A salty dilemma: A case report of anorexia with osmotic demyelination syndrome due to hypernatremia

Background

Osmotic demyelination syndrome (ODS¹) is a rare neurological condition characterized by rapid demyelination of neural cells. It often occurs due to aggressive correction of chronic hyponatremia. However, it might develop in other osmotic stresses like hypernatremia.

Wernicke-Korsakoff syndrome (WKS²) is a complication of thiamine deficiency. It mainly occurs in alcoholic patients, but conditions such as malnutrition might also lead to it.

Here we present a case of anorexia due to a possible major depressive disorder who developed signs and symptoms of hypernatremic ODS and WKS in the setting of chronic malnutrition.

Case presentation

The patient is a 39-year-old woman with a history of anorexia for seven months due to a possible major depressive disorder episode following her mother's death. She was admitted due to impaired consciousness and generalized weakness. On admission, her sodium level was 179 mEq/L, and her MRI showed signs of ODS and WKS. Intravenous fluid gradually dropped the sodium level to 149 mEq/L. Thiamine (1 g IV BID) was also administered due to signs of WKS from day 1. Despite treatments, her consciousness level worsened, and eventually, she died of septic shock followed by cardiac arrest and brain death on the sixth day.

Conclusion

To date, hypernatremia has been argued as a rare cause of ODS. However, the risk of hypernatremic ODS increase when other comorbidities (e.g., malnutrition) are present. Thiamine deficiency might lead to WKS that overlaps with ODS in patients with malnutrition. Primary care physicians are encouraged to detect early signs of major depressive disorder to prevent catastrophic medical and psychiatric complications. Also, Careful monitoring of electrolytes and vitamins and early detection of neurological symptoms are the keys to managing anorexia patients.