central pontine myelinolysis ( cpm ) is a demyelinating condition affecting the pons characterized by an acute progressive quadriplegia , dysarthria , dysphagia , and alterations of consciousness . pathologic features include prominent demyelination in the central pons with sparing of axons and neurons . this condition is usually associated with systemic disorders such as hyponatremia , chronic alcoholism , liver failure , severe burns , malignant neoplasms , hemorrhagic pancreatitis , hemodialysis , and sepsis . in about 10% cases , cpm is associated with extrapontine myelinolysis ( epm ) leading to the appearance of parkinsonian symptoms such as rigidity of limbs , bradykinesia , tremors , and decreased blinking . studies on cpm have mainly focussed on its etiology , neurological manifestations , radiological appearance , and outcome.[35 ] there is limited literature available on neuropsychiatric complications of central pontine / extrapontine myelinolysis ( cpem ) . some of the behavioral manifestations that have been described so far are - personality change , inappropriate affect , emotional lability or incontinence , disinhibition , poor judgment , and delirium . a few reports have also described occurrence of catatonic syndrome as a rare manifestation due to epm.[810 ] however , there are limited reports of psychosis in patients with cpem . we have described a case of cpem with psychosis as a complication which recovered completely with treatment given for short duration using low dose atypical antipsychotic ( quetiapine ) . a 53-year - old male presented to emergency department with complaints of acute onset , generalized rigidity and tremors of all limbs , difficulty speaking and swallowing along with slowness of movements , masked facies , and decreased blinking . he was recently discharged from medical icu after being managed for episodes of vomiting and decreased food intake associated with confusion , lethargy , disorientation to time and place . his serum na was found to be very low ( 102 meq / ml ) . he was also put on tab levetiracetam 1000 mg for seizure prophylaxis . at the time of discharge after 6 days of hospitalization his hyponatremia had been corrected rapidly ( by 13 meq / ml in initial 8 h ) . he also underwent magnetic resonance imaging ( mri ) of the brain which did not reveal any abnormality except for chronic ischemic changes in the bilateral centrum semiovale . detailed assessment did not reveal psychiatric symptoms or any previous psychiatric illness nor was there any history of substance abuse . there was no family history of any psychiatric illness as well . from the history and review of medical records , neuroleptic malignant syndrome was ruled out as patient was not subjected to any antipsychotics in previous hospital as per records . he was started on oral trihexyphenidyl ( centrally acting anticholinergic ) 1 mg tds along with supportive treatment . mri brain was repeated on day 4 of admission ( after 5 days of onset of symptoms ) which showed pontine hyperintensities and bilateral basal ganglia ( caudate and putamen ) hyperintensities on t2w1 and flair sequences confirming the diagnosis of cpem ( secondary to rapid correction of hyponatremia ) [ figures 1 and 2 ] . pontine hyperintensities and bilateral basal ganglia ( caudate and putamen ) hyperintensities on t2w1 and flair sequences bilateral basal ganglia ( caudate and putamen ) hyperintensities on t2w1 and flair sequences confirming the diagnosis of central pontine / extrapontine myelinolysis patient 's symptoms started improving dramatically after the treatment was started . hormone supplementation was started following reports of low adrinocorticotrophic hormone ( acth ) , thyroid stimulating hormone ( tsh ) , follicle stimulating hormone ( fsh ) and leutinising hormone ( lh ) levels . after 3 days of hospitalization , he developed behavioral symptoms for which psychiatric consultation was again taken . he was found to have disturbed sleep , irritability , suspiciousness toward a fellow patients in the ward and aggression toward treating resident doctors . he developed delusion of persecution and reference , claiming that a female patient on neighboring bed was passing insulting remarks to him indirectly when talking to others and was also teasing him through her gestures . he was started on quetiapine 50 mg and dose was increased to 100 mg over a period of 3 days . he tolerated it well and his psychotic symptoms started improving over a period of 4 weeks . he was discharged from the ward after his extrapyramidal symptoms got completely resolved . during follow - up visits , trihexyphenidyl was tapered off over next 1 month and quetiapine was gradually tapered off over next 6 months without any new symptoms . in this case , diagnosis of cpem could be established both clinically ( presence of dysphagia and dysarthria suggested pontine involvement and presence of generalized rigidity , bradykinesia , tremors , and related parkinsonian symptoms indicated extrapontine lesion ) as well as radiologically . we did consider the possibility of levetiracetam - induced psychosis but ruled it out given the fact that this drug was used in a low dose ( 1000 mg / day ; approximately 166 mg / kg ) and patient 's psychotic symptoms subsided with quetiapine without the need to stop levetiracetam . however , it was used at very low dose in the present case ( 3 mg / day ) . additionally , the nature of trihexyphenidyl psychosis , as described in literature , is toxic psychosis . thus , the psychotic symptoms that appeared could be attributed to brain lesions that are associated with cpem . this case highlights that psychotic symptoms could occur as a complication of cpem and can be managed effectively . these features subside shortly with resolution of neurological signs and symptoms associated with the brain lesions . the case in study hints at the possible role of basal ganglia in etiopathogenesis of psychotic symptoms given the fact that huntington , wilson , and parkinson disease , which all have basal ganglia involvement are also associated with psychotic symptoms , at times . the present case also reiterates the fact that in cpem , the outcome is not always dismal . additionally , correction of hyponatremia should be paced appropriately and should be limited to about 25 mmol / l during the initial 24 - 48 h.