Introduction: Cerebral ischaemic events in young patients due to patent foramen ovale are rare. A more plausible diagnosis had clouded the initial management and diagnosis of such a case in a young male patient.
Case report: A 19-year-old gentleman was admitted with vomiting and profound hyponatraemia of 99 mmol/l. He was diagnosed to have Addisons disease (with positive adrenal antibodies) following a flat short synacthen test. He warranted ITU admission and subsequently developed new neurological features of facial drooping, speech deficit and subtle weakness in his right upper and lower limb following rapid sodium correction over a few days. His sodium was corrected to 131 mmol/l within 72 h of admission, and MRI brain scans did not demonstrate any evidence of central or extra pontine myelinolysis. However subsequent imaging showed features consistent with ischaemic changes. The patients Addisons disease is now well controlled with oral hydrocortisone and fludrocortisone replacement, and a subsequent repeat cranial MRI showed high intensity at the left temporal lobe and bilateral pre-central sulcus that was in keeping with ischaemic events. His thrombophilia screen was negative, and he underwent a bubble contrast Echocardiogram that showed evidence of a patent foramen ovale on valsalva manoeuvre. He is now listed for closure of his patent foramen ovale under the care of the cardiologists.
Conclusion: The likelihood of the diagnosis was clouded by another more plausible diagnosis, the initial clinical presentation, and the rarity of cerebral ischaemic events in young patients. Although clinical suspicions were initially biased towards extra pontine myelinolysis, such rare conditions can occur and although well recognised, such situations are less commonly perceived in clinical practice.