Late Presenting Central Pontine Myelinolysis Post-tonsillectomy in a Child: Case Report

Central pontine myelinolysis (CPM) is a notorious grave complication of rapid correction of hyponatremia. CPM is a noninflammatory demyelination. It presents clinically with variable degrees of loss of coordination, unconsciousness, blurred vision, cranial nerve affection, progressive spasticity, quadriparesis, pseudo bulbar palsy up to locked in syndrome, coma and death. We report a 4.5-year-old who presented to emergency room (ER) with generalized tonic-clonic seizures, and sepsis. His parents reported that he underwent un-eventful tonsillectomy 3 days earlier. Two days post-tonsillectomy he developed fever. On third day post-tonsillectomy he developed an attack of convulsions at home, 3 hours prior to presenting to ER. He presented to the ER by another attack of seizures. His seizures were controlled on IV midazolam and levetiracetam loading dose. His conscious level was clouded beyond the postictal 30 minutes. His Glasgow Coma scale was 12 which necessitated Pediatric Intensive Care Unit (PICU) admission. His condition was complicated by acute liver and kidney injury that improved within 48 hours. Upon admission his sodium level was 141 mmol/L, and did not drop below 140 mmol/L all through the hospital stay. By the 7th day after admission the child developed left sided convergent squint (6th cranial nerve palsy) and progressive spasticity. Magnetic resonance imaging revealed CPM. The isolated CPM in this child developed irrespective of hemodynamic stability, lack of hyponatremia and its rapid correction. CPM in our studied child might be an isolated presentation of sepsis associated encephalopathy, or a late complication post-tonsillectomy.