Post partum Hypernatremic Osmotic demyelination, Stress Cardiomyopathiy

A patient by name ******,23 F, G1P1L1 delivered a female baby by vacuum assisted NVD on 10/7/2024 at private hospital, 20 minutes post delivery she had an Seizure ( GTCS type ) episode managed conservatively, Over next 2 hrs she had two more seizure episodes for which she is referred to Tertiary hospital for further management, There She had one more seizure episode & was unresponsive I/v/o low GCS patient is Intubated and Connected to MV. Patient is evaluated with CT brain which showed ill defined hypodensities along cortical & subcortical white matter of Right parietal lobe a possibility of PRESS to be considered. So Patient is referred to Our Hospital, Neurology Dept for Further management. On arrival her GCS is E1VtM3, PR- 110bpm, BP- 120/80mmhg , Evaluation with MRI brain showed bilateral medial temporal lobe & insular cortex & Thalamic hyperintesnities a possibility of Atypical PRESS or Viral meningitis is considered & Treated accordingly. Her 2decho showed Global hypokinesia , EF - 32% suggesting post partum stress cardiomyopathiy for which she's treated as per Cardiologist orders.LP & CSF analysis showed 1 Cell, Protein -50mg/dl, Glucose- 76mg/dl, Chloride is 138.8mmol/L. Blood investigations revealed elevated TLC ( 18,210 ) Serum Na+ 149.5mmol/L, CRP- 21 remaining parameters are in Normal range. Patient is Treated with Antibiotics, Anti seizure medication, PPI's, Antiemetics, Doubutamine infusions. Her sensorium improved but since limb movements are poor a  repeat MRI BRAIN & C spine is done with showed B/L T2 / Flair Hyperintesnities with corresponding diffusion restriction in centrum semiovale, Corona radiata, lentiform nucleus, thalamus, post.Limb of internal capsule, Splenium of corpus callosum, medial temporal lobe Suggesting a possibility of Post partum Hypernatremic demyelination & she's on treatment for this Condition.Currently patient is conscious on MV , Moving all limbs with non purposive movements to painful stimulus, Her vitals are Bp-130/80mmhg, PR- 100bpm. In view of prolonged intubation Tracheostomy is done. Et culture showed Acinetobacter for which Colistin , tigecycline  are added later her fever spikes reduced & patient shifted to ward. Over next 1 week pt power in All limbs improved to 3 /5 & she's responding to commands decannulation of tracheostomy tube done along with removal of ryles tube. Pt is tolerating oral feeds and discharged in stable condition.

wine glass appearance of Corticospinal tracts & Internal capsul in coronal DWI

CPk - levels are normal.

https://www.ajnr.org/ajnr-case-collections-diagnosis/postpartum-hypernatremic-osmoticdemyelination#:~:text=Postpartum%20hypernatremia%20is%20a%20recently,hyperintensities%20suggestive%20of%20osmotic%20demyelination

Postpartum hypernatremia is a recently described entity where severe hypernatremia occurs in the postpartum period and presents as an encephalopathy with rhabdomyolysis with diffuse white matter hyperintensities suggestive of osmotic demyelination.

Clinical Presentation:

Clinical features of postpartum hypernatremia include quadriparesis, delirium, disorientation, irrelevant speech, dysarthria, ataxia, seizures, rhabdomyolysis, hyperuricemia, acute kidney injury, encephalopathy, and coma.