Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942009000300010
Brazilian Journal of Anesthesiology
Clinical Information

Mielinólise pontina central após transplante hepático: o sódio é o único vilão? Relato de caso

Central pontine myelinolysis after liver transplantation: is sodium the only villain? Case report

Bruno Salomé de Morais; Fabiano Soares Carneiro; Rodolfo de Morais Araújo; Guilherme Freitas Araújo; Rodrigo Bernardes de Oliveira

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Resumo

JUSTIFICATIVA E OBJETIVOS: A ocorrência de sintomas neurológicos em pacientes gravemente enfermos é comum e, muitas vezes, um desafio propedêutico. Descrita há cerca de 50 anos, a desmielinização dos neurônios da região pontina é uma alteração patológica associada a quadros neurológicos e psiquiátricos após transplante hepático. O objetivo deste relato foi apresentar a mielinólise pontina central diagnosticada no pós-operatório de transplante hepático e discutir sua fisiopatologia. RELATO DO CASO: Paciente do sexo feminino, 29 anos, submetida a transplante hepático devido insuficiência hepática fulminante. No pós-operatório apresentou quadro neurológico característico de Síndrome Locked In e lesões compatíveis com mielinólise pontina central à ressonância nuclear magnética. A paciente não apresentou oscilações exageradas do sódio plasmático, íon frequentemente incriminado como agente causal, evoluindo com melhora significativa em algumas semanas. CONCLUSÕES: A mielinólise pontina central tem etiologia multifatorial e atenção especial deve ser dada ao grupo de pacientes com maior risco, tais como aqueles submetidos a alterações abruptas da natremia, transplantados de fígado, etilistas crônicos e desnutridos. É importante reconhecer que as síndromes desmielinizantes osmósticas podem surgir em pacientes com níveis séricos de sódio baixo, normal ou elevado, evidenciando a contribuição de outros fatores desencadeantes.

Palavras-chave

CIRURGIA, Transplante, COMPLICAÇÕES

Abstract

BACKGROUND AND OBJECTIVES: Critically ill patients frequently develop neurologic symptoms, which frequently become a clinical challenge. Described approximately 50 years ago, pontine neuronal demyelination is a pathologic change associated with neurologic and psychiatric problems after liver transplantation. The objective of this report was to present a case of central pontine myelinolysis diagnosed after liver transplantation and to discuss its pathophysiology. CASE REPORT: A 29 years old female patient underwent liver transplantation for fulminant hepatic failure. Postoperatively, she developed neurologic symptoms characteristic of the Locked In Syndrome and the MRI showed changes compatible with central pontine myelinolysis. The patient did not develop dramatic changes in sodium plasma levels, which is frequently incriminated as the causal agent, and improved considerably within a few weeks. CONCLUSIONS: The etiology of central pontine myelinolysis is multifactorial, and special attention should be given to the group of patients at greater risk, such as those with sudden changes in the plasma levels of sodium, liver transplantation, chronic alcoholics, and malnourished. It is important to recognize that osmotic demyelination can develop in patients with low, normal, or elevated plasma levels of sodium, indicating the contribution of other trigger factors.

Keywords

COMPLICATIONS, SURGERY, Transplantation

References

Kim BS, Lee SG, Hwang S. - Neurologic complications in adult living donor liver transplant recipients. Clin Transplant. 2007;21:544-547.

Huq S, Wong M, Chan H. Osmotic demyelination syndromes: central and extrapontine myelinolysis. J Clin Neurosci. 2007;14:684-688.

Lewis MB, Howdle PD. Neurologic complications of liver transplantation in adults. Neurology. 2003;61:1174-1178.

Lopez OL, Estol C, Colina I. Neurological complications after liver retransplantation. Hepatology. 1992;16:162-166.

Sterzi R, Santilli I, Donato MF. Neurologic complications following orthotopic liver transplantation. Transplant Proc. 1994;26:3679-3680.

Burkhalter EL, Starzl TE, Van Thiel DH. Severe neurological complications following orthotopic liver transplantation in patients receiving FK 506 and prednisone. J Hepatol. 1994;21:572-577.

Ghaus N, Bohlega S, Rezeig M. Neurological complications in liver transplantation. J Neurol. 2001;248:1042-1048.

Bronster DJ, Emre S, Boccagni P. Central nervous system complications in liver transplant recipients: incidence, timing, and long-term follow-up. Clin Transplant. 2000;14:1-7.

Adams RD, Victor M, Mancall EL. Central pontine myelinolysis: a hitherto undescribed disease occurring in alcoholic and malnourished patients. AMA Arch Neurol Psychiatry. 1959;81:154-172.

Starzl TE, Schneck SA, Mazzoni G. Acute neurological complications after liver transplantation with particular reference to intraoperative cerebral air embolus. Ann Surg. 1978;187:236-240.

Yu J, Zheng SS, Liang TB. Possible causes of central pontine myelinolysis after liver transplantation. World J Gastroenterol. 2004;10:2540-2543.

Soupart A, Ngassa M, Decaux G. Therapeutic relowering of the serum sodium in a patient after excessive correction of hyponatremia. Clin Nephrol. 1999;51:383-386.

Sterns RH, Baer J, Ebersol S. Organic osmolytes in acutehyponatremia. Am J Physiol. 1993;264:F833-836.

Newell KL, Kleinschmidt-DeMasters BK. Central pontine myelinolysis at autopsy: a twelve year retrospective analysis. J Neurol Sci. 1996;142:1394-1399.

Brown WD. Osmotic demyelination disorders: central pontine and extrapontine myelinolysis. Curr Opin Neurol. 2000;13:691-697.

Ashrafian H, Davey P. A review of the causes of central pontine myelinosis: yet another apoptotic illness?. Eur J Neurol. 2001;8:103-109.

Taneja K, Sabharwal RK, Taneja A. Central pontine myelinolysis in a normonatremic child. Indian Pediatr. 1997;34:153-156.

Mast H, Gordon PH, Mohr JP. Central pontine myelinolysis: clinical syndrome with normal serum sodium. Eur J Med Res. 1995;1:168-170.

Ardizzone G, Arrigo A, Schellino MM. Neurological complications of liver cirrhosis and orthotopic liver transplant. Transplant Proc. 2006;38:789-792.

Grimaldi D, Cavalleri F, Vallone S. Plasmapheresis improves the outcome of central pontine myelinolysis. J Neurol. 2005;252:734-735.

Snell DM, Bartley C. Osmotic demyelination syndrome following rapid correction of hyponatraemia. Anaesthesia. 2008;63:92-95.

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