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Hiraga A. Hand knob sign in Marchiafava-Bignami disease and Wernicke's encephalopathy. Neurol Sci 2024; 45:2903-2904. [PMID: 38265535 DOI: 10.1007/s10072-024-07345-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/19/2024] [Indexed: 01/25/2024]
Affiliation(s)
- Akiyuki Hiraga
- Department of Neurology, Chiba Rosai Hospital, 2-16 Tatsumidai-Higashi, Ichihara-shi, Chiba, 290-0003, Japan.
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Koca O, Turna ZH. Letter to the Editor: Total parenteral nutrition-induced Wernicke's encephalopathy after oncologic gastrointestinal surgery. Open Med (Wars) 2024; 19:20240920. [PMID: 38463520 PMCID: PMC10921446 DOI: 10.1515/med-2024-0920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 03/12/2024] Open
Affiliation(s)
- Oguzhan Koca
- Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53 Fatih, 34098Istanbul, Turkey
| | - Zeynep Hande Turna
- Division of Medical Oncology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Koca O, Demir B, Derin S, Turna ZH. A case report of Wernicke Korsakoff syndrome in a patient with cholangiocellular carcinoma: An underestimated cause of encephalopathy in cancer patients. Medicine (Baltimore) 2022; 101:e31904. [PMID: 36482648 PMCID: PMC9726370 DOI: 10.1097/md.0000000000031904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Wernicke's encephalopathy, a disorder caused by thiamin deficiency, is characterized by a classical triad of encephalopathy, ataxia, and ophthalmoplegia. Although alcoholism is the most common predisposing factor, it can also be associated with nonalcoholic states (hyperemesis gravidarum, intestinal obstruction, bariatric surgery, and others). This work presents a case of nonalcoholic Wernicke-Korsakoff syndrome diagnosed in a cholangiocellular carcinoma patient and literature review. CASE REPORT A 65-year-old male patient with a history of cholangiocellular carcinoma (Klatskin tumor) was treated with radiotherapy at the operation site after Roux-en-Y hepaticojejunostomy. During follow-up, the patient developed gastric outlet obstruction and was diagnosed with peritoneal carcinomatosis after a palliative gastrojejunostomy. As the patient could not tolerate oral nutrition during hospitalization, total parenteral nutrition was administered. After 10 days of admission, the patient showed decreased response to verbal stimuli as well as bilateral horizontal nystagmus, lethargy, and disorientation. Furthermore, the patient displayed confabulation. Clinical and imaging findings were consistent with Wernicke's encephalopathy. Therefore, treatment with intravenous thiamin replacement was initiated. The patient's encephalopathy regressed on the second day after treatment, and he recovered the place-person-time orientation. In the following month, the abnormal imaging findings were almost entirely resolved. CONCLUSION In order to prevent irreversible brain damage induced by chronic thiamin deficiency, thiamin replacement therapy with parenteral nutrition solutions should be included as a treatment for hospitalized cancer patients unable to receive enteral nutrition for a long time.
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Affiliation(s)
- Oguzhan Koca
- Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Bilal Demir
- Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sumeyra Derin
- Division of Medical Oncology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Zeynep Hande Turna
- Division of Medical Oncology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Abu-Abaa M. Seizure as the Main Manifestation of Nonalcoholic Wernicke’s Encephalopathy but Without Cortical Involvement: A Case Report. Cureus 2022; 14:e28866. [PMID: 36225406 PMCID: PMC9541440 DOI: 10.7759/cureus.28866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
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Benzalim M, Arharas S, Alj S, Elouardi Y, Khallouki M. Gayet Wernicke's encephalopathy with cortical damage following a subtotal gastrectomy: An uncommon association. Radiol Case Rep 2020; 16:94-97. [PMID: 33204379 PMCID: PMC7649599 DOI: 10.1016/j.radcr.2020.10.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/19/2020] [Accepted: 10/23/2020] [Indexed: 11/30/2022] Open
Abstract
Wernicke's encephalopathy is a pathological entity caused by Vitamin B1 (Thiamine) deficiency in malnourished individuals, especially alcoholics, patients operated for digestive surgery or suffering from gastrointestinal tract's diseases or incoercible vomiting. Classically it manifests by confusion with oculomotor disorders and ataxia. However, other neurological manifestations are possible. Magnetic resonance imaging is the gold standard imaging technique for diagnosis. It shows signal abnormality on periventricular area around the third and fourth ventricles and on mammillary bodies in the most common cases, however other localizations are possible, in particular the cerebral cortex, which can explain the occurrence of epileptic seizures in some patients. Early administration of Thiamine, intravenously or intramuscularly, allows ad-integrum recovery, while delayed treatment is associated with serious consequences in terms of mortality and morbidity with debilitating neurological sequelae. The presence of cortical lesions is of poor prognosis despite a well-managed treatment. In this article, we report a nonalcoholic Wernicke's encephalopathy case, following a subtotal gastrectomy. Epileptic seizures were the major clinical manifestation, related to the associated cortical lesions. Despite early and well-managed treatment, the patient had a poor prognosis, with progression, after one month, to a persistent chronic vegetative state.
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Affiliation(s)
- Meriam Benzalim
- Department of Radiology, Ibn Tofail Hospital, Mohammed VI University Hospital Center, CADI AYYAD University, Faculty of Medicine and Pharmacy of Marrakech, Abdelouahab Derraq street, Marrakech 40000, Morocco
| | - Soumaya Arharas
- Department of Radiology, Ibn Tofail Hospital, Mohammed VI University Hospital Center, CADI AYYAD University, Faculty of Medicine and Pharmacy of Marrakech, Abdelouahab Derraq street, Marrakech 40000, Morocco
| | - Soumaya Alj
- Department of Radiology, Ibn Tofail Hospital, Mohammed VI University Hospital Center, CADI AYYAD University, Faculty of Medicine and Pharmacy of Marrakech, Abdelouahab Derraq street, Marrakech 40000, Morocco
| | - Youssef Elouardi
- Department of Anesthesia and Intensive Care Medicine, Ibn Tofail Hospital, Mohammed VI University Hospital Center, CADI AYYAD University, Faculty of Medicine and Pharmacy of Marrakech, Marrakech, Morocco
| | - Mohamed Khallouki
- Department of Anesthesia and Intensive Care Medicine, Ibn Tofail Hospital, Mohammed VI University Hospital Center, CADI AYYAD University, Faculty of Medicine and Pharmacy of Marrakech, Marrakech, Morocco
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WERNICKE ENCEPHALOPATHY IN A PATIENT WITH GASTRIC CANCER RECURRENCE AFTER UPPER GASTROINTESTINAL SURGERY: A CASE REPORT AND REVIEW OF THE LITERATURE. Gastroenterol Nurs 2020; 43:463-469. [PMID: 33259433 DOI: 10.1097/sga.0000000000000549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Mohammed EA, Hajji SA, Aljenaee K, Ghanbar MI. Wernicke's encephalopathy-induced hearing loss complicating sleeve gastrectomy. BMJ Case Rep 2020; 13:13/9/e233144. [PMID: 32933905 DOI: 10.1136/bcr-2019-233144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 25-year-old woman brought to the hospital with symptoms of acute confusion, disorientation, diplopia, hearing loss and unsteady gait which started 4 days prior to her presentation with rapid worsening in its course until the day of admission. She had a surgical history of laparoscopic sleeve gastrectomy 2 months earlier which was complicated by persistent vomiting around one to three times per day. She lost 30 kg of her weight over 2 months and was not compliant to vitamin supplementation. CT of the brain was unremarkable. Brain MRI was done which showed high signal intensity lesions involving the bilateral thalamic regions symmetrically with restricted diffusion on fluid-attenuated inversion recovery imaging. Other radiological investigations, such as magnetic resonance venography and magnetic resonance angiography of the brain were unremarkable. An official audiogram confirmed the sensorineural hearing loss. A diagnosis of Wernicke's encephalopathy due to thiamin deficiency post-sleeve gastrectomy was made based on the constellation of her medical background, clinical presentation and further supported by the distinct MRI findings. Consequently, serum thiamin level was requested and intravenous thiamin 500 mg three times per day for six doses was started empirically, then thiamin 250 mg intravenously once daily given for 5 more days. Marked improvement in cognition, eye movements, strength and ambulation were noticed soon after therapy. She was maintained on a high caloric diet with calcium, magnesium oxide, vitamin D supplements and oral thiamin with successful recovery of the majority of her neurological function with normal cognition, strength, reflexes, ocular movements, but had minimal resolution of her hearing deficit. Serum thiamin level later was 36 nmol/L (67-200).
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Affiliation(s)
| | | | - Khaled Aljenaee
- Endocrine and Diabetes, Al Adan Hospital, Kuwait, Al Asimah, Kuwait
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Friedrich M, Herrmann R, Klötzsch C. [Confusion, grand mal series and lactic acidosis in a 46-year-old woman]. DER NERVENARZT 2020; 91:740-742. [PMID: 32488415 DOI: 10.1007/s00115-020-00932-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mirko Friedrich
- Neurologische Abteilung, Hegau-Bodensee-Klinikum Singen, Virchowstraße 10, 78224, Singen, Deutschland
| | - Ruxandra Herrmann
- Neurologische Abteilung, Hegau-Bodensee-Klinikum Singen, Virchowstraße 10, 78224, Singen, Deutschland
| | - Christof Klötzsch
- Neurologische Abteilung, Hegau-Bodensee-Klinikum Singen, Virchowstraße 10, 78224, Singen, Deutschland.
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Kim JS, Rho SY, Hwang HK, Lee WJ, Kang CM. A case of Wernicke's encephalopathy following complicated laparoscopic pylorus-preserving pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg 2019; 23:295-299. [PMID: 31501822 PMCID: PMC6728253 DOI: 10.14701/ahbps.2019.23.3.295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 04/20/2019] [Accepted: 04/20/2019] [Indexed: 01/06/2023] Open
Abstract
Laparoscopic pylorus-preserving pancreaticoduodenectomy (PPPD)/pancreaticoduodenectomy (PD) is cautiously regarded as a safe and effective approach in well-selected patients with periampullary cancer. However, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postoperative bleeding, and sepsis and detrimental complications that can follow PPPD/PD. These complications can result in poor oral intake for a significant period of nothing per oral (NPO) or deterioration of long-term function. A 65-year-old man underwent laparoscopic PPPD for ampulla of vater (AoV) cancer. After surgery, He experienced POPF, DGE, Postoperative bleeding and these complications result in poor oral intake for one month. Approximately 50 days after surgery, an abrupt confused state was noted. He had horizontal nystagmus and ataxia. Abnormal Brain magnetic resonance imaging tomography findings detected in the bilateral medial thalami, dorsal midbrain, and medulla. The association of confusion, ataxia, and horizontal nystagmus along with poor oral intake and the MRI findings suggested acute Wernicke's encephalopathy. After thiamine therapy, He recovered completely. Wernicke's encephalopathy is very rare, but it can progress coma and even death. Therefore, Wernicke's encephalopathy needs to be considered in patients with complicated PPPD/PD associated with malnutrition.
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Affiliation(s)
- Ji Su Kim
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seoung Yoon Rho
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woo Jung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
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Chang HW, Yang PY, Han TI, Meng NH. Wernicke encephalopathy concurrent with polyradiculoneuropathy in a young man after bariatric surgery: A case report. Medicine (Baltimore) 2019; 98:e14808. [PMID: 30855500 PMCID: PMC6417542 DOI: 10.1097/md.0000000000014808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
RATIONALE Bariatric surgery is the recommended treatment for morbid obesity because of its rapid and sustained body weight loss effect. Nutrient deficiency-related neurological complications after bariatric surgery are often disabling. Thus, early recognition of these complications is important. Neurological complications involving the central and peripheral nerve system after bariatric surgery were reported. However, the report on the clinical course of the concurrent involvement of central and peripheral nervous system is limited. We present a rare case of a patient who developed Wernicke encephalopathy concurrent with polyradiculoneuropathy after receiving bariatric surgery. PATIENT CONCERNS A 22-year-old man with a history of morbid obesity presented progressive bilateral lower limbs weakness, blurred vision, and gait disturbance 2 months after receiving laparoscopic sleeve gastrectomy. Bilateral lower limb numbness and cognition impairment were also noted. DIAGNOSIS Brain magnetic resonance imaging and electrophysiologic studies confirmed the diagnosis of Wernicke encephalopathy concurrent with acute polyradiculoneuropathy. INTERVENTIONS Vitamin B and folic acid were given since admission. He also received regular intensive rehabilitation program. OUTCOMES The subject's cognitive impairment and diplopia improved 1 week after admission under medical treatments, yet lower limb weakness and gait disturbance were still noted. After a month of intensive inpatient rehabilitation, he was able to ambulate with a walker for 30 munder supervision. LESSONS Nutrient deficiency-related neurological complications after bariatric surgery are often disabling and even fatal. Prevention of neurological complications can be improved through close postsurgical follow-up of the nutritional status. Recognizing the signs and symptoms and evaluating the medical history are critical to the early diagnosis and treatment of this potentially serious yet treatable condition.
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Affiliation(s)
- Heng-Wei Chang
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital
| | - Pei-Yu Yang
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Ting-I Han
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital
| | - Nai-Hsin Meng
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital
- School of Medicine, China Medical University, Taichung, Taiwan
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Nakajima K, Masubuchi Y, Ito Y, Inohana M, Takino M, Saegusa Y, Yoshida T, Sugita-Konishi Y, Shibutani M. Developmental exposure of citreoviridin transiently affects hippocampal neurogenesis targeting multiple regulatory functions in mice. Food Chem Toxicol 2018; 120:590-602. [DOI: 10.1016/j.fct.2018.07.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 07/26/2018] [Accepted: 07/28/2018] [Indexed: 12/18/2022]
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Shang W, Chen X, Li X, Chen H, Tang S, Hong H. Epileptic seizures in nonalcoholic Wernicke's encephalopathy: a case report and literature review. Metab Brain Dis 2017; 32:2085-2093. [PMID: 28875427 DOI: 10.1007/s11011-017-0106-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 08/29/2017] [Indexed: 11/28/2022]
Abstract
Wernicke encephalopathy (WE) is characterized by eye signs, cerebellar dysfunction, and confusion. Epileptic seizures are rare in nonalcoholic WE. We reviewed the clinical, laboratory, radiological, and prognostic characteristics of nonalcoholic WE accompanied by epileptic seizures. We reported 1 case and searched similar cases using PubMed, WoK, Ovid, and Embase. WE was diagnosed according to dietary deficiencies, clinical symptoms and brain magnetic resonance imaging (MRI). We reviewed 13 patients (median age, 27 years; 5 men) with clear histories of thiamine deficiency and symptoms of typical WE. The type of epileptic seizures reported in the 13 cases reviewed was generically reported as seizures or convulsions in 4 patients; 7 patients had generalized tonic-clonic seizures, 1 partial seizure, and 1 generalized convulsive status epileptics. Two patients had epileptic seizures as the first symptom of WE. Laboratory tests mainly indicated metabolic acidosis and electrolyte disturbances. Electroencephalography may present as normal patterns, increased slow waves or epileptic discharge. Six patients had cortical lesions on brain MRI. These lesions were usually diffuse and band-like, and sometimes involved all lobes either symmetrically or asymmetrically, with the frontal lobe as the most susceptible area. All cortical lesions were accompanied by non-cortical lesions typical of WE. Brain MRI abnormalities, after thiamine treatment, mostly disappeared on follow-up MRIs. The patients had good prognoses. Only 1 patient had repeated seizures, and there were no comas or deaths. Patients with nonalcoholic WE accompanied by seizures are young and generally have good prognoses. Most patients experienced generalized convulsive seizures, which may have been related to abnormal cerebral cortical metabolism due to subacute thiamine deficiency.
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Affiliation(s)
- Wenjin Shang
- Department of Neurology, First Affiliated Hospital of Sun Yat-sen University, Zhongshan 2nd Road 58, Guangzhou, Guangdong Province, 510080, China
| | - Xiuhui Chen
- Department of Neurology, First Affiliated Hospital of Sun Yat-sen University, Zhongshan 2nd Road 58, Guangzhou, Guangdong Province, 510080, China
| | - Xunhua Li
- Department of Neurology, First Affiliated Hospital of Sun Yat-sen University, Zhongshan 2nd Road 58, Guangzhou, Guangdong Province, 510080, China
| | - Hongbing Chen
- Department of Neurology, First Affiliated Hospital of Sun Yat-sen University, Zhongshan 2nd Road 58, Guangzhou, Guangdong Province, 510080, China
| | - Shujin Tang
- Department of Neurology, First Affiliated Hospital of Sun Yat-sen University, Zhongshan 2nd Road 58, Guangzhou, Guangdong Province, 510080, China
| | - Hua Hong
- Department of Neurology, First Affiliated Hospital of Sun Yat-sen University, Zhongshan 2nd Road 58, Guangzhou, Guangdong Province, 510080, China.
- Department of Neurology, Seventh Affiliated Hospital of Sun Yat-sen University, Zhenyuan Road 628, Shenzhen, Guangdong Province, 518017, China.
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Tsao WC, Ro LS, Chen CM, Chang HS, Kuo HC. Non-alcoholic Wernicke's encephalopathy with cortical involvement and polyneuropathy following gastrectomy. Metab Brain Dis 2017; 32:1649-1657. [PMID: 28660359 DOI: 10.1007/s11011-017-0055-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 06/16/2017] [Indexed: 11/25/2022]
Abstract
In this study, we present the clinical manifestations, brain magnetic resonance imaging (MRI) and concurrent polyneuropathies in two patients with non-alcoholic Wernicke's encephalopathy (WE) after gastrojejunostomy (Billroth II) anastomosis procedures. These patients developed sub-acute onset of disorientation and disturbance of consciousness following several weeks of poor intake. Peripheral neuropathy of varying severity was noted before and after the onset of WE. Brain MRI of the patients showed cerebellar vermis and symmetric cortical abnormalities in addition to typical WE changes. Electrophysiological studies demonstrated axonal sensorimotor polyneuropathy. Prompt thiamine supplement therapy was initiated and both patients gradually recovered, however mild amnesia was still noted 6 months later. We reviewed non- alcoholic WE with atypical cortical abnormalities in English language literatures and identified 29 more cases. Eight out of 31 (25.8%) patients died during follow-up. Nine patients with gait disturbance or motor paresis had showed hyporeflexia in neurological examinations. In addition to classic triad, seizure was recorded in seven patients. Dietary deprivation is a risk factor for non-alcoholic WE among elderly patients receiving gastrointestinal surgery. The prognosis is good after thiamine supplement therapy. Recognizing the MRI features and predisposing factors in patients who have undergone gastrectomy can aid in the diagnosis and management.
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Affiliation(s)
- Wei-Chia Tsao
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Long-Sun Ro
- Section of Neuromuscular Disorders, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuhsing Street, Kueishan, Taoyuan, Taiwan
| | - Chiung-Mei Chen
- Section of Neuromuscular Disorders, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuhsing Street, Kueishan, Taoyuan, Taiwan
| | - Hong-Shiu Chang
- Section of Neuromuscular Disorders, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuhsing Street, Kueishan, Taoyuan, Taiwan
| | - Hung-Chou Kuo
- Section of Neuromuscular Disorders, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuhsing Street, Kueishan, Taoyuan, Taiwan.
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