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Q J Med 2003; 96: 935-947
© Association of Physicians 2003; all rights reserved.

Masterclasses in medicine

Osmotic demyelination syndrome: a potentially avoidable disaster

S.-H. Lin1, Y.-J. Hsu1, J.-S. Chiu1, S.-J. Chu1, M.R. Davids2 and M.L. Halperin3

From the 1Division of Nephrology, Departments of Medicine and Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC, 2Nephrology Unit and Department of Internal Medicine, University of Stellenbosch, Cape Town, South Africa and 3Division of Nephrology, St Michael's Hospital, University of Toronto, Toronto, Canada

Osmotic demyelination of the brain (ODS) is a dreaded complication that typically occurs several days after aggressive therapy for chronic hyponatraemia, but is eminently avoidable. In this teaching exercise, Professor McCance, an imaginary consultant, is asked to explain how he would have treated a 28-year-old female who had hyperkalaemia, hypoglycaemia, hypotension and hyponatraemia (118 mM) to prevent the development of ODS. He begins with a review of the physiology, including his own landmark work on chronic hyponatraemia associated with a contracted extracellular fluid volume. Adding quantitative analysis, the cause of the excessive rise in plasma sodium concentration is revealed, and a better plan for therapy is proposed.

Address correspondence to Professor M.L. Halperin, University of Toronto, St. Michael's Hospital Annex, Lab #1, Research Wing, 38 Shuter Street, Toronto, Ontario, M5B 1A6, Canada. e-mail: mitchell.halperin{at}utoronto.ca


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