Central pontine myelinolysis differential diagnosis: Difference between revisions

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==Differentiating central pontine myelinolysis from other Diseases==
==Differentiating central pontine myelinolysis from other Diseases==
On the basis central pontine myelinolysis must be differentiated diseases that cause acute [[confusion]], [[lethargy]], [[speech difficulties]] and bilateral [[weakness]] or [[quadriplegia]] such as:<ref name="pmid19938667">{{cite journal| author=Kawabori M, Murata J, Abe S, Saito H| title=[A case of brainstem variant of reversible posterior leukoencephalopathy syndrome]. | journal=No Shinkei Geka | year= 2009 | volume= 37 | issue= 11 | pages= 1105-9 | pmid=19938667 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19938667  }} </ref><ref name="pmid23533856">{{cite journal| author=Osman Y, Imam YZ, Salem K, Al-Hail H, Uthman B, Deleu D| title=Isolated brainstem involvement in a patient with hypertensive encephalopathy. | journal=Case Rep Neurol Med | year= 2013 | volume= 2013 | issue=  | pages= 540947 | pmid=23533856 | doi=10.1155/2013/540947 | pmc=3600275 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23533856  }} </ref><ref name="pmid16093630">{{cite journal| author=Uchino A, Sawada A, Takase Y, Kudo S| title=Symmetrical lesions of the middle cerebellar peduncle: MR imaging and differential diagnosis. | journal=Magn Reson Med Sci | year= 2004 | volume= 3 | issue= 3 | pages= 133-40 | pmid=16093630 | doi=10.2463/mrms.3.133 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16093630  }} </ref><ref name="pmid25610237">{{cite journal| author=Uzkeser M, Akoz A, Ozdemir G, Emet M, Bayramoglu A| title=Wide central pontine, bulbar and thalamic myelinolysis with sequela. | journal=Eurasian J Med | year= 2012 | volume= 44 | issue= 3 | pages= 179-81 | pmid=25610237 | doi=10.5152/eajm.2012.42 | pmc=4261386 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25610237  }} </ref><ref name="pmid23482893">{{cite journal| author=Choi JM, Kim YH, Roh SY| title=Acute hepatic encephalopathy presenting as cortical laminar necrosis: case report. | journal=Korean J Radiol | year= 2013 | volume= 14 | issue= 2 | pages= 324-8 | pmid=23482893 | doi=10.3348/kjr.2013.14.2.324 | pmc=3590348 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23482893  }} </ref><ref name="pmid26834941">{{cite journal| author=Quattrocchi CC, Errante Y, Rossi Espagnet MC, Galassi S, Della Sala SW, Bernardi B et al.| title=Magnetic resonance imaging differential diagnosis of brainstem lesions in children. | journal=World J Radiol | year= 2016 | volume= 8 | issue= 1 | pages= 1-20 | pmid=26834941 | doi=10.4329/wjr.v8.i1.1 | pmc=4731345 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26834941  }} </ref>
On the basis central pontine myelinolysis must be differentiated diseases that cause acute [[confusion]], [[lethargy]], [[speech difficulties]] and bilateral [[weakness]] or [[quadriplegia]] such as:<ref name="pmid19938667">{{cite journal| author=Kawabori M, Murata J, Abe S, Saito H| title=[A case of brainstem variant of reversible posterior leukoencephalopathy syndrome]. | journal=No Shinkei Geka | year= 2009 | volume= 37 | issue= 11 | pages= 1105-9 | pmid=19938667 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19938667  }} </ref><ref name="pmid23533856">{{cite journal| author=Osman Y, Imam YZ, Salem K, Al-Hail H, Uthman B, Deleu D| title=Isolated brainstem involvement in a patient with hypertensive encephalopathy. | journal=Case Rep Neurol Med | year= 2013 | volume= 2013 | issue=  | pages= 540947 | pmid=23533856 | doi=10.1155/2013/540947 | pmc=3600275 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23533856  }} </ref><ref name="pmid16093630">{{cite journal| author=Uchino A, Sawada A, Takase Y, Kudo S| title=Symmetrical lesions of the middle cerebellar peduncle: MR imaging and differential diagnosis. | journal=Magn Reson Med Sci | year= 2004 | volume= 3 | issue= 3 | pages= 133-40 | pmid=16093630 | doi=10.2463/mrms.3.133 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16093630  }} </ref><ref name="pmid25610237">{{cite journal| author=Uzkeser M, Akoz A, Ozdemir G, Emet M, Bayramoglu A| title=Wide central pontine, bulbar and thalamic myelinolysis with sequela. | journal=Eurasian J Med | year= 2012 | volume= 44 | issue= 3 | pages= 179-81 | pmid=25610237 | doi=10.5152/eajm.2012.42 | pmc=4261386 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25610237  }} </ref><ref name="pmid23482893">{{cite journal| author=Choi JM, Kim YH, Roh SY| title=Acute hepatic encephalopathy presenting as cortical laminar necrosis: case report. | journal=Korean J Radiol | year= 2013 | volume= 14 | issue= 2 | pages= 324-8 | pmid=23482893 | doi=10.3348/kjr.2013.14.2.324 | pmc=3590348 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23482893  }} </ref><ref name="pmid26834941">{{cite journal| author=Quattrocchi CC, Errante Y, Rossi Espagnet MC, Galassi S, Della Sala SW, Bernardi B et al.| title=Magnetic resonance imaging differential diagnosis of brainstem lesions in children. | journal=World J Radiol | year= 2016 | volume= 8 | issue= 1 | pages= 1-20 | pmid=26834941 | doi=10.4329/wjr.v8.i1.1 | pmc=4731345 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26834941 }} </ref><ref name="pmid21686359">{{cite journal| author=Shalchi Z, Bennett A, Hargroves D, Nash J| title=Diagnostic delay in a case of herpes simplex encephalitis. | journal=BMJ Case Rep | year= 2009 | volume= 2009 | issue=  | pages=  | pmid=21686359 | doi=10.1136/bcr.12.2008.1350 | pmc=3028237 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21686359 }} </ref>


*[[Posterior leucoencephalopathy syndrome|Posterior leukoencephalopathy syndrome]]
*[[Posterior leucoencephalopathy syndrome|Posterior leukoencephalopathy syndrome]]
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*[[Brain tumors]] such as [[glioma]]
*[[Brain tumors]] such as [[glioma]]


== Differential diagnosis ==
Stroke should be differentiated from other causes of muscle weakness and paralysis. The differentials include the following:<ref name="pmid29433111">{{cite journal |vauthors=Kira R |title=[Acute Flaccid Myelitis] |language=Japanese |journal=Brain Nerve |volume=70 |issue=2 |pages=99–112 |date=February 2018 |pmid=29433111 |doi=10.11477/mf.1416200962 |url=}}</ref><ref name="pmid29433111">{{cite journal |vauthors=Kira R |title=[Acute Flaccid Myelitis] |language=Japanese |journal=Brain Nerve |volume=70 |issue=2 |pages=99–112 |date=February 2018 |pmid=29433111 |doi=10.11477/mf.1416200962 |url=}}</ref><ref name="pmid29181601">{{cite journal |vauthors=Hopkins SE |title=Acute Flaccid Myelitis: Etiologic Challenges, Diagnostic and Management Considerations |journal=Curr Treat Options Neurol |volume=19 |issue=12 |pages=48 |date=November 2017 |pmid=29181601 |doi=10.1007/s11940-017-0480-3 |url=}}</ref><ref name="pmid27422805">{{cite journal |vauthors=Messacar K, Schreiner TL, Van Haren K, Yang M, Glaser CA, Tyler KL, Dominguez SR |title=Acute flaccid myelitis: A clinical review of US cases 2012-2015 |journal=Ann. Neurol. |volume=80 |issue=3 |pages=326–38 |date=September 2016 |pmid=27422805 |pmc=5098271 |doi=10.1002/ana.24730 |url=}}</ref><ref name="pmid29028962">{{cite journal |vauthors=Chong PF, Kira R, Mori H, Okumura A, Torisu H, Yasumoto S, Shimizu H, Fujimoto T, Hanaoka N, Kusunoki S, Takahashi T, Oishi K, Tanaka-Taya K |title=Clinical Features of Acute Flaccid Myelitis Temporally Associated With an Enterovirus D68 Outbreak: Results of a Nationwide Survey of Acute Flaccid Paralysis in Japan, August-December 2015 |journal=Clin. Infect. Dis. |volume=66 |issue=5 |pages=653–664 |date=February 2018 |pmid=29028962 |pmc=5850449 |doi=10.1093/cid/cix860 |url=}}</ref><ref name="pmid29482893">{{cite journal |vauthors=Messacar K, Asturias EJ, Hixon AM, Van Leer-Buter C, Niesters HGM, Tyler KL, Abzug MJ, Dominguez SR |title=Enterovirus D68 and acute flaccid myelitis-evaluating the evidence for causality |journal=Lancet Infect Dis |volume=18 |issue=8 |pages=e239–e247 |date=August 2018 |pmid=29482893 |doi=10.1016/S1473-3099(18)30094-X |url=}}</ref><ref name="pmid30200066">{{cite journal |vauthors=Chen IJ, Hu SC, Hung KL, Lo CW |title=Acute flaccid myelitis associated with enterovirus D68 infection: A case report |journal=Medicine (Baltimore) |volume=97 |issue=36 |pages=e11831 |date=September 2018 |pmid=30200066 |pmc=6133480 |doi=10.1097/MD.0000000000011831 |url=}}</ref><ref name="urlBotulism | Botulism | CDC">{{cite web |url=https://www.cdc.gov/botulism/index.html |title=Botulism &#124; Botulism &#124; CDC |format= |work= |accessdate=}}</ref><ref name="pmid3290234">{{cite journal |vauthors=McCroskey LM, Hatheway CL |title=Laboratory findings in four cases of adult botulism suggest colonization of the intestinal tract |journal=J. Clin. Microbiol. |volume=26 |issue=5 |pages=1052–4 |date=May 1988 |pmid=3290234 |pmc=266519 |doi= |url=}}</ref><ref name="pmid16614251">{{cite journal |vauthors=Lindström M, Korkeala H |title=Laboratory diagnostics of botulism |journal=Clin. Microbiol. Rev. |volume=19 |issue=2 |pages=298–314 |date=April 2006 |pmid=16614251 |pmc=1471988 |doi=10.1128/CMR.19.2.298-314.2006 |url=}}</ref><ref name="pmid17224901">{{cite journal |vauthors=Brook I |title=Botulism: the challenge of diagnosis and treatment |journal=Rev Neurol Dis |volume=3 |issue=4 |pages=182–9 |date=2006 |pmid=17224901 |doi= |url=}}</ref><ref name="pmid23642721">{{cite journal |vauthors=Dimachkie MM, Barohn RJ |title=Guillain-Barré syndrome and variants |journal=Neurol Clin |volume=31 |issue=2 |pages=491–510 |date=May 2013 |pmid=23642721 |pmc=3939842 |doi=10.1016/j.ncl.2013.01.005 |url=}}</ref><ref name="pmid23418763">{{cite journal |vauthors=Walling AD, Dickson G |title=Guillain-Barré syndrome |journal=Am Fam Physician |volume=87 |issue=3 |pages=191–7 |date=February 2013 |pmid=23418763 |doi= |url=}}</ref><ref name="pmid21969911">{{cite journal |vauthors=Gilhus NE |title=Lambert-eaton myasthenic syndrome; pathogenesis, diagnosis, and therapy |journal=Autoimmune Dis |volume=2011 |issue= |pages=973808 |date=2011 |pmid=21969911 |pmc=3182560 |doi=10.4061/2011/973808 |url=}}</ref><ref name="pmid14977560">{{cite journal |vauthors=Krishnan C, Kaplin AI, Deshpande DM, Pardo CA, Kerr DA |title=Transverse Myelitis: pathogenesis, diagnosis and treatment |journal=Front. Biosci. |volume=9 |issue= |pages=1483–99 |date=May 2004 |pmid=14977560 |doi= |url=}}</ref><ref name="pmid24305450">{{cite journal |vauthors=Amato AA, Greenberg SA |title=Inflammatory myopathies |journal=Continuum (Minneap Minn) |volume=19 |issue=6 Muscle Disease |pages=1615–33 |date=December 2013 |pmid=24305450 |doi=10.1212/01.CON.0000440662.26427.bd |url=}}</ref><ref name="pmid24365430">{{cite journal |vauthors=Berger JR, Dean D |title=Neurosyphilis |journal=Handb Clin Neurol |volume=121 |issue= |pages=1461–72 |date=2014 |pmid=24365430 |doi=10.1016/B978-0-7020-4088-7.00098-5 |url=}}</ref>
{|
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |<small>Diseases</small>
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;|Diseases
! colspan="8" |<small>History and Physical
| colspan="3" |'''Clinical manifestations'''
! colspan="2" |<small>Diagnostic tests</small>
! colspan="2" rowspan="2" |Para-clinical findings
! rowspan="2" |<small>Other Findings</small>
| colspan="1" rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Gold standard'''
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;|Additional findings
!<small>Motor Deficit</small>
!<small>Sensory deficit</small>
!<small>Cranial nerve Involvement</small>
!<small>Autonomic dysfunction</small>
!<small>Proximal/Distal/Generalized</small>
!<small>Ascending/Descending/Systemic</small>
!<small>Unilateral (UL)
 
or Bilateral (BL)
 
or
 
No Lateralization (NL)</small>
!<small>Onset</small>
!<small>Lab or Imaging Findings</small>
!<small>Specific  test</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Acute Flaccid Myelitis
| style="background: #DCDCDC; padding: 5px; text-align: center;" | +
| style="background: #DCDCDC; padding: 5px; text-align: center;" | +
| style="background: #DCDCDC; padding: 5px; text-align: center;" | +
| style="background: #DCDCDC; padding: 5px; text-align: center;" | -
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Proximal > Distal
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Ascending
| style="background: #DCDCDC; padding: 5px; text-align: center;" |UL/BL
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Sudden
| style="background: #DCDCDC; padding: 5px; text-align: center;" |MRI (Longitudinal hyperintense lesions)
| style="background: #DCDCDC; padding: 5px; text-align: center;" |MRI and CSF PCR for viral etiology
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Drooping eyelids
Difficulty swallowing
 
Respiratory failure
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Adult Botulism
! colspan="3" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Descending
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |Toxin test
| style="background: #F5F5F5; padding: 5px; text-align:center" |Blood, Wound, or Stool culture
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Diplopia]], [[Hyporeflexia|Hyporeflexia,]] [[Hypotonia]], possible respiratory paralysis
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Infant Botulism
!Lab Findings
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
!Imaging
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Descending
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |Toxin test
| style="background: #F5F5F5; padding: 5px; text-align:center" |Blood, Wound, or Stool culture
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Flaccid paralysis]] ([[Floppy baby syndrome]]), possible respiratory paralysis
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Guillian-Barre syndrome]]
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Confusion
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Weakness and quadriplegia
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Speech difficulties
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Hypoosmotic hyponatremia
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |MRI
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Ascending
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" |CSF: ↑Protein
 
↓Cells
 
| style="background: #F5F5F5; padding: 5px; text-align:center" |Clinical & Lumbar Puncture
| style="background: #F5F5F5; padding: 5px; text-align:center" |Progressive [[ascending paralysis]] following infection, possible respiratory paralysis
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Eaton lambert syndrome|Eaton Lambert syndrome]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Central pontine myelinolysis
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px;" | ++
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px;" |++
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px;" |++
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" |++
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
* Symmetric signal intensity abnormality in the central pons at T2-weighted and FLAIR imaging
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
* Decreased T1 signal intensity
| style="background: #F5F5F5; padding: 5px; text-align:center" |Intermittent
* Fluid attenuated inversion recovery (FLAIR) hyperintense lesion in the [[pons]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | [[EMG]], repetitive nerve stimulation test (RNS)
* Intramedullary central T2 hyperintensity at axial T2W of [[spinal cord]] and sagittal T2W of thoracic [[spinal cord]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Voltage gated calcium channel|Voltage gated calcium channe]]<nowiki/>l<nowiki/> (VGCC) antibody
| style="background: #F5F5F5; padding: 5px;" |MRI
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Diplopia]], [[ptosis]], improves with movement (as the day progresses)
| style="background: #F5F5F5; padding: 5px;" |The most common cause of central pontine myelinolysis is rapid correction(>48-hours duration) of [[hyponatremia]] in patients with the history of prolonged [[hyponatremia]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Myasthenia gravis]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Intermittent
| style="background: #F5F5F5; padding: 5px; text-align:center" | [[Electromyography|EMG]], [[Edrophonium|Edrophonium test]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Acetylcholine receptor|Ach receptor]] antibody
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Diplopia]], [[ptosis]], worsening with movement (as the day progresses)
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Electrolyte disturbance]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" | Electrolyte panel
| style="background: #F5F5F5; padding: 5px; text-align:center" |↓Ca++, ↓Mg++, ↓K+
| style="background: #F5F5F5; padding: 5px; text-align:center" |Possible [[arrhythmia]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Organophosphate poisoning|Organophosphate toxicity]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Ascending
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" | Clinical diagnosis: physical exam & history
| style="background: #F5F5F5; padding: 5px; text-align:center" |Clinical suspicion confirmed with RBC AchE activity
| style="background: #F5F5F5; padding: 5px; text-align:center" |History of exposure to i[[Insecticide|nsecticide]] or living in farming environment. with : [[Diarrhea]], [[Urination]], [[Miosis]], [[Bradycardia]], [[Lacrimation]], [[Emesis]], [[Salivation]], [[Sweating]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Tick paralysis]] ([[Dermacentor andersoni|Dermacentor tick]])
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Ascending
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" | Clinical diagnosis: physical exam & history
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |History of outdoor activity in Northeastern United States. The tick is often still latched to the patient at presentation (often in head and neck area)
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Tetrodotoxin]] poisoning
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" | Clinical diagnosis: physical exam & dietary history
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | History of consumption of puffer fish species.
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Stroke]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+/-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px; text-align:center" |UL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" | MRI +ve for ischemia or hemorrhage
| style="background: #F5F5F5; padding: 5px; text-align:center" |MRI
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden unilateral motor and sensory deficit in a patient with a history of [[Atherosclerosis|atherosclero]]<nowiki/>tic risk factors (diabetes, hypertension, smoking) or [[Atrial fibrillation|atrial fibrillation.]]
|-
| style="background: #DCDCDC; padding: 5px; text-align:center;" | [[Poliomyelitis]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px; text-align:center" |Proximal > Distal
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL or UL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |
| style="background: #F5F5F5; padding: 5px; text-align:center" |PCR of CSF
| style="background: #F5F5F5; padding: 5px; text-align:center" |Asymmetric paralysis following a flu-like syndrome.
|-
| style="background: #DCDCDC; padding: 5px; text-align:center;" | [[Transverse myelitis]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Proximal > Distal
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL or UL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |MRI & [[Lumbar puncture]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |MRI
| style="background: #F5F5F5; padding: 5px; text-align:center" |History of chronic viral or autoimmune disease (e.g. [[HIV]])
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Neurosyphilis]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Posterior leukoencephalopathy syndrome
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px;" |++
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px;" |-/+
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px;" |-/+
| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px;" |Multiple cortico-subcortical areas of T2-weighted hyperintense signal involving the [[occipital]] and [[parietal lobe]]<nowiki/>s bilaterally and [[pons]].
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px;" |MRI
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px;" |Other symptoms include: [[Seizure]], [[headache]], [[visual disturbance]]<nowiki/>s, [[focal neurologic signs]], and [[status epilepticus]].
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious<nowiki/>
| style="background: #F5F5F5; padding: 5px; text-align:center" |MRI & [[Lumbar puncture]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |CSF [[VDRL]]-specifc
CSF [[FTA-ABS|FTA-Ab]] -sensitive
| style="background: #F5F5F5; padding: 5px; text-align:center" |History of unprotected sex or multiple sexual partners.


History of [[genital ulcer]] ([[chancre]]), diffuse [[Maculopapular rash|maculopapular ras]]<nowiki/>h.
Many cases resolve within 1–2 weeks of controlling blood pressure and eliminating the inciting factor.
|-
| style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Muscular dystrophy]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Proximal > Distal
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" | Genetic testing
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Muscle biopsy]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |Progressive proximal lower limb weakness with calf pseudohypertrophy in early childhood. [[Gowers' sign|Gower sign]] positive.
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Multiple sclerosis]] exacerbation
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px; text-align:center" |NL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align:center" |'''[[CSF|↑]]'''[[CSF]] [[IgG]] levels
(monoclonal)
| style="background: #F5F5F5; padding: 5px; text-align:center" |Clinical assessment and [[MRI]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Blurred vision|Blurry vision]], [[urinary incontinence]], [[fatigue]]
|-
| style="background: #DCDCDC; padding: 5px; text-align:center" |[[Amyotrophic lateral sclerosis]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" | Normal [[Lumbar puncture|LP]] (to rule out DDx)
| style="background: #F5F5F5; padding: 5px; text-align:center" |MRI & [[Lumbar puncture|LP]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |Patient initially presents with [[upper motor neuron]] deficit ([[spasticity]]) followed by [[lower motor neuron]] deficit ([[flaccidity]]).
|-
| style="background: #DCDCDC; padding: 5px; text-align:center;" | [[Myositis|Inflammatory myopathy]]
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align:center" |Proximal > Distal
| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
| style="background: #F5F5F5; padding: 5px; text-align:center" |UL or BL
| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
| style="background: #F5F5F5; padding: 5px; text-align:center" |Elevated [[Creatine kinase|CK]] & [[Aldolase]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Muscle biopsy]]
| style="background: #F5F5F5; padding: 5px; text-align:center" |Progressive proximal muscle weakness in 3rd to 5th decade of life. With or without skin manifestations.
|-
|-
|}
|Ischemic Brain stem infarction
|  -/+
|  +
|  -/+
|  -
|Abnormal high signal within the [[brainstem]] [[white matter]] and [[gray matter]]
|MRI
|




===Differentiating [disease name] from other diseases on the basis of [symptom 1], [symptom 2], and [symptom 3]===
The brain stem infarct can affect essential body functions, such as:


On the basis [symptom 1], [symptom 2], and [symptom 3], [disease name] must be differentiated from [disease 1], [disease 2], [disease 3], [disease 4], [disease 5], and [disease 6].
* Breathing
{|
* Swallowing
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
* Eye movement
! rowspan="4"  style="background: #4479BA; color: #FFFFFF; text-align: center;|Diseases
* Facial movement and sensation
| colspan="6" rowspan="1"  style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Clinical manifestations'''
* Hearing
! colspan="7" rowspan="2"  style="background: #4479BA; color: #FFFFFF; text-align: center;|Para-clinical findings
* Heart rate
| colspan="1" rowspan="4"  style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Gold standard'''
* Blood pressure
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;|Additional findings
* Body temperature
|-
| colspan="3" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Symptoms'''
! colspan="3" rowspan="2"  style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical examination
|-
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab Findings
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|Histopathology
|-
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 1
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 2
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 3
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 1
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 2
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 3
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 1
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 2
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 3
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 1
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 2
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 3
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 1
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Hypertensive encephalopathy
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-/+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-/+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Diffuse extensive periventricular deep white matter T2 hyperintensity changes
* Ex vacuo [[ventriculomegaly]]
* Global, symmetrical, supra and infratentorial involutional changes
| style="background: #F5F5F5; padding: 5px;" |MRI
| style="background: #F5F5F5; padding: 5px;" |Symptoms typically start to occur 12–48 hours after a sudden and sustained increase in [[blood pressure]].
The first symptom is a [[Headache|severe headache.]]
Other symptoms include:
Impaired judgement and memory
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 2
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Infective encephalitis
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-/+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-/+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-/+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 3
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Diseases
!Symptom 1
! colspan="1" rowspan="1" |Symptom 2
!Symptom 3
!Physical exam 1
! colspan="1" rowspan="1" |Physical exam 2
!Physical exam 3
!Lab 1
!Lab 2
!Lab 3
!Imaging 1
!Imaging 2
!Imaging 3
!Histopathology
|'''Gold standard'''
!Additional findings
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 4
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 5
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 6
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* High signal in both white and grey matter
* Region of hypodensity
*
| style="background: #F5F5F5; padding: 5px;" |MRI
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* [[Viruses]] are the most common cause of infectious encephalitis.
* [[Bacteria]], [[fungus]] and [[parasites]] also can cause infectious encephalitis
<br />
|}
|}


Latest revision as of 22:40, 2 March 2020

Central pontine myelinolysis Microchapters

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Differentiating Central pontine myelinolysis from other Diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Overview

On the basis central pontine myelinolysis must be differentiated diseases that cause acute confusion, lethargy, speech difficulties and bilateral weakness or quadriplegia such as: Posterior leukoencephalopathy syndrome, infective encephalitis, ischemic Brain stem infarction, thalamus infarction due thrombosis of the basilar artery, diffuse hypoxic encephalopathy, metastasis to the brain and brain tumors such as glioma.

Differentiating central pontine myelinolysis from other Diseases

On the basis central pontine myelinolysis must be differentiated diseases that cause acute confusion, lethargy, speech difficulties and bilateral weakness or quadriplegia such as:[1][2][3][4][5][6][7]

Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Lab Findings Imaging
Confusion Weakness and quadriplegia Speech difficulties Hypoosmotic hyponatremia MRI
Central pontine myelinolysis ++ ++ ++ ++
  • Symmetric signal intensity abnormality in the central pons at T2-weighted and FLAIR imaging
  • Decreased T1 signal intensity
  • Fluid attenuated inversion recovery (FLAIR) hyperintense lesion in the pons
  • Intramedullary central T2 hyperintensity at axial T2W of spinal cord and sagittal T2W of thoracic spinal cord
 MRI The most common cause of central pontine myelinolysis is rapid correction(>48-hours duration) of hyponatremia in patients with the history of prolonged hyponatremia
Posterior leukoencephalopathy syndrome ++ -/+ -/+ - Multiple cortico-subcortical areas of T2-weighted hyperintense signal involving the occipital and parietal lobes bilaterally and pons. MRI Other symptoms include: Seizure, headache, visual disturbances, focal neurologic signs, and status epilepticus.

Many cases resolve within 1–2 weeks of controlling blood pressure and eliminating the inciting factor.

Ischemic Brain stem infarction -/+ + -/+ - Abnormal high signal within the brainstem white matter and gray matter MRI


The brain stem infarct can affect essential body functions, such as:

  • Breathing
  • Swallowing
  • Eye movement
  • Facial movement and sensation
  • Hearing
  • Heart rate
  • Blood pressure
  • Body temperature
Hypertensive encephalopathy -/+ -/+ + -
  • Diffuse extensive periventricular deep white matter T2 hyperintensity changes
  • Ex vacuo ventriculomegaly
  • Global, symmetrical, supra and infratentorial involutional changes
 MRI Symptoms typically start to occur 12–48 hours after a sudden and sustained increase in blood pressure.

The first symptom is a severe headache.

Other symptoms include:

Impaired judgement and memory

Infective encephalitis -/+ -/+ -/+ -
  • High signal in both white and grey matter
  • Region of hypodensity
 MRI


References

  1. ↑ Kawabori M, Murata J, Abe S, Saito H (2009). "[A case of brainstem variant of reversible posterior leukoencephalopathy syndrome]". No Shinkei Geka. 37 (11): 1105–9. PMID 19938667.
  2. ↑ Osman Y, Imam YZ, Salem K, Al-Hail H, Uthman B, Deleu D (2013). "Isolated brainstem involvement in a patient with hypertensive encephalopathy". Case Rep Neurol Med. 2013: 540947. doi:10.1155/2013/540947. PMC 3600275. PMID 23533856.
  3. ↑ Uchino A, Sawada A, Takase Y, Kudo S (2004). "Symmetrical lesions of the middle cerebellar peduncle: MR imaging and differential diagnosis". Magn Reson Med Sci. 3 (3): 133–40. doi:10.2463/mrms.3.133. PMID 16093630.
  4. ↑ Uzkeser M, Akoz A, Ozdemir G, Emet M, Bayramoglu A (2012). "Wide central pontine, bulbar and thalamic myelinolysis with sequela". Eurasian J Med. 44 (3): 179–81. doi:10.5152/eajm.2012.42. PMC 4261386. PMID 25610237.
  5. ↑ Choi JM, Kim YH, Roh SY (2013). "Acute hepatic encephalopathy presenting as cortical laminar necrosis: case report". Korean J Radiol. 14 (2): 324–8. doi:10.3348/kjr.2013.14.2.324. PMC 3590348. PMID 23482893.
  6. ↑ Quattrocchi CC, Errante Y, Rossi Espagnet MC, Galassi S, Della Sala SW, Bernardi B; et al. (2016). "Magnetic resonance imaging differential diagnosis of brainstem lesions in children". World J Radiol. 8 (1): 1–20. doi:10.4329/wjr.v8.i1.1. PMC 4731345. PMID 26834941.
  7. ↑ Shalchi Z, Bennett A, Hargroves D, Nash J (2009). "Diagnostic delay in a case of herpes simplex encephalitis". BMJ Case Rep. 2009. doi:10.1136/bcr.12.2008.1350. PMC 3028237. PMID 21686359.

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