A Dad Drank 50 Beers Everyday For 6 Weeks.
This Is What Happened To His Brain.
JW is a 42 year old man, presenting to the emergency room with status epilepticus, a
15 minute seizure.
Nurses use medicine to terminate his seizure, but 5 minutes later, JW starts seizing again.
This didn’t phase anyone, because this is his second time presenting to the emergency
room this month.
JW was a dad.
When his sons were young, he took them on a fishing trip.
He told them he was going to get some bread and snacks for the fish, but he never came
back.
12 years ago, JW started drinking every day.
In the last few years, he had been admitted into the hospital 25 times for alcohol related
problems.
He always told doctors about his boys, and how excited he was to get better and be back
in their lives.
They’re such good kids, he would say, but, JW never got better.
He always ended up back with his beer.
About 2 months ago, medical staff leaving their shift from the emergency room would
see JW on the street nearby, sitting on the floor slumped in a pile of his own beer cans.
No one could do anything about it.
Day in and day out, JW didn’t drink to his heart’s content, he drank to just feel normal.
50 beers daily, was his only dietary intake for more than a month, which gives us some
clues as to what’s happening to him.
The medical team was familiar with drunk JW presenting to the emergency room, but this
time, something’s wrong.
Alcohol is a nervous system depressant, meaning it slows down all processes of the brain.
But a seizure, is all the of the brain processes firing off at the same time, opposite the
action of a depressant.
You don’t usually seize when you’re drunk at 42 years old.
JW is still breathing, it doesn’t look like he’s ingested anything else.
Drunk JW is not the one presenting to this emergency room this time meaning something
else is happening to him.
It’s possible that he could be suffering from alcohol withdrawal.
Chronic, misuse of alcohol builds dependence.
This is a time when structures in the brain adapt to the excess amounts of ethanol placed
in the body.
Areas of the brain that are supposed to insulate electrical signals are stimulated by the alcohol,
meaning after repeat stimulation, more and more alcohol is needed to maintain the same
level of inhibition.
This is modulated by GABA which is an important neurotransmitter, and excess ethanol induces
insensitivity to it.
So more inhibitor is needed to hold a constant inhibitory tone.
This is called tolerance.
But it’s not done (finished) here.
Alcohol also blocks a chemical in the brain called glutamate that excites the brain, so
in this area, more structures that receive glutamate are constructed here in the hopes
that alcohol can’t block everything, and that some glutamate can get through because
the brain needs that excitation to function normally.
A chronic alcoholic’s brain is physically changed after years of misuse, so if JW hasn’t
had a drink for a few hours, electrical signals aren’t insulated anymore.
The increased number of glutamate receptors aren’t blocked anymore, so everything gets
excited, resulting in status epilepticus, creating a dependency on alcohol.
If he doesn’t drink for just a short period of time, bad things happen to his brain.
JW seizes for the 6th time, and nurses terminate it again.
But how can we be sure that JW has alcohol withdrawal?
In-between seizures, JW is confused, and disoriented.
When asked when his last drink was, he can’t even slur out an answer because he can’t
even say his own name.
If his only dietary intake was 50 beers everyday for weeks, then he has protein malnutrition.
He has vitamin deficiency, which are well known to cause neurologic issues in chronic
alcoholics.
Both of these can be an easy fix.
If he needs vitamins, give him vitamins, and make sure he doesn’t stop receiving vitamins.
Proteins can also be important, but more urgently, a blood test finds that JW has chronic hyponatremia.
Hypo meaning Low Natre, referring to Sodium, or more formally
Natrium as shown by its symbol on the periodic table of elements
and -emia meaning presence in blood.
Low sodium presence in blood.
Chronic meaning this has been developing on a timescale of several weeks now, pointing
us back to the 50 beers he drank everyday, that are sitting inside his body at the moment.
Hyponatremia can also be the cause of his seizures too, which brings us to the next
clue.
50 cans of beer, is more than 4 and a half gallons of liquid, that’s been going in
to JW’s body, daily.
Interestingly enough, in the emergency room, JW has barely made any urine at all, meaning
that there hasn’t really been a net flow out of his body.
His body is holding on to all of that liquid, and it’s not just from 1 day’s worth of
beer, it’s a staggered accumulation over weeks.
But let’s look at the name hyponatremia.
Low sodium presence in blood.
Low sodium fits because in 1 can of beer, there’s only about 10 milligrams of sodium.
This is about as much sodium as in 1 cup of tap water.
When natremia is measured, it’s reported as the amount of sodium present, divided by
a volume of body water.
So low sodium presence in blood can be caused by a large volume of fluid, like 4 and half
gallons of beer everyday.
But this also means that a low value can be caused by an actual low amount of sodium going
in to the body, everyday.
Usually, hyponatremia is a problem with water because that’s harder for the body to balance,
when something is wrong.
But if JW’s only dietary intake for 6 weeks was 50 cans of beer daily, then this means
he has both a lot of water that he’s holding on to, and has little sodium in his body because
beer doesn’t really have salt in it.
But sodium isn’t the only electrolyte that matters here.
Beer also doesn’t have potassium.
Potassium also has influence on body water through its impact on urine production, but
JW also has hypokalemia, or low potassium presence in blood because of that beer.
Both sodium and potassium electrolytes interplay with urea, which is a breakdown product of
protein in the kidneys to help produce urine, and JW hasn’t eaten any protein lately,
although if he hasn’t eaten for weeks, then his muscles should be wasting away in atrophy,
and this could count as protein to make urea for urine, but that isn’t happening because
beer has carbs.
Carbohydrates, which in the body, are broken down to sugar, and water.
Sugar induces the response of insulin, an anabolic hormone which prevents the breakdown
of muscle meaning no urea is available for urine production.
Along with hyponatremia and hypokalemia, these are all causing him to hold on to all that
water because the kidneys need to exchange these when it makes urine.
This beer potomania, Poto from an Ancient Greek word meaning to drink and mania referring
in this case to an excess, is a hypotonic hyponatremia that is causing all of JW’s
problems.
Samples of the little urine he’s made since presenting to the emergency room were analyzed.
No solutes were found, meaning his urine was maximally dilute [specific gravity].
But, this should make sense.
We’ve already established he’s got a lot of water inside him.
When someone is well hydrated, the urine is supposed to be dilute.
But well-hydrated in JW’s case is an understatement— he should be bursting at the seams with fluid
overload.
He should be puffy and swollen everywhere.
He should be peeing every couple of minutes.
But he isn’t.
He looks, mostly normal.
So, where exactly are those hundreds of cans of beer, inside his body?
Well, body water is supposed to have 0.9% sodium chloride.
In the medical world, we call this isotonic.
This means for every 1 liter of water, there are 9 grams of sodium chloride, which is this
table salt.
0.9%, is thousands of times more sodium content than beer.
Most of the body’s water isn’t in the blood, it’s inside the cells, and it exists
as 0.9% sodium chloride.
Sodium creates something called an osmotic gradient.
Which means wherever sodium is, water will flow towards it.
In this small science experiment, I dissolve salt in this water and place it into a tube.
I submerge the tube in a pool of water that has no salt dissolved in it.
You’ll see that water flows into the tube, that water flows towards the sodium.
So, if his body water has been diluted by hundreds of cans of beer, then it means water
in the cells is saltier.
And because water flows towards sodium, then JW’s body water is flowing in to his cells.
This would mean that his organs like his liver and his intestines are starting to swell with
water.
That should be ok, because the abdomen is soft.
But what about the brain?
It’s enclosed in a hard space.
The skull has only room for a brain expansion of 8% before it starts to crush up against
the sides of the skull and ooze out into the sutures, or the gaps of the skull, pinching
blood flow as parts of JW’s brain start to necrose, or quite literally, die.
This damage upon brain expansion is known as herniation and means permanent brain damage
in JW’s case, bringing us back to his seizures.
If JW’s hyponatremia is caused by a low daily intake of sodium, then simply giving
him just salt, will fix his problems.
Interestingly enough, this is one of the few instances of hyponatremia where giving just
salt is the fix.
But the medical team can’t give him tablets by mouth, because he’s disoriented.
Giving him anything by mouth could cause him to choke.
So he’s given a small injection of 3% sodium chloride.
Small injection because he doesn’t need anymore fluid.
And 3% sodium chloride being saltier than isotonic 0.9% saline.
Within a few hours, JW produces gallons of urine.
His kidneys are able to exchange the salts for water, as it starts pouring out of his
body.
His seizures stop, and he regains consciousness while medicines are given for his alcohol
withdrawal.
The medical team repeat the 3% sodium chloride injection 2 more times throughout the day
to help with the cerebral edema.
As the days go by, JW’s sodium levels normalize.
He is in stable condition.
He gets vitamins and proteins.
He recovers, and is well enough for discharge from the hospital.
But just before doctors sign off on his discharge, JW complains of general weakness.
His speech is slurred and incoherent.
Neurology consult finds coordination deficits in JW.
His movements in the limbs above his waist were uncoordinated, with intended positioning
often missing the target at varying lengths.
This is called dysmetria.
Dys meaning wrong and metria meaning length.
Similarly, he had dysdiadochokinesia, meaning his ability to perform rapid, alternative
movements was compromised.
All of this pointing to possible neurodegeneration in JW, that has worsened since his hyponatremia
was corrected days ago because he didn’t have these problems back then.
He’s not ready to be discharged.
As the hours go by, he becomes weak in all 4 limbs.
Nurses ask him to move his arms and legs, but no response.
His muscles are floppy, as his limbs become paralyzed.
And an MRI of his brain reveals that JW has central pontine myelinolysis.
Lysis meaning breaking down of myelin, the conductive sheath covering nerve cells.
And central pontine referring to the central pons of the brain where it connects to the
brain stem to deliver nerve impulses throughout the body.
If his hyponatremia has been corrected, and JW has been sober for many days now under
medical supervision, then how could he just suddenly, become paralyzed?
Well, do you remember that name, chronic hyponatremia?
Well, chronic means that his body had low sodium presence in blood on a timescale of
at least weeks to months because of the 50 beers only that he drank everyday.
When sodium presence in blood starts decreasing, water starts flowing into cells pretty quickly.
The brain does start to swell a bit in this initial phase, but the brain has an outlet
called the cerebrospinal fluid, which flows into the spinal cord, and cushions the brain
inside the skull.
When hyponatremia is chronic, the swelling, even if it’s slow, keeps happening, and
the brain is forced to pump out organic salts, or carbon-containing salts to prevent further
swelling.
These organic salts are like sodium in that wherever they are, water will flow towards
them, too so when they’re out of the brain, water will follow them out.
And because of this adaptation, this is why JW’s brain didn’t immediately swell up
after just a couple of weeks of drinking 50 beers everyday, because as he was slowly losing
sodium day by day, the adaptions in the brain were adjusting to the chronic hyponatremia.
Sodium correction in a patient like JW is difficult because of all the metabolic derangements
inside of his body, some of which are unmasked after initiation of therapy.
His adapted brain started to shrink in the presence of sodium.
Sodium and potassium, rushed in to his brain cells by design, without the proper presence
of those organic salts, because those take time to get pumped in and enter the brain
cells.
When there is high sodium presence in a cell, the DNA there starts to break.
The cell, thinks it’s been mortally damaged and initiates programmed death because of
those DNA breaks.
This happens in all cells in the body and is a defense mechanism against things like
cancer.
But in the brain cells, the myelin sheath in JW sloughs off and parts of his brain start
to die again, leaving him paralyzed for life.
Chronic hyponatremia is a completely different case from acute hyponatremia, where the brain
has not had time to adapt, meaning the correction in the case of acute can be quick and aggressive
in an effort to save someone from the cerebral edema and resulting brain herniation.
Beer potomania can be difficult to identify if you don’t know what you’re looking
for, because electrolyte disturbances are just so common in chronic alcoholism.
And chronic alcoholics may not tell you exactly what happened, because they may not even know themselves
About 18% of patients who have beer potomania are at risk for osmotic demyelination, and
hypokalemia and hypophosphatemia are also increased risk factors for it, especially
since these patients are almost always severely malnourished, just like JW.
Thank you so much for watching.
Take care of yourself and be well.