Hideya Itagaki, Tomoyuki Endo
Osmotic demyelination syndrome (ODS) is a rare neurological disorder typically associated with rapid correction of hyponatremia, whereas alcohol-related peripheral neuropathy (ALN) is a common complication of chronic alcohol use. The coexistence of ODS and ALN is uncommon and may obscure timely diagnosis. We report the case of a 51-year-old man with a long-standing history of alcohol dependence who presented to the emergency department with vomiting and diarrhea persisting for six days. Laboratory tests revealed hyponatremia, macrocytic anemia, thrombocytopenia, and electrolyte imbalances. Neurological examination demonstrated distal paresthesia, diminished reflexes in the lower extremities, and positive Babinski and Chaddock signs. MRI revealed a hyperintense trident-shaped lesion in the pons consistent with ODS. These findings suggested the concomitant presence of ALN and ODS. The patient was treated conservatively with vitamin supplementation, careful correction of electrolytes, and gradual nutritional rehabilitation. Sodium levels normalized without the need for rapid correction, and the patient's symptoms improved, leading to discharge on the eighth hospital day. This case underscores two essential points: ODS was identified before any documented rapid in-hospital correction of hyponatraemia, and alcohol-dependent patients may present with overlapping features of ALN and ODS. Recognition of pyramidal signs is critical for differentiating central from peripheral neurological complications in this population. Clinicians should maintain a high index of suspicion for concomitant ODS in alcohol-dependent patients with neuropathy, particularly when pyramidal signs are present.