title: Plasmapheresis and Intravenous Immune Globulin Improve Neurologic Outcome of Central Pontine Myelinolysis Occurring Post Orthotopic Liver Transplant.
abstract: OBJECTIVE
  To report 2 cases of central pontine myelinolysis (CPM) post liver transplantation in which treatment with plasmapheresis and intravenous immune globulin improved expected neurologic outcome.
  
  
  METHODS
  Two patients who underwent orthotopic liver transplant developed CPM early in their postoperative course. Magnetic resonance imaging of the brain demonstrated severe demyelination of either the pons or the midbrain, respectively. Both patients developed significant neurologic abnormalities, including acute mental status changes, severe muscle weakness, spasticity, and/or prolonged paralysis. Pretransplant laboratory results indicated serum sodium levels fluctuating between 115 mEq/L and 152 mEq/L. Both patients received 6 days of plasmapheresis (PP) followed by 5 consecutive days of intravenous immune globulin (IVIG). Significant neurologic improvement was experienced at 2 and 4 weeks, respectively, after therapy was initiated. Complete resolution of neurologic symptoms was evident at 1 year follow-up.
  
  
  CONCLUSIONS
  Currently, specific guidelines or recommendations for the treatment of CPM are practically nonexistent. CPM remains a neurologic complication that is difficult to treat and may result in permanent significant neurologic sequelae. The etiology and pathogenesis of this disease are unclear, although aggressive osmolar correction, particularly in the setting of hyponatremia, is the main risk factor. While patients may eventually show some improvement with supportive care, progress is often protracted, and complete resolution of symptoms is exceedingly rare. The severity of the midbrain lesions juxtaposed against the rapidity of symptom resolution in these 2 patients alludes to a potential therapeutic benefit after initiation of therapy with PP and IVIG.
  
  
  CONCLUSIONS
  These cases suggest that prompt recognition of CPM and initiation of PP and IVIG may help modulate its progress and improve long-term neurologic outcome.
authors.affiliation: Kyle P Ludwig PharmD BCPS, Surgical Intensive Care Unit Clinical Pharmacy Specialist, University of Utah Hospitals and Clinics, Salt Lake City, UT.
authors.forename: Kyle P
authors.initials: KP
authors.lastname: Ludwig
authors.affiliation: Heather F Thiesset MPH, Clinical Research Coordinator, University of Utah.
authors.forename: Heather F
authors.initials: HF
authors.lastname: Thiesset
authors.affiliation: Timothy J Gayowski MD, Professor of Surgery, University of Utah.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Gayowski
authors.affiliation: Jason J Schwartz MD FACS, Assistant Professor of Surgery, University of Utah jason.schwartz@hsc.utah.edu.
authors.forename: Jason J
authors.initials: JJ
authors.lastname: Schwartz
mesh_terms: D005260:Female; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D017590:Myelinolysis, Central Pontine / Q000628:therapy*; D010956:Plasmapheresis; D011183:Postoperative Complications / Q000628:therapy*
chemical_list: D016756:Immunoglobulins, Intravenous