(Kiosk 3) Functional Gains in a Patient with Corticospinal Tract Demyelination and Central Adrenal Insufficiency: A Case Report

Case Diagnosis: Corticospinal tract demyelination due to central adrenal insufficiency

Case Description or Program Description: A 64-year-old female presented to PM&R clinic for initial consultation with spastic quadriparesis (asymmetric), bilateral upper motor neuron signs, emotional lability, neurogenic bladder, and dysphagia two years after traumatic subarachnoid hemorrhage (SAH). MRI at time of traumatic brain injury (TBI) showed trace right convexity SAH but also T2/FLAIR hyperintensity involving pontine and medullary corticospinal tracts, initially attributed to small vessel disease. She was lost to follow-up after TBI, with symptoms misattributed to “stroke” over time. Once established with PM&R, further workup was pursued. Chronic hyponatremia and vitamin deficiencies were suspected etiology of corticospinal tract abnormalities. Mild B12 deficiency was treated but symptoms progressed. Follow-up imaging showed progressive T2/FLAIR hyperintensities in the pons, medulla, and now left cerebral peduncle. Hyponatremia was initially attributed to alcohol however persisted despite sobriety. Lack of accessible transportation limited outpatient adrenal testing (requires completion prior to 8AM, repeated lab draws). During outpatient workup (4.5 months duration), patient fell. C4-5 disc herniation required decompression. She was subsequently admitted to Inpatient Rehabilitation Facility (IRF).

Setting: Academic medical center

Assessment/Results: Hyponatremia workup confirmed central adrenal insufficiency. Emotional lability correlated with low sodium during admission. Hyponatremia improved with hydrocortisone. Patient made functional gains with management of adrenal insufficiency, spasticity, and rehabilitation. On IRF admission, she required moderate-maximal assistance for mobility and self-care. Upon discharge, she was modified independent for household distances. Emotional lability improved.

Discussion (relevance): Chronic hyponatremia is the strongest risk factor for osmotic demyelination syndrome; this patient was at risk due to central adrenal insufficiency. Predominant corticospinal tract involvement is unusual.

Conclusions: Meaningful functional gains are possible in osmotic demyelination syndrome with treatment of underlying conditions. The IRF setting is uniquely equipped to coordinate multidisciplinary care and rehabilitation of complex medical conditions. Outpatient diagnosis of adrenal insufficiency was impacted by limited mobility and transportation access.