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Acquired focal dystonia following recovery from central pontine myelinolysis.

Sir: Focal dystonia and hemidystonia are rare disorders of movement characterised by forceful and prolonged simultaneous contraction of agonist and antagonist muscles which distort the affected extremities into typical postures.1 Although the precise pathophysiological basis of hemidystonia is undetermined, symptomatic hemidystonia has been described in association with focal structural brain lesions including tumour, infarction, haemorrhage and arteriovenous malformations2 3 as well as several inflammatory and metabolic disorders (such as Wilson's disease, Leigh's disease, syphilis, and encephalitis). We describe a patient who developed monomelic dystonia following recovery from central pontine myelinolysis (CPM). A 57 year old man presented to a community hospital with confusion after a prodrome of viral gastroenteritis. He had a long history ofalcohol use without any associated deleterious medical complication. He had no prior history of any movement disorder, neuroleptic use, or familial dystonia. Initial neurological examination revealed an awake, disoriented man. Laboratory evaluation revealed a serum sodium of 100 mmoVl. Replacement therapy with normal saline was initiated at a rate of 1 4 mmol/l/hour over the first 24 hours to a level of 128 mmol/l. The patient's sensorium cleared. Two days later, the patient developed diplopia followed by quadriparesis and a pseudobulbar affect. Two CT scans during the first 2 weeks of admission were normal