Wernicke's lethal encephalopathy in voluntary, total, prolonged fasting

A Therapeutic Fast for Lymphoma Resulting in Wernicke Encephalopathy

BACKGROUND

Wernicke encephalopathy is an acute neurological emergency caused by thiamine (vitamin B1) deficiency. The syndrome is associated with a significant morbidity and mortality, and prompt recognition and treatment of the syndrome in the emergency department (ED) is essential to improving patient outcomes. Numerous factors and clinical settings have been identified that predispose a patient to thiamine deficiency and subsequent Wernicke encephalopathy.

CASE REPORT

We present the rare case of a 42-year-old man with a recent diagnosis of non-Hodgkin lymphoma who opted against chemotherapy in favor of a 60-day therapeutic water-only fast. On day 53 of his fast, the patient arrived to our ED in a coma and respiratory failure. Moments after the administration of thiamine, the patient's mental status and respiratory status improved significantly. Prior to admission and transport to the medical intensive care unit, the patient was awake, alert, and following basic commands. He was ultimately diagnosed with Wernicke encephalopathy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With the increasing incidence of patients choosing alternative medical therapies to treat a variety of diseases, numerous electrolyte, metabolic, and nutritional disorders are becoming increasingly more common in the ED setting. In some cases, patients may choose a therapeutic fast in an effort to combat a malignancy; the danger being that patients with cancers such as lymphoma are already at risk for thiamine deficiency as a result of the increased thiamine consumption associated with rapid cellular turnover. Wernicke encephalopathy is a life-threatening neurological emergency, and the emergency physician must be aware of the numerous predisposing factors to the condition, as early identification and treatment improves patient outcomes.

Refeeding procedures after 43 days of total fasting

Refeeding syndrome encompasses fluid and electrolyte imbalances and metabolic, intestinal, and cardiorespiratory derangements associated with appreciable morbidity and mortality. Although refeeding syndrome has been well documented in concentration-camp subjects, and more recently during parenteral therapy of critically ill patients, little is known about the importance of refeeding syndrome during recovery from a hunger strike. Thus, we studied the response to a four-step dietary replenishment routine in eight hunger strikers who refused food for 43 d. In this retrospective, observational study, we assessed the safety and efficacy of the refeeding procedure and analyzed the clinical and nutritional course of the cohort during both starvation and refeeding, mainly on the basis of clinical as well as a few biochemical determinations. During starvation, average weight loss was about 18% and, with the exception of occasional oral vitamins and electrolytes, the subjects consumed only water. Available body-composition and biochemical profiles showed no clinically significant changes during starvation, but one-half of the group displayed spontaneous diarrhea at some time before refeeding. Stepwise nutritional replenishment lasted for 9 d, after which all patients tolerated a full, unrestricted diet. Only one episode of diarrhea occurred during this phase, and both clinical and biochemical indexes confirmed a favorable clinical course, without any manifestation of refeeding syndrome. In conclusion, we observed the following: 1) Hypophosphatemia and other micronutrient imbalances did not occur, nor was macronutrient intolerance detected. 2) Despite some episodes of diarrhea, nutritional replenishment was not associated with significant enteral dysfunction. 3) There was some fluid retention, but this was mild. 4) Acute-phase markers were abnormally elevated during the refeeding phase, without associated sepsis or inflammation.

Hunger strikes: preventing harm to students

When the health center encountered a student hunger strike, an initial search for medical information regarding fasting provided very little on which to build management decisions. The result of a more thorough evaluation of starvation literature is presented, along with survey responses from students who fasted. Starvation may produce many adverse events, including death. Yet, according to reports, acaloric fasts that include full water intake seem to be readily tolerated for 2 weeks in young, healthy adults. Our students included juice, sports drinks, and vitamins in their diets and completed their strike without major problems. Supplementation with carbohydrates and vitamins may improve the safety or comfort of a hunger striker, but clear proof of this effect does not exist.

Wernicke-Korsakoff syndrome following self-induced starvation

A non-alcoholic patient is reported who as a result of self-induced starvation was found to have nystagmus, gait ataxia and severe deficits in recent and remote memory and new learning, with intact immediate recall, abstraction and judgement capabilities. This pattern of cognitive deficit with nystagmus and ataxia suggests the diagnosis of Wernicke-Korsakoff syndrome.