Osmotic demyelination syndrome is one of the serious complications of rapid correction of severe hyponatremia that possibly can lead to irreversible damage. Here we are reporting a case of a 51-year-old male, with history of recurrent vomiting, recent thiazide diuretic use and alcohol consumption, who presented with severe symptomatic hyponatremia in form of seizure and diminished level of consciousness with an initial sodium level of 99 mEq/L. He was managed with hypertonic saline with significant improvement in his symptoms and he had overcorrected sodium, which was managed with hypotonic saline and desmopressin. Successfully his sodium level maintained at the level of 115 mEq/L in the first 48 hours. However, after 7 days of hospital stay he had drop in his level of consciousness that required intubation and his brain MRI showed features of osmotic demyelination syndrome. After 3 months of hospital stay, the patient’s mentation improved and he became fully oriented and alert, able to talk and moving with assistance. The important learning points of this case are to be very cautious with managing such cases especially those who have high risk factors with limiting the rate of sodium correction to the lowest possible level as 4-6 mEq/L/day and to maintain that even after the first 48 hours until the sodium reached a safe level.
 

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