
Electrolyte imbalance
• Locked in syndrome
• Brainstem encephalitis

23. Investigations
CBC:
Hb % - 11.2
WBC -7000 cu/mm
Neu-65 %
Lymph- 17.8 %
Mono -5.9 %
Eosino- 1.1%
Platelet- 195000
ESR- 22mm in 1st
hour

24. S. Electrolytes
S. Electrolyte Value Date
S. Sodum 108mmol/l 1.11.14
S. Sodum 129mmol/l 2.11.14
S. Sodum 145mmol/l 5.11.14
S. Sodum 138mmol/l 9.11.14
S. Sodum 139mmol/l 12.11.14

25. S. Electrolytes
Na-139 mmol/l
K-4.1 mmol/l
Cl: 108 mmol/l
HCO3: 23 mmol/l
Ca- 8.9 mmol/l
Mg- 0.8 mmol/l
Phosphate-2.8

26. Lipid profile:
TG: 136 mg/dl
T. Chol : 122 mg/dl
LDL: 55 mg/dl
HDL: 40 mg/dl
LFT:
ALT: 28 iu/L
AST: 32 iu/L
RFT:
S. Creatinine: 0.9mmol/l
S Urea: 36 mmol/l

27. Sugar - Nil
Albumin – Nil
Ketone- Nil
Epi. cell: A few /HPF
Pus cell: 1-2 /HPF
RBC: Nil
URINE R/M/E

28. Chest X-Ray
NORMAL

29. ECG
Normal

30. MRI of Brain

31. MRI of Brain

32. MRI of Brain

33. MRI of Brain

34. MRI of Brain

35. MRI of Brain

36. MRI of Brain

37. Endoscopy of upper GIT:
Erosive antral gastritis

38. Final diagnosis:
• Diabetes mellitus type 2
• Osmotic demyelination syndrome due to
hyponatremia
• Erosive antral gastritis

39. Treatment:
Short acting insulin
Cap. Omeprazole
Neurorehabilitation
Supportive treatment
Patient was counseled about Course and
prognosis of the disease

40. Follow UP
Patient was advised to follow up in Neurology
OPD for further clinical evaluation &
management

41. Acknowledgement :
Department of Physical Medicine