Vertical and horizontal nystagmus in magnesium deficiency

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Vertical and Horizontal Nystagmus in Magnesium Deficiency w.

O. SMITH, MD, ROBERT M. CLARK, MD, JOHN MOHR, MD, and ROBERT WHANG, MD,t Oklahoma City, Okla

mained disoriented with visual hallucinations . In addition to nystagmus, physical examination revealed positive bilateral Babinski's signs. Measurement of magnesium in serum drawn immediat.ely after cardiopulmonary arrest was reported as 1.2 mEqlliter (normal, 1.4 to 2.0) and magnesium replacement was begun. A total of7 gm of intramuscular MgSO .. was given during the first two days of hospitalization, raising the serum magnesium level to 1.7 mEqlliter. At this point vertical and horizontal nystagmus were no longer spontaneous but were manifested with provocative measures. During hel- third and fourth hospital days the patient received a total of 19.7 gm of magnesium (2 gm of intramuscular MgSO., and 19.5 gm orally via a magnesium-containing antacid) , resulting in an increase in the serum magnesium level to 2.1 mEq/liter. On her fifth hospital day the patient's mental status bega n to clear, and within 12 hours she was alert, oriented , and without vertical or horizontal nystagmus. She had no further problems and was discharged after eight days of hospitalization.

THE CLINI CAL MANIFESTATIONS of magnesium deficiency relate primarily to hyperirritability of the central nervous and neuromuscular systems. Cardiovascular aberrations are also observed at times. Vertical nystagmus has been re ported in two patients. I.' This re po rt concerns an additi o nal patie nt with magnesium deliciency who developed both verti cal and horizontal nystagmus. CASE REPORT

A 36-year-old black woman with a long history of alcohol abuse presented to the emergency room with a two-day history of "cramping" in both hands, increased respiratory rate, and perioral tingling. Physical examination revealed bilateral carpal spasm and a positive Chvostek's sign . Arterial blood gas values on room air revealed a pH o f7.51 , PaCO, 01'31 mm I-Ig, and Pa O" 83 mm I-Ig. Serum calcium value was8.4 mg/dl; serum sodium concentratio n was 136 mEqlliter; potassium level, 3.1 mEq/liter; chlo ride, 90 mEq/liter; and CO" 24 mEq/liter. She was treated with a rebreathing bag and given diazepam, 5 mg intramuscularly, and 14 mEq ofCaCI intravenously. Forty minutes later the patient su ffel-ed a generalized to nic-clonic seizure follo wed by cardiopulmona ry arrest. Monitoring revealed ve ntricular fibrillation, which converted to sinus tachycardia after cardiopulm onary resuscitation and DC countershock. Spontaneous r espirations began and the patient became alert but was disoriented and nonresponsive to verbal commands. She was markedly agitated and hyperexcitable. Laboratory d ata obtained after the patient was stabilized revealed a serum sodium concentration of 134 mEqlliter, potassium value of 4 .5 mEq/liter, chloride 86 mEq/liter, and CO, content 18 mEq/liter. Other values were serum urea nitrogen concentration , 5 mg/dl ; creatinine, 0.6 mg/dl ; calcium, 11.7 mg/dl ; albumin, 3.6 gm/dl; and phosphate, 2.5mg/dl. Serum lactate was 3.8 mEqlliter (n ormal, 0.5 to 2.2), and serum was negative for ketones and salicylates .

COMMENT

Vertical nystagmus has been previously reported in magnesiumdeficient patients. This is the tirst report of a patient who demonstrated horizontal nystagmus in association with hypomagnesemia. Wernicke's ence phalopath y was initially considered in this patient because of the nystagmus, but no ocular paresis was demonstrated at any time, nor was ataxia present, and the mental state was one of excitement rather than apathy. Since calcium and magnesium are physiologic antagonists , it is possible that the administration of calcium may have induced ventricular fibrillation in this hypomagnesemic patient. This also may have been a factor in the development o f other manifestations of magnesium depletion , including the nystagmus. SUMMARY

Twelve hours after admission vertical nystagmus was noticed for the first tim e and, shortly thereafter, this began alternating with horizontal nystagmus. Ophthalmoplegia was never noted. Although alert, th e patient was extremely restless and anxious, and she re-

We report a patient with magnesium deficiency in whom both horizontal and vertical nystagmus subsided after magnesium replacement.

tFrom the Medical Service, Oklahoma City Veterans Administration Medical Center, and the De/JarUnent of Medicine, University of Oklaho ma Health Sciences Center, Okla IO Illa City. Re print re'lucsts to Medical Service (Ill A), VA Medical Center, 921 N E 13th St, Okia tOIlla City, Okla 73104 (Dr. Smith) .

References 1. Smith WO: Magnesium deficiency in the surgical patient. Am J Cardial 13 :667-670, 1963 2. I-lamed lA, Lindeman RD : Dysphagia and vertical nystagmus in magnesium deficiency. Ann In/CI'n Med 89:222 -223, 1978

Meningitis In Typhoid Fever: An Unusual COluplication P. NEVIUS , MD, G. CONTRONI, MS, and W. J. RODRIGUEZ , MD,i' Washington , DC TYI'HOID FEVER in children under 2 years of age, though well documented, is rare," " and meningitis is even more infreque nt in SaluWlll'lIa Iy/)hi infection ."'" tFrolll the Departments or Pediatric Medicine, Clinical Micl'Obioloh'Y, and Inrectious Diseases, Children's Hospital National Medical Center and George Washinglon University School or Medicine, Washington, DC. Reprint requests to Infectious Diseases, Children's Hospital National Medical Cenler, III Michigan Ave NW, Washington, DC 20010 (Dr. Rodrigue,.) . *Analytab Products, Inc., Plainview, NY.

The first case of Salmunt'lla meningitis was reported by Ghon 7 in 1907. Since then, the literature concerning this disease has bee n revie wed by Smith ," Watson," Luder and Tomson ,lII and Rabinowilz and McLeod." Because it had been customary to distinguish clinically between infectio ns due to S I),/)h.i and other salmonellae, Henderson 12 in his communication d ealing Wilh S".!lIumdla me ningitis cited onl y those patien ts with Saillunudia I!nlaitis meningitis, excluding those with typhoid meningitis. In a subsequelll. review, however, Beene et alII

Smith et al

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NYSTAGMUS IN MAGNESIUM DEFICIENCY

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