Localized brainstem ischemic damage and Ondine's curse after near-drowning

A 19-year-old man was a victim of near-drowning in fresh water. After he was resuscitated, examination showed nystagmus, absent gag reflex, diminished facial sensation, dysmetria of all limbs, and failure of automatic respiration. His intellect was perfectly preserved. Eight months later, he died suddenly, and the essential neuropathologic findings were limited to the lower brainstem. There was marked neuronal depletion bilaterally in the nucleus gracilis, nucleus cuneatus, nucleus of the tractus solitarius, nucleus ambiguus, and nucleus retroambiguus; several other lower-brainstem nuclei showed evidence of damage, but to lesser extent. The neuropathologic findings seem to have been an unusual consequence of anoxia-ischemia and support previous concepts of the anatomical localization of the human respiratory centers.