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.
I got confused for a second, then elated. Love the crossover.
All jw had to do was not leave his kids while fishing
My first expression was "wait what the fuck?"
Basically, if you're an alcoholic who only drinks beer, eat some junk food too.
Is it me or does this guy look like Genghis Khan?
I drink till I'm drunk
I had to do a doubletake when I saw this on my feed.