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

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

doi:10.1590/S0034-70942009000300010

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

http://dx.doi.org/10.1590/S0034-70942009000300010 Braz J Anesthesiol, vol.59, n3, p.344-349, 2009

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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

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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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