1
|
Kuzume D, Morimoto Y, Tsutsumi S, Yamasaki M, Hosomi N. [Analysis of factors leading to brain MRI lesions in Wernicke's encephalopathy]. Rinsho Shinkeigaku 2024; 64:361-363. [PMID: 38644211 DOI: 10.5692/clinicalneurol.cn-001919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
[Objective] To investigate association between Wernicke encephalopathy (WE) and brain MRI. [Subjects] 26 patients (7 females, mean age 63.9 ± 12.7 years) with WE admitted to our department between May 2008 and September 2022. [Methods] Wernicke's encephalopathy in patients with MRI lesions was defined as "MRI-positive group" (MPG), and those without MRI lesions as "MRI-negative group" (MNG). The following parameters were assessed between the two groups: age, sex, alcoholism, neurological symptoms, vitamin B1, lymphocyte, total cholesterol, albumin, and outcome at discharge. [Results] There were 17 patients in MPG. Compared to MNG, MPG had lower rates of alcohol abuse (10.0% vs 77.8%, P = 0.025), lower vitamin B1 (median 10.0 ng/ml vs 29.0 ng/ml, P < 0.001), and more vitamin B1 treatment dose (median 1900 mg vs 600 mg, P = 0.016). [Conclusion] Alcoholic WE may be overlooked if the focus is solely on brain MRI findings.
Collapse
|
2
|
Rasiah R, Gregoriano C, Mueller B, Kutz A, Schuetz P. Hospital Outcomes in Medical Patients With Alcohol-Related and Non-Alcohol-Related Wernicke Encephalopathy. Mayo Clin Proc 2024; 99:740-753. [PMID: 38069922 DOI: 10.1016/j.mayocp.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 05/05/2024]
Abstract
OBJECTIVE To conduct a nationwide retrospective cohort study to assess trends and hospitalization-associated outcomes in patients with Wernicke encephalopathy. PATIENTS AND METHODS In this nationwide retrospective cohort study, we used in-hospital claims data of patients hospitalized with Wernicke encephalopathy in Switzerland from January 1, 2012, to December 31, 2020. We estimated incidence rates per 100,000 person-years among the overall Swiss population stratified by alcohol and non-alcohol-induced Wernicke encephalopathy. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included progression to Korsakoff syndrome and 1-year hospital readmission. We estimated odds ratios (ORs) for binary outcomes. RESULTS It was found that 4098 of 4393 hospitalizations (93.3%) for Wernicke encephalopathy during the 8-year study were alcohol-related. Incidence rates for hospitalizations were 14-fold higher in alcohol-related compared with non-alcohol-related Wernicke encephalopathy (5.43 vs 0.39 per 100,000 person-years). The risk for in-hospital mortality was significantly lower in patients with alcohol-related vs non-alcohol-related Wernicke encephalopathy (3.2% vs 8.5%; adjusted OR, 0.38; 95% CI, 0.23 to 0.62). Patients with alcohol-related Wernicke encephalopathy had higher risk for development of Korsakoff syndrome (16.9% vs 1.7%; adjusted OR, 10.64; 95% CI, 4.37 to 25.92) and 1-year hospital readmission (31.6% vs 18.7%; adjusted OR, 1.4; 95% CI, 1.04 to 1.88). CONCLUSION In this Swiss nationwide cohort study, Wernicke encephalopathy was a rare but serious cause for hospitalization and mainly alcohol-related. Patients with alcohol-related Wernicke encephalopathy had lower risks of in-hospital mortality but were more likely to develop Korsakoff syndrome and be readmitted to the hospital.
Collapse
Affiliation(s)
- Roshaani Rasiah
- Medical University Department, Division of General Internal and Emergency Medicine, Cantonal Hospital Aarau, Aarau, Switzerland.
| | - Claudia Gregoriano
- Medical University Department, Division of General Internal and Emergency Medicine, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Cantonal Hospital Aarau, Aarau, Switzerland; Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexander Kutz
- Medical University Department, Division of General Internal and Emergency Medicine, Cantonal Hospital Aarau, Aarau, Switzerland; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Cantonal Hospital Aarau, Aarau, Switzerland; Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| |
Collapse
|
3
|
Mazzacane F, Ferrari F, Malvaso A, Mottese Y, Gastaldi M, Costa A, Pichiecchio A, Cavallini A. Acute amnestic syndrome in fornix lesions: a systematic review of reported cases with a focus on differential diagnosis. Front Neurol 2024; 15:1338291. [PMID: 38333604 PMCID: PMC10850356 DOI: 10.3389/fneur.2024.1338291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/09/2024] [Indexed: 02/10/2024] Open
Abstract
Introduction Acute amnestic syndrome is an uncommon clinical presentation of neurological disease. Differential diagnosis encompasses several syndromes including Wernicke-Korsakoff and transient global amnesia (TGA). Structural lesions of the fornix account for a minority of cases of acute amnestic syndromes. Etiology varies from iatrogenic injury to ischemic, inflammatory, or neoplastic lesions. A prompt diagnosis of the underlying pathology is essential but challenging. The aim of this review is to systematically review the existing literature regarding cases of acute amnestic syndrome associated with non-iatrogenic lesions of the fornix. Methods We performed a systematic literature search on PubMed, Scopus, and Web of Science up to September 2023 to identify case reports and case series of patients with amnestic syndrome due to fornix lesions. The systematic review was conducted according to PRISMA guidelines. The research was limited to articles written in English. Cases of fornix damage directly ascribable to a surgical procedure were excluded. Results A total of 52 publications reporting 55 cases were included in the review. Focusing on acute/subacute onset, vascular etiology was highly prevalent, being responsible for 78% of cases, 40/55 (74%) of which were due to acute ischemic stroke. The amnestic syndrome was characterized by anterograde amnesia in all patients, associated with retrograde amnesia in 27% of cases. Amnesia was an isolated presentation in most cases. Up to two thirds of patients had persistent memory deficits of any severity at follow-up. Discussion Acute amnestic syndrome can be rarely caused by fornix lesions. In most cases of acute/subacute presentation, the etiology is ischemic stroke, mainly caused by strokes involving the subcallosal artery territory. The differential diagnosis is challenging and a distinction from common mimics is often difficult on a clinical basis. A high index of suspicion should be maintained to avoid misdiagnosis and provide adequate acute treatment to patients with time-dependent disease, also employing advanced neuroimaging. More research is needed to better understand the outcome and identify prognostic factors in patients with amnestic syndrome due to fornix lesions.
Collapse
Affiliation(s)
- F. Mazzacane
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Department of Emergency Neurology and Stroke Unit, IRCCS Fondazione Mondino, Pavia, Italy
- Unit of Behavioral Neurology, Mondino Foundation, Pavia, Italy
| | - F. Ferrari
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Department of Emergency Neurology and Stroke Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | - A. Malvaso
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Neuroimmunology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Y. Mottese
- Department of Neuroradiology, IRCCS Mondino Foundation, Pavia, Italy
| | - M. Gastaldi
- Neuroimmunology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - A. Costa
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Unit of Behavioral Neurology, Mondino Foundation, Pavia, Italy
| | - A. Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Department of Neuroradiology, IRCCS Mondino Foundation, Pavia, Italy
| | - A. Cavallini
- Department of Emergency Neurology and Stroke Unit, IRCCS Fondazione Mondino, Pavia, Italy
| |
Collapse
|
4
|
Ono K, Hayano S, Kashima M. Wernicke encephalopathy: limitations in a laboratory and radiological diagnosis. BMJ Case Rep 2023; 16:e254786. [PMID: 38081738 PMCID: PMC10729136 DOI: 10.1136/bcr-2023-254786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
Wernicke encephalopathy is an emergent neurological disorder caused by vitamin B1 (thiamine) deficiency. Here, we present a case of Wernicke encephalopathy in a male patient in his 70s with normal serum thiamine levels and MRI findings on admission. He had a history of heavy alcohol consumption and a gradual decrease in food intake. On arrival at the hospital, his consciousness was impaired which persisted even after glucose replacement. Moreover, horizontal nystagmus and cerebellar ataxia were observed. Head CT scan and MRI revealed no abnormal findings. Further, his serum thiamine level was within the normal range. The patient was clinically diagnosed with Wernicke encephalopathy, and high-dose thiamine therapy was started. Then, his symptoms improved immediately. Thus, in case of clinical suspicion, treatment for Wernicke encephalopathy must be initiated promptly even in patients with normal serum thiamine levels.
Collapse
Affiliation(s)
- Kohei Ono
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Satoshi Hayano
- Department of Internal Medicine, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Masayuki Kashima
- Department of Internal Medicine, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| |
Collapse
|
5
|
Novo-Veleiro I, Mateos-Díaz AM, Rosón-Hernández B, Medina-García JA, Muga R, Fernández-Solá J, Martín-González MC, Seco-Hernández E, Suárez-Cuervo C, Monte-Secades R, Machado-Prieto B, Puerta-Louro R, Prada-González C, Fernández-Rial Á, Sabio-Repiso P, Vázquez-Vigo R, Antolí-Royo AC, Gomila-Grange A, Felipe-Pérez NC, Sanvisens-Bergé A, Antúnez-Jorge E, Fernández-Rodríguez CM, Alvela-Suárez L, Fidalgo-Navarro A, Castro J, Polvorosa-Gómez MA, Valle-Sánchez MD, López-Castro J, Chamorro AJ, Marcos M. Treatment variability and its relationships to outcomes among patients with Wernicke's encephalopathy: A multicenter retrospective study. Drug Alcohol Depend 2023; 252:110961. [PMID: 37748425 DOI: 10.1016/j.drugalcdep.2023.110961] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/09/2023] [Accepted: 09/01/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Despite guidelines and recommendations, Wernicke's encephalopathy (WE) treatment lacks evidence, leading to clinical practice variability. AIMS Given the overall lack of information on thiamine use for WE treatment, we analyzed data from a large, well-characterized multicenter sample of patients with WE, examining thiamine dosages; factors associated with the use of different doses, frequencies, and routes; and the influence of differences in thiamine treatment on the outcome. METHODS This retrospective study was conducted with data from 443 patients from 21 centers obtained from a nationwide registry of the Spanish Society of Internal Medicine (from 2000 to 2012). Discharge codes and Caine criteria were applied for WE diagnosis, and treatment-related (thiamine dosage, frequency, and route of administration) demographic, clinical, and outcome variables were analyzed. RESULTS We found marked variability in WE treatment and a low rate of high-dose intravenous thiamine administration. Seventy-eight patients out of 373 (20.9%) received > 300mg/day of thiamine as initial dose. Patients fulfilling the Caine criteria or presenting with the classic WE triad more frequently received parenteral treatment. Delayed diagnosis (after 24h hospitalization), the fulfillment of more than two Caine criteria at diagnosis, mental status alterations, and folic acid deficiency were associated significantly with the lack of complete recovery. Malnutrition, reduced consciousness, folic acid deficiency, and the lack of timely thiamine treatment were risk factors for mortality. CONCLUSIONS Our results clearly show extreme variability in thiamine dosages and routes used in the management of WE. Measures should be implemented to ensure adherence to current guidelines and to correct potential nutritional deficits in patients with alcohol use disorders or other risk factors for WE.
Collapse
Affiliation(s)
- Ignacio Novo-Veleiro
- Department of Internal Medicine, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain.
| | - Ana-M Mateos-Díaz
- Department of Internal Medicine, Hospital Universitario de Salamanca-IBSAL, University of Salamanca, Salamanca, Spain; Department of Internal Medicine, Hospital Virgen del Puerto, Plasencia, Cáceres, Spain.
| | | | | | - Roberto Muga
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona. Universitat Autònoma de Barcelona, Barcelona, Spain.
| | | | | | - Elena Seco-Hernández
- Department of Internal Medicine, Complexo Hospitalario Universitario de Ourense, Ourense, Spain.
| | | | - Rafael Monte-Secades
- Department of Internal Medicine, Hospital Universitario Lucus Augusti, Lugo, Spain.
| | - Begoña Machado-Prieto
- Department of Internal Medicine, Complexo Hospitalario Universitario de Vigo, Vigo, Spain.
| | | | | | | | | | - Rocío Vázquez-Vigo
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - Ana-C Antolí-Royo
- Department of Internal Medicine, Complejo Asistencial de Ávila, Ávila, Spain.
| | | | | | - Arantza Sanvisens-Bergé
- Epidemiology Unit and Girona Cancer Registry, Institut Català d'Oncologia, Pla Director d'Oncologia, Girona, Spain.
| | | | | | - Lucia Alvela-Suárez
- Department of Internal Medicine, HM Rosaleda Hospital, Santiago de Compostela, A Coruña, Spain.
| | | | | | | | | | | | - Antonio-J Chamorro
- Department of Internal Medicine, Hospital Universitario de Salamanca-IBSAL, University of Salamanca, Salamanca, Spain.
| | - Miguel Marcos
- Department of Internal Medicine, Hospital Universitario de Salamanca-IBSAL, University of Salamanca, Salamanca, Spain.
| |
Collapse
|
6
|
Knight-Dunn L, Gorchynski J. Alcohol-Related Metabolic Emergencies. Emerg Med Clin North Am 2023; 41:809-819. [PMID: 37758425 DOI: 10.1016/j.emc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Patients with alcohol use disorders are commonly identified and managed in the emergency department. Although the alcohol-intoxicated patient has a high risk for significant injury and diseases, the majority will be allowed to sober in the emergency department and can be discharged without incident. However, there are metabolic derangements in these patients, such as alcoholic ketoacidosis, Wernicke-Korsakoff, and potomania that very commonly present similar to intoxication and can be misdiagnosed by emergency clinicians.
Collapse
Affiliation(s)
| | - Julie Gorchynski
- Department of Emergency Medicine, UT Health San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, TX 78229-3900, USA.
| |
Collapse
|
7
|
Habas E, Farfar K, Errayes N, Rayani A, Elzouki AN. Wernicke Encephalopathy: An Updated Narrative Review. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2023; 11:193-200. [PMID: 37533659 PMCID: PMC10393093 DOI: 10.4103/sjmms.sjmms_416_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/27/2022] [Accepted: 06/07/2023] [Indexed: 08/04/2023]
Abstract
Wernicke's encephalopathy (WE) and Korsakoff Syndrome (KS) are distinct neurological disorders that may have overlapping clinical features. Due to the overlap, they are collectively known as Wernicke-Korsakoff syndrome. WE is related to diencephalic and mesencephalic dysfunction due to thiamine. WE typically manifests as confusion, ophthalmoplegia, nystagmus, and gait ataxia (Wernicke's triad), although they may not consistently occur together. Although WE mostly occurs in alcoholics, other etiologies, such as post-bariatric surgery, must be considered. Early diagnosis and therapy by intravenous thiamine are essential to prevent WE complications and to reduce morbidity and mortality. Therefore, physicians' and patients' awareness of WE is essential for early diagnosis and therapy. Accordingly, this narrative review aimed to provide an update on WE by reviewing articles published between April 2015 to April 2022 about the etiology, pathophysiology, diagnosis, and WE management updates. EMBASE, PubMed, Google Scholar, Google, and Scopus search engines were used to conduct the literature search.
Collapse
Affiliation(s)
- Elmukhtar Habas
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Kalifa Farfar
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Nada Errayes
- Department of Epidemiology, University of Lincoln, Lincoln, UK
| | | | - Abdel-Naser Elzouki
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, Doha, Qatar
- Department of Medicine, College of Medicine, Qatar University, Doha, Qatar
| |
Collapse
|
8
|
Arts NJM, van Dorst MEG, Vos SH, Kessels RPC. Coordination and Cognition in Pure Nutritional Wernicke’s Encephalopathy with Cerebellar Degeneration after COVID-19 Infection: A Unique Case Report. J Clin Med 2023; 12:jcm12072511. [PMID: 37048595 PMCID: PMC10094782 DOI: 10.3390/jcm12072511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Background: Alcoholic cerebellar degeneration is a restricted form of cerebellar degeneration, clinically leading to an ataxia of stance and gait and occurring in the context of alcohol misuse in combination with malnutrition and thiamine depletion. However, a similar degeneration may also develop after non-alcoholic malnutrition, but evidence for a lasting ataxia of stance and gait and lasting abnormalities in the cerebellum is lacking in the few patients described with purely nutritional cerebellar degeneration (NCD). Methods: We present a case of a 46-year-old woman who developed NCD and Wernicke’s encephalopathy (WE) due to COVID-19 and protracted vomiting, resulting in thiamine depletion. We present her clinical course over the first 6 months after the diagnosis of NCD and WE, with thorough neuropsychological and neurological examinations, standardized clinical observations, laboratory investigations, and repeated MRIs. Results: We found a persistent ataxia of stance and gait and evidence for an irreversible restricted cerebellar degeneration. However, the initial cognitive impairments resolved. Conclusions: Our study shows that NCD without involvement of alcohol neurotoxicity and with a characteristic ataxia of stance and gait exists and may be irreversible. We did not find any evidence for lasting cognitive abnormalities or a cerebellar cognitive-affective syndrome (CCAS) in this patient.
Collapse
Affiliation(s)
- Nicolaas J. M. Arts
- Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, 5803 DN Venray, The Netherlands
- Winkler Neuropsychiatry Clinic and Korsakoff Centre, Pro Persona Institute for Psychiatry, 6874 BE Wolfheze, The Netherlands
| | - Maud E. G. van Dorst
- Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, 5803 DN Venray, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6525 GD Nijmegen, The Netherlands
| | - Sandra H. Vos
- Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, 5803 DN Venray, The Netherlands
| | - Roy P. C. Kessels
- Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, 5803 DN Venray, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6525 GD Nijmegen, The Netherlands
- Tactus Addiction Care, 7400 AD Deventer, The Netherlands
- Correspondence:
| |
Collapse
|
9
|
Silva AR, Almeida-Xavier S, Lopes M, Soares-Fernandes JP, Sousa F, Varanda S. Is there a time window for MRI in Wernicke encephalopathy - a decade of experience from a tertiary hospital. Neurol Sci 2023; 44:703-708. [PMID: 36335281 DOI: 10.1007/s10072-022-06477-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Wernicke encephalopathy (WE) is a neuropsychiatric syndrome caused by thiamine deficiency. Despite its low sensitivity, brain magnetic resonance imaging (MRI) is the most useful diagnostic technique. Our aim was to investigate whether the timing of the imaging study, and thiamine replacement can influence brain MRI findings in these patients. METHODS Retrospective observational study of hospitalized patients between January/2008 and December/2020 with a clinical diagnosis of WE. Data from clinical presentation, diagnostic features, therapeutic approach, and outcomes were collected. RESULTS We identified 41 patients (55 ± 13.3 years) with WE. Brain MRI was performed in 36 patients, and one third had T2/FLAIR hyperintensities suggestive of WE. We found an association between a history of poor diet and periventricular hyperintensities (p = 0.023), especially on the ventral surface of the thalamus and the periaqueductal region. It was found that the odds of having a typical imaging of WE decreased by 5.3% for each additional unit (100 mg) of thiamine administered (p = 0.046) (95% CI [0.89, 0.99]). On the other hand, the number of days from clinical presentation was not found to be a viable predictor (p = 0.254) (95% CI [0.88, 1.03]) Recovery was positively correlated with the total dose of thiamine received until discharge (p = 0.020). CONCLUSIONS MRI hyperintensities seem to be dependent on the timing of thiamine correction and, particularly, on the thiamine dosage prescribed at admission. Nevertheless, thiamine replacement should not be delayed, as its timely prescription is associated with a better prognosis at discharge.
Collapse
Affiliation(s)
- Ana Rita Silva
- Department of Neurology, Hospital de Braga, Braga, Portugal.
| | | | | | | | - Filipa Sousa
- Department of Neurology, Hospital de Braga, Braga, Portugal
| | - Sara Varanda
- Department of Neurology, Hospital de Braga, Braga, Portugal
| |
Collapse
|
10
|
Duve KV, Shkrobot SI. THE NEUROLOGICAL MANIFESTATIONS AND FUNCTIONAL INDEPENDENCE IN PATIENTS WITH ENCEPHALOPATHIES OF DIFFERENT TYPES. POLSKI MERKURIUSZ LEKARSKI : ORGAN POLSKIEGO TOWARZYSTWA LEKARSKIEGO 2023; 51:489-495. [PMID: 38069849 DOI: 10.36740/merkur202305107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Aim: To access the neurological manifestations and activities of daily living in patients with encephalopathy of one of the following types: post-infectious, chronic traumatic encephalopathy, alcohol-induced, and microvascular ischemic disease of the brain. PATIENTS AND METHODS Materials and Methods: In the period of 2021-2022 we examined 520 patients, who signed the informed consent, taking into account their age, sex, occupation, the cause, and the disease duration. Such parameters were evaluated, as the data of neurological manifestations, the activities of daily living (Barthel index), cognitive functioning (MoCA-test), and statistical methods (Statistica 13.0). RESULTS Results: A probable influence of the age factor on the frequency of occurrence of different types of encephalopathies was established (χ2=235.05; p<0.001). The cognitive impairment was diagnosed in 53.79 % of patients with CTE, 66.21% with SVD, and 58.82% with AE. 40% of patients with CTE are dependent on their activities of daily living, among patients with SVD - 31,72 %, among patients with AE - 44.12%, among patients with PIE - 53.91%. 17.97% of patients with PIE had moderate dependence by the Barthel index. Thus, the severity of disability doesn't depend on the age or sex of patients but is correlating with the duration of the disease. CONCLUSION Conclusions: The neurological manifestations in patients with encephalopathies and their activities of daily living were studied profoundly and the data obtained opened new directions in the following research.
Collapse
Affiliation(s)
- Khrystyna V Duve
- I. HORBACHEVSKY TERNOPIL NATIONAL MEDICAL UNIVERSITY OF THE MINISTRY OF HEALTH OF UKRAINE, TERNOPIL, UKRAINE
| | - Svitlana I Shkrobot
- I. HORBACHEVSKY TERNOPIL NATIONAL MEDICAL UNIVERSITY OF THE MINISTRY OF HEALTH OF UKRAINE, TERNOPIL, UKRAINE
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
A Clinician's View of Wernicke-Korsakoff Syndrome. J Clin Med 2022; 11:jcm11226755. [PMID: 36431232 PMCID: PMC9693280 DOI: 10.3390/jcm11226755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/06/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022] Open
Abstract
The purpose of this article is to improve recognition and treatment of Wernicke-Korsakoff syndrome. It is well known that Korsakoff syndrome is a chronic amnesia resulting from unrecognized or undertreated Wernicke encephalopathy and is caused by thiamine (vitamin B1) deficiency. The clinical presentation of thiamine deficiency includes loss of appetite, dizziness, tachycardia, and urinary bladder retention. These symptoms can be attributed to anticholinergic autonomic dysfunction, as well as confusion or delirium, which is part of the classic triad of Wernicke encephalopathy. Severe concomitant infections including sepsis of unknown origin are common during the Wernicke phase. These infections can be prodromal signs of severe thiamine deficiency, as has been shown in select case descriptions which present infections and lactic acidosis. The clinical symptoms of Wernicke delirium commonly arise within a few days before or during hospitalization and may occur as part of a refeeding syndrome. Wernicke encephalopathy is mostly related to alcohol addiction, but can also occur in other conditions, such as bariatric surgery, hyperemesis gravidarum, and anorexia nervosa. Alcohol related Wernicke encephalopathy may be identified by the presence of a delirium in malnourished alcoholic patients who have trouble walking. The onset of non-alcohol-related Wernicke encephalopathy is often characterized by vomiting, weight loss, and symptoms such as visual complaints due to optic neuropathy in thiamine deficiency. Regarding thiamine therapy, patients with hypomagnesemia may fail to respond to thiamine. This may especially be the case in the context of alcohol withdrawal or in adverse side effects of proton pump inhibitors combined with diuretics. Clinician awareness of the clinical significance of Wernicke delirium, urinary bladder retention, comorbid infections, refeeding syndrome, and hypomagnesemia may contribute to the recognition and treatment of the Wernicke-Korsakoff syndrome.
Collapse
|
13
|
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
|
14
|
Abu-Abaa M, Patel S. An Uncommon Presentation of Hyperthyroidism Can Culminate in Devastating Neurological Consequences: A Case Report. Cureus 2022; 14:e28424. [PMID: 36176825 PMCID: PMC9509528 DOI: 10.7759/cureus.28424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/06/2022] Open
Abstract
Wernicke’s encephalopathy remains largely an underdiagnosed condition. It has two variants: alcoholic and non-alcoholic. A 56-year-old female patient presented with two weeks of persistent nausea, vomiting, and unintentional weight loss. Initial investigations revealed hypercalcemia associated with pancreatitis of biliary origin for which she underwent cholecystectomy as well as thyroiditis resulting in postoperative initiation of methimazole. Persistent symptoms prompted esophagogastroduodenoscopy (EGD), which was unremarkable. She developed diffuse weakness and impaired memory with poor orientation. Magnetic resonance imaging of the brain showed fluid-attenuated inversion recovery (FLAIR) hyperintensity at the central pons and bilateral thalami. Her mental status continued to worsen rapidly within a few days, and she became minimally responsive, hypothermic, and hypotensive; as such, she was intubated for airway protection. Cerebrospinal fluid analysis was unremarkable. She received a thiamine replacement. Repeat MRI after a few days showed improving thalamic hyperintensities with improvement in mentation. This case serves to remind clinicians of the uncommon link between hyperthyroidism and non-alcoholic Wernicke’s encephalopathy (WE).
Collapse
|
15
|
Qureshi ZA, Ponnachan D, Ghazanfar H, Acherjee T, Altaf F, Dhallu M. A Case Report of Wernicke’s Encephalopathy Disguised As Limbic Encephalitis: A Clinical Puzzle. Cureus 2022; 14:e28070. [PMID: 36127954 PMCID: PMC9477437 DOI: 10.7759/cureus.28070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/05/2022] Open
Abstract
Wernicke's encephalopathy (WE) is the presence of neurological symptoms in the central nervous system caused by thiamine (Vitamin B1) deficiency. It is an acute clinical condition characterized by confusion, ataxia, and ophthalmoplegia triad. WE is most commonly observed in chronic alcohol users, while it can also present in non-alcoholics. We present a 33-year-old man with alcohol-induced WE who presented with altered mental status and fever. His initial diagnosis was skewed towards bacterial meningitis and limbic encephalitis, but MRI findings were consistent with WE. The patient responded promptly to intravenous (IV) thiamine infusion, and his mental status changed significantly. Repeat EEG in 15 days shows complete recovery with normal brain wave activity. Untreated WE is a significant cause of permanent neurological morbidity and mortality, easily preventable. High suspicion of WE should always be entertained, especially when patients have a known history of alcohol use. Early initiation of IV thiamine could prevent the consequences. Hence, it is essential to raise awareness of WE to take measures without delay and reduce mortality and morbidity with an improved prognosis.
Collapse
|
16
|
Palm A, Vataja R, Talaslahti T, Ginters M, Kautiainen H, Elonheimo H, Suvisaari J, Lindberg N, Koponen H. Incidence and mortality of alcohol-related dementia and Wernicke-Korsakoff syndrome: A nationwide register study. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5775. [PMID: 35789035 PMCID: PMC9546078 DOI: 10.1002/gps.5775] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epidemiological data on alcohol-related cognitive disorders are scarce. Up-to-date population-based incidence and mortality rates for Wernicke-Korsakoff syndrome (WKS) and alcohol-related dementia (ARD) are necessary to understand the burden of these diseases. METHODS We collected diagnostic data from the Finnish Hospital Discharge Register and mortality data from Statistics Finland for all persons aged ≥40 years who had received a diagnosis of WKS (n = 1149) or ARD (n = 2432) between 1998 and 2015 in Finland. We calculated the incidences and mortality in relation to the age-, sex- and calendar year-matched general population. Causes of death were ascertained from death certificates. RESULTS For WKS, the incidence per 100,000 person-years (95% confidence interval (CI)) was 3.7 (3.4-3.9) in men and 1.2 (1.1-1.3) in women. For ARD, the incidence was 8.2 (7.9-8.6) in men and 2.1 (1.9-2.3) in women. The incidence of WKS peaked in people aged 50-59 years and the incidence of ARD in people aged 70-79 years. The standardized mortality ratio (95% CI) was 5.67 (5.25-6.13) in WKS patients and 5.41 (5.14-5.70) in ARD patients. Most of the excess mortality resulted from alcohol-related causes. CONCLUSIONS To our knowledge, this is the first study describing population-based incidence and mortality rates, sex-segregated data and causes of death in patients with WKS or ARD. Our results establish a point of reference for the incidence of WKS and ARD and show the high mortality and poor prognosis of these disorders.
Collapse
Affiliation(s)
- Anniina Palm
- Department of PsychiatryUniversity of HelsinkiHelsinkiFinland,Helsinki University HospitalHelsinkiFinland
| | - Risto Vataja
- Department of PsychiatryUniversity of HelsinkiHelsinkiFinland,Helsinki University HospitalHelsinkiFinland
| | - Tiina Talaslahti
- Department of PsychiatryUniversity of HelsinkiHelsinkiFinland,Helsinki University HospitalHelsinkiFinland
| | - Milena Ginters
- Department of PsychiatryUniversity of HelsinkiHelsinkiFinland,Helsinki University HospitalHelsinkiFinland
| | - Hannu Kautiainen
- Primary Health Care UnitKuopio University HospitalHelsinkiFinland,Folkhälsan Research CenterHelsinkiFinland
| | | | - Jaana Suvisaari
- Finnish Institute for Health and WelfareHelsinkiFinland,Mental Health UnitHelsinkiFinland
| | - Nina Lindberg
- Department of PsychiatryUniversity of HelsinkiHelsinkiFinland,Helsinki University HospitalHelsinkiFinland
| | - Hannu Koponen
- Department of PsychiatryUniversity of HelsinkiHelsinkiFinland,Helsinki University HospitalHelsinkiFinland
| |
Collapse
|
17
|
Nikjoo A, Rashid H, Chung R, Sadat MA. A rare case of Wernicke encephalopathy in stage IV gastric cancer. Neurocase 2022; 28:123-125. [PMID: 35188084 DOI: 10.1080/13554794.2022.2041043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A 38-year-old male with stage IV gastric adenocarcinoma presented with abdominal pain, nausea, bilious non-bloody vomiting, and lethargy. He was found to have an ileus and was treated appropriately with bowel rest and nasogastric tube decompression. However, the patient was also noted to have confusion and nystagmus. While he was abstinent from alcohol for 20 years, he was found to have Wernicke Encephalopathy (WE) as a result of malnutrition from the underlying malignancy.
Collapse
Affiliation(s)
- Arya Nikjoo
- Department of Internal Medicine, HCA Houston Healthcare Kingwood, Kingwood, TX, USA
| | - Hytham Rashid
- Department of Internal Medicine, HCA Houston Healthcare Kingwood, Kingwood, TX, USA
| | - Randy Chung
- Texas Digestive Disease Consultants, Kingwood, TX, USA
| | - Mir Ali Sadat
- Department of Internal Medicine, HCA Houston Healthcare Kingwood, Kingwood, TX, USA
| |
Collapse
|
18
|
Mateos-Díaz AM, Marcos M, Chamorro AJ. Wernicke-Korsakoff syndrome and other diseases associated with thyamine deficiency. Med Clin (Barc) 2022; 158:431-436. [PMID: 35039171 DOI: 10.1016/j.medcli.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 11/17/2022]
Abstract
Wernicke-Korsakoff syndrome is the best known consequence of thiamine deficiency, frequently associated with patients with chronic and excessive alcohol consumption, but it can be produced by any cause that produces thiamine deficiency. The disease is underdiagnosed so it is essential to have a high clinical suspicion, mainly in patients who do not have alcohol consumption as a risk factor. For this, the diagnosis continues to be eminently clinical, with the difficulty of high clinical variability. Complementary tests are used to support the diagnosis and rule out other causes that can produce similar symptoms, with magnetic resonance imaging being the most cost-effective imaging test. Treatment is based on the administration of thiamine, which should be started early, and parenterally at the appropriate doses, in all patients with compatible symptoms, without waiting to confirm the diagnosis.
Collapse
Affiliation(s)
- Ana-María Mateos-Díaz
- Servicio de Medicina Interna, Hospital Virgen del Puerto, Plasencia, Cáceres, España
| | - Miguel Marcos
- Servicio de Medicina Interna, Hospital Universitario de Salamanca-IBSAL, Universidad de Salamanca, Salamanca, España
| | - Antonio-Javier Chamorro
- Servicio de Medicina Interna, Hospital Universitario de Salamanca-IBSAL, Universidad de Salamanca, Salamanca, España.
| |
Collapse
|
19
|
Novo-Veleiro I, Herrera-Flores J, Rosón-Hernández B, Medina-García JA, Muga R, Fernández-Solá J, Martín-González MC, Seco-Hernández E, Suárez-Cuervo C, Mateos-Díaz AM, Monte-Secades R, Machado-Prieto B, Puerta-Louro R, Prada-González C, Fernández-Rial Á, Sabio-Repiso P, Vázquez-Vigo R, Antolí-Royo AC, Gomila-Grange A, Felipe-Pérez NC, Sanvisens-Bergé A, Antúnez-Jorge E, Fernández-Rodríguez CM, Alvela-Suárez L, Fidalgo-Navarro A, Castro J, Polvorosa-Gómez MA, Del Valle-Sánchez M, López-Castro J, Chamorro AJ, Marcos M. Alcoholic Liver Disease Among Patients with Wernicke Encephalopathy: A Multicenter Observational Study. Drug Alcohol Depend 2022; 230:109186. [PMID: 34864357 DOI: 10.1016/j.drugalcdep.2021.109186] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/05/2021] [Accepted: 11/05/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND data regarding the association between Wernicke encephalopathy (WE) and alcoholic liver disease (ALD) are scarce in spite of alcohol consumption being the main risk factor for WE. AIMS to describe the frequency of ALD in a cohort of patients diagnosed with WE and alcohol use disorders (AUDs) and to compare the characteristics of WE patients with and without ALD. METHODS we conducted an observational study in 21 centers through a nationwide registry of the Spanish Society of Internal Medicine. WE Caine criteria were applied and demographic, clinical, and outcome variables were analyzed. RESULTS 434 patients were included in the study, of which 372 were men (85.7%), and the mean age was 55 ± 11.8 years. ALD was present in 162 (37.3%) patients and we found a higher percentage of cases with tremor, flapping and hallucinations in the ALD group. A total of 22 patients (5.0%) died during admission (7.4% with ALD vs 3.7% without ALD; P = 0.087). Among the ALD patients, a relationship between mortality and the presence of anemia (Odds ratio [OR]=4.6 Confidence interval [CI]95% 1.1-18.8; P = 0.034), low level of consciousness (OR=4.9 CI95% 1.1-21.2; P = 0.031) and previous diagnosis of cancer (OR=10.3 CI95% 1.8-59.5; P = 0.009) was detected. Complete recovery was achieved by 27 patients with ALD (17.8%) and 71 (27.8%) without ALD (P = 0.030). CONCLUSION the association of WE and ALD in patients with AUDs is frequent and potentially linked to differences in clinical presentation and to poorer prognosis, as compared to alcoholic patients with WE without ALD.
Collapse
Affiliation(s)
- Ignacio Novo-Veleiro
- Department of Internal Medicine, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Javier Herrera-Flores
- Department of Internal Medicine, Hospital Universitario de Salamanca-IBSAL, University of Salamanca, Salamanca, Spain
| | | | | | - Roberto Muga
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona. Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Elena Seco-Hernández
- Department of Internal Medicine, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | | | - Ana-M Mateos-Díaz
- Department of Internal Medicine, Hospital Virgen del Puerto, Plasencia, Cáceres, Spain
| | - Rafael Monte-Secades
- Department of Internal Medicine, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - Begoña Machado-Prieto
- Department of Internal Medicine, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | | | | | - Álvaro Fernández-Rial
- Department of Internal Medicine, Complexo Hospitalario Universitario de Ferrol, A Coruña, Spain
| | | | - Rocío Vázquez-Vigo
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Ana-C Antolí-Royo
- Department of Internal Medicine, Complejo Asistencial de Ávila, Ávila, Spain
| | - Aina Gomila-Grange
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Arantza Sanvisens-Bergé
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona. Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Lucía Alvela-Suárez
- Department of Internal Medicine, HM Rosaleda Hospital, Santiago de Compostela, A Coruña, Spain
| | | | - Joaquín Castro
- Hospital Santa Bárbara, Puerto Llano, Ciudad-Real, Spain
| | | | | | | | - Antonio-J Chamorro
- Department of Internal Medicine, Hospital Universitario de Salamanca-IBSAL, University of Salamanca, Salamanca, Spain
| | - Miguel Marcos
- Department of Internal Medicine, Hospital Universitario de Salamanca-IBSAL, University of Salamanca, Salamanca, Spain.
| | | |
Collapse
|
20
|
Bagash H, Marwat A, Marwat A, Kraus B. A Case of Chronic Wernicke Encephalopathy (WE): An Underdiagnosed Phenomena. Cureus 2021; 13:e19100. [PMID: 34868752 PMCID: PMC8627220 DOI: 10.7759/cureus.19100] [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] [Accepted: 10/28/2021] [Indexed: 12/15/2022] Open
Abstract
Wernicke encephalopathy (WE) is the most common neurological complication of thiamine deficiency in patients who have a background of chronic alcohol use disorder. WE is characterized by acute onset of confusion, gait ataxia, and oculomotor dysfunction. Prompt treatment with parenteral thiamine leads to improvement. Untreated WE has mortality rates of up to 20% and many cases progress to the more chronic Korsakoff syndrome. Cases of untreated WE in which symptoms last beyond the acute phase and become chronic are rarely found in the literature. Here, we present a case of a 64-year-old female having a background of chronic alcohol use disorder presenting with symptoms of gait ataxia, recurrent falls, and decreased concentration. These symptoms had progressed over a period of nine months. The patient was seen by her family physician and several specialists undergoing many diagnostic studies with inconclusive results. Ultimately, with a high index of suspicion for thiamine deficiency, she was admitted for IV thiamine treatment. Upon follow-up in the clinic, the patient reported improvement in her balance and concentration further confirming the initial suspicion of WE with thiamine deficiency as the cause of her symptoms. This case corroborates the existence of WE as a chronic phenomenon in addition to the more commonly reported acute WE. Furthermore, this case highlights the importance of recognizing WE as a potential cause of chronic neurological symptoms in people with alcohol-related disorders and the role of IV thiamine in treatment.
Collapse
Affiliation(s)
- Hina Bagash
- Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK
| | - Assad Marwat
- Internal Medicine, Shifa Tameer-E-Millat University, Shifa College of Medicine, Islamabad, PAK
| | - Asghar Marwat
- Internal Medicine, Prairie Ridge Health, Sun Prairie, USA.,Internal Medicine, Conemaugh Memorial Medical Center, Johnstown, USA
| | - Bruce Kraus
- Internal Medicine, Prairie Ridge Health, Columbus, USA
| |
Collapse
|
21
|
Abstract
A 34-year-old woman (gravida 4; para 3) at 17 weeks of pregnancy presented with abnormal behaviour for 3 weeks associated with difficulties in walking. She had been admitted 2 months prior with hyperemesis gravidarum and was also diagnosed with thyrotoxicosis. Vomiting and poor oral intake persisted after discharge. She was euthyroid otherwise. Clinical examination revealed a dehydrated and confused patient. She had nystagmus and ataxic gate. Magnetic resonance imaging of the brain showed symmetrical signal changes of posteromedial part of thalamus. A diagnosis of Wernicke's encephalopathy (WE) was made and intravenous thiamine was given leading to gradual improvement of symptoms. Her thyroid function test normalised without any treatment. WE can occur in severe hyperemesis gravidarum. Prompt recognition of WE and replacement with thiamine is important to prevent neurological sequelae and mortality. Gestational transient thyrotoxicosis, which is self-limiting, is more prominent in patients with hyperemesis gravidarum and requires only symptomatic treatment.
Collapse
|
22
|
Wang Q, Charmchi Z, George IC. Restrictive diet in a patient with irritable bowel syndrome leading to Wernicke encephalopathy. BMC Gastroenterol 2021; 21:179. [PMID: 33879093 PMCID: PMC8056557 DOI: 10.1186/s12876-021-01758-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 04/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background We present a case of a woman with a past medical history of irritable bowel syndrome (IBS) and anxiety, who presents with ophthalmoplegia, ataxia and memory loss, characteristic of Wernicke encephalopathy. Case presentation A 64-year-old woman presented with double vision, unsteady gait and memory loss. These symptoms began after 3 months on an unfortified restricted diet, which she initiated to alleviate IBS symptoms. Magnetic resonance imaging of the brain demonstrated hyperintense T2-weighted signal in the dorsomedial aspect of bilateral thalami, periaqueductal grey matter and around the third ventricle. The patient’s visual symptoms improved significantly after thiamine supplementation, although her memory deficits persisted. Conclusion Although WE is often associated with chronic alcohol abuse, this case demonstrates the importance of recognizing WE in any patient with a restricted diet and subsequent timely initiation of thiamine.
Collapse
Affiliation(s)
- Qiang Wang
- Department of Neurology, Kings County Hospital Center, SUNY Downstate Medical Center and Maimonides Medical Center, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Zeinab Charmchi
- Department of Neurology, Kings County Hospital Center, SUNY Downstate Medical Center and Maimonides Medical Center, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Ilena C George
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
| |
Collapse
|
23
|
Jain K, Singh J, Jain A, Khera T. A Case Report of Nonalcoholic Gayet-Wernicke Encephalopathy: Don't Miss Thiamine. A A Pract 2021; 14:e01230. [PMID: 32496424 DOI: 10.1213/xaa.0000000000001230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Gayet-Wernicke encephalopathy (WE) is an acute neurological disorder resulting from deficiency of thiamine, commonly related to chronic abuse of alcohol, but frequently missed or overlooked as a diagnosis when a nonalcoholic patient presents with atypical signs and symptoms of the disease. The diagnosis of the disease is clinical, and confirmation is done by magnetic resonance imaging. We aim to highlight a case of WE in a nonalcoholic postoperative surgical patient receiving total parental nutrition where high-dose intravenous administration of thiamine in time mitigated the symptoms of disease and prevented permanent neurological sequelae. We spotlight the significance of adequate thiamine for postoperative malnourished surgical patients.
Collapse
Affiliation(s)
- Kompal Jain
- From the Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Jasveer Singh
- From the Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Anant Jain
- Department of Internal Medicine, Westchester Medical Center, Valhalla, New York
| | - Tanvi Khera
- From the Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| |
Collapse
|
24
|
Mates E, Alluri D, Artis T, Riddle MS. A Retrospective Case Series of Thiamine Deficiency in Non-Alcoholic Hospitalized Veterans: An Important Cause of Delirium and Falling? J Clin Med 2021; 10:jcm10071449. [PMID: 33916273 PMCID: PMC8037750 DOI: 10.3390/jcm10071449] [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: 03/09/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/19/2022] Open
Abstract
Thiamine deficiency (TD) in non-alcoholic hospitalized patients causes a variety of non-specific symptoms. Studies suggest it is not rare in acutely and chronically ill individuals in high income countries and is underdiagnosed. Our aim is to demonstrate data which help define the risk factors and constellation of symptoms of TD in this population. We describe 36 cases of TD in hospitalized non-alcoholic veterans over 5 years. Clinical and laboratory data were extracted by chart review +/− 4 weeks of plasma thiamine level 7 nmol/L or less. Ninety-seven percent had two or more chronic inflammatory conditions (CICs) and 83% had one or more acute inflammatory conditions (AICs). Of possible etiologies of TD 97% had two or more of: insufficient intake, inflammatory stress, or increased losses. Seventy-five percent experienced 5% or more weight loss. Ninety-two percent had symptoms with the most common being weakness or falling (75%) followed by neuropsychiatric manifestations (72%), gastrointestinal dysfunction (53%), and ataxia (42%). We conclude that TD is underdiagnosed in this population with consequent morbidity and mortality. TD likely develops because of inflammatory stress from CIC’s compounded by AIC’s combined with decreased energy intake or increased nutrient losses.
Collapse
Affiliation(s)
- Elisabeth Mates
- Medicine Department, Veterans Affairs Sierra Nevada Healthcare System, Reno, NV 89502, USA;
- School of Medicine, University of Nevada, Reno, NV 89502, USA;
- Correspondence:
| | - Deepti Alluri
- Sound Physicians, Lutheran Hospital, Fort Wayne, IN 46804, USA;
| | - Tailer Artis
- School of Medicine, University of Nevada, Reno, NV 89502, USA;
| | - Mark S. Riddle
- Medicine Department, Veterans Affairs Sierra Nevada Healthcare System, Reno, NV 89502, USA;
- School of Medicine, University of Nevada, Reno, NV 89502, USA;
| |
Collapse
|
25
|
Nasir S, Abou Areda M, Ma EL, Chow RD, Verceles A, Peng CCH. Non-alcoholic Wernicke's encephalopathy: toxic ingestion or an honest mis-steak? J Community Hosp Intern Med Perspect 2021; 11:147-151. [PMID: 33552440 PMCID: PMC7850391 DOI: 10.1080/20009666.2020.1843236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
A 21-year-old male presented with a 2-week history of nausea and non-bloody, non-bilious vomiting, accompanied by diffuse chronic myalgia. The patient endorsed headaches, dizziness, and diplopia that had started one day prior to admission. The patient had consumed a meat-only diet for the prior year. The patient was found to have a high anion gap metabolic acidosis with a superimposed normal anion gap metabolic acidosis in the setting of a several-month history of ingesting multiple naturopathic substances as well as recent use of disulfiram for management of his chronic myalgia. Magnetic resonance imaging (MRI) of the brain demonstrated symmetric hyperintensity involving bilateral thalami, periventricular regions, putamina, pons and medulla, with sparing of the mammillary bodies, consistent with Wernicke’s encephalopathy (WE). The patient was treated with intravenous thiamine, a balanced nutritional diet, and hydration. Over the ensuing four days, his metabolic derangements resolved and a repeat MRI demonstrated significantly decreased FLAIR signal abnormality.
Collapse
Affiliation(s)
- Salahuddin Nasir
- American University of Antigua, College of Medicine, Osbourn, Antigua and Barbuda
| | - Moustafa Abou Areda
- Department of Medicine, University of Maryland Medical CenterMidtown Campus, Baltimore, Maryland, USA
| | - Elise L Ma
- Department of Medicine, University of Maryland Medical CenterMidtown Campus, Baltimore, Maryland, USA
| | - Robert D Chow
- Department of Medicine, University of Maryland Medical CenterMidtown Campus, Baltimore, Maryland, USA
| | - Avelino Verceles
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Carol Chiung-Hui Peng
- Department of Medicine, University of Maryland Medical CenterMidtown Campus, Baltimore, Maryland, USA
| |
Collapse
|
26
|
The contribution of mamillary body damage to Wernicke's encephalopathy and Korsakoff's syndrome. HANDBOOK OF CLINICAL NEUROLOGY 2021; 180:455-475. [PMID: 34225949 DOI: 10.1016/b978-0-12-820107-7.00029-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Histopathological alterations of the mamillary bodies are the most conspicuous and the most consistent neuropathological features of several disorders that occur after severe thiamine deficiency, such as Wernicke's encephalopathy and Korsakoff's syndrome. Moreover, they are among the few abnormalities that are visible to the naked eye in these disorders. With a lifetime prevalence of approximately 1.3%, Wernicke's encephalopathy is by far the most frequent cause of damage to the mamillary bodies in humans. Still, there is a persisting uncertainty with regard to the development and the clinical consequences of this damage, because it is virtually impossible to study in isolation. As a rule, it always occurs alongside neuropathology in other subcortical gray matter structures, notably the medial thalamus. Converging evidence from other pathologies and animal experiments is needed to assess the clinical impact of mamillary body damage and to determine which functions can be attributed to these structures in healthy subjects. In this chapter, we describe the history and the current state of knowledge with regard to thiamine deficiency disorders and the contribution of mamillary body damage to their clinical presentations.
Collapse
|
27
|
Vassallo GA, Mirijello A, Dionisi T, Tarli C, Augello G, Gasbarrini A, Addolorato G. Wernicke's Encephalopathy in Alcohol Use Disorder Patients after Liver Transplantation: A Case Series and Review of Literature. J Clin Med 2020; 9:jcm9123809. [PMID: 33255603 PMCID: PMC7761291 DOI: 10.3390/jcm9123809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/19/2020] [Accepted: 11/21/2020] [Indexed: 12/19/2022] Open
Abstract
Wernicke’s encephalopathy (WE) is an acute neurological disorder resulting from thiamine deficiency, commonly found in alcohol use disorder (AUD) patients. Liver transplantation (LT) could represent a risk factor for the onset of WE in AUD patients, due to the onset of chronic depletion of thiamine in this population and the high metabolic demand of surgery and the postoperative period. However, few data are available about the risk of the onset of WE in AUD patients after LT. Here we report three cases of AUD patients who developed WE with confusion and delirium after LT. Prompt parenteral administration of thiamine led to a rapid improvement of the clinical condition and a complete remission of neurological symptoms after 3–4 days. In addition, a search of the available English literature was conducted in order to perform a review of the possible association between the onset of WE and LT in AUD patients. A prophylactic treatment regimen based on the administration of thiamine could be suggested in AUD patients before and after LT. Further studies are needed to determine the optimal regimen of thiamine in the prevention of WE in this setting.
Collapse
Affiliation(s)
- Gabriele A. Vassallo
- Department of Internal Medicine, Barone Lombardo Hospital, 92024 Canicattì, Italy; (G.A.V.); (G.A.)
| | - Antonio Mirijello
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza Hospital, 71013 San Giovanni Rotondo, Italy;
| | - Tommaso Dionisi
- Alcohol Use Disorder and Alcohol Related Disease Unit, Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (T.D.); (C.T.)
| | - Claudia Tarli
- Alcohol Use Disorder and Alcohol Related Disease Unit, Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (T.D.); (C.T.)
| | - Giuseppe Augello
- Department of Internal Medicine, Barone Lombardo Hospital, 92024 Canicattì, Italy; (G.A.V.); (G.A.)
| | - Antonio Gasbarrini
- Internal Medicine, Gastroenterology and Hepatology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
- Institute of Internal Medicine and Gastroenterology, Catholic University of Rome, 00168 Rome, Italy
| | - Giovanni Addolorato
- Alcohol Use Disorder and Alcohol Related Disease Unit, Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (T.D.); (C.T.)
- Internal Medicine Unit, Columbus-Gemelli Hospital, Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-06-30154334; Fax: +39-06-35502775
| | | |
Collapse
|
28
|
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
|
29
|
Ota Y, Capizzano AA, Moritani T, Naganawa S, Kurokawa R, Srinivasan A. Comprehensive review of Wernicke encephalopathy: pathophysiology, clinical symptoms and imaging findings. Jpn J Radiol 2020; 38:809-820. [PMID: 32390125 DOI: 10.1007/s11604-020-00989-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/29/2020] [Indexed: 12/14/2022]
Abstract
Wernicke's encephalopathy (WE) is a severe and life-threatening illness resulting from vitamin B1 (thiamine) deficiency. The prevalence of WE has been estimated from 0.4 to 2.8%. If not treated properly, severe neurologic disorders such as Korsakoff psychosis and even death may occur. The classical triad of clinical symptoms (abnormal mental state, ataxia, and ophthalmoplegia) is found in only 16-33% of patients on initial examination. The originally described underlying condition of WE is alcoholism, but it accounts for about 50% of causes of WE. Nonalcoholic patients are also affected by WE and likely to present symptoms and radiological imaging findings different from patients with alcoholism, which further complicates the diagnosis of WE. Being familiar with predisposing causes, symptoms and radiological imaging findings of WE is important for radiologists and clinicians when making the diagnosis to start immediate treatment. This review discusses pathophysiologies, underlying causes, clinical symptoms, imaging findings and their mimics.
Collapse
Affiliation(s)
- Yoshiaki Ota
- The Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA. .,Department of Radiology, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, 465 Kajii-cho, Kyoto, Kyoto, 602-8566, Japan.
| | - Aristides A Capizzano
- The Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
| | - Toshio Moritani
- The Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
| | - Shotaro Naganawa
- The Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
| | - Ryo Kurokawa
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Ashok Srinivasan
- The Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
| |
Collapse
|
30
|
Liu YL, Xiao WM, Liang MQ, Wu ZQ, Wang YZ, Qu JF, Chen YK. Clinical characteristics and magnetic resonance imaging findings in nine patients with nonalcoholic Wernicke's encephalopathy: a retrospective study. Neuropsychiatr Dis Treat 2019; 15:2433-2441. [PMID: 31692555 PMCID: PMC6716582 DOI: 10.2147/ndt.s217237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/03/2019] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Wernicke's encephalopathy (WE) is a severe neurological disorder caused by thiamine deficiency. The most common cause of WE is alcoholism. However, there is a significant paucity of information in the existing literature relating to nonalcoholic WE. In this study, we investigated the clinical characteristics and neuroimaging findings of nine patients with nonalcoholic WE. PATIENTS AND METHODS We retrospectively collated clinical data from nine patients who had been diagnosed with WE in accordance with established criteria including age, gender, risk factors and clinical manifestations. We also collated initial hematological and neuroimaging findings. RESULTS The mean age of the nine patients was 54.0±17.1 years; four of these patients (44.4%) were male. All nine patients had a history of fasting (range, 5-47 days) prior to WE. Four of the nine patients (44.4%) exhibited the classical triad, and eight (88.9%) showed alterations in mental status. Magnetic resonance imaging (MRI) scans showed that all nine patients had symmetric lesions of the medial thalamus. MRI also revealed other WE-related lesions in mammillary bodies (22.2%), the periaqueductal region (55.6%), the tectal plate of the midbrain (77.8%), cranial nerve nuclei (77.8%) and in the symmetric subcortical white matter (11.1%). CONCLUSION Our analysis showed that fasting is a common cause of WE in nonalcoholic patients and that MRI is a useful tool for the diagnosis of WE. The most common MRI findings were symmetrical lesions of the medial thalamus lesions, followed by the tectal plate of the midbrain and cranial nerve nuclei.
Collapse
Affiliation(s)
- Yong-Lin Liu
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Wei-Min Xiao
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Man-Qiu Liang
- Department of Radiology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Zhi-Qiang Wu
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Ya-Zhi Wang
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Jian-Feng Qu
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Yang-Kun Chen
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| |
Collapse
|
31
|
Nikolakaros G, Kurki T, Paju J, Papageorgiou SG, Vataja R, Ilonen T. Korsakoff Syndrome in Non-alcoholic Psychiatric Patients. Variable Cognitive Presentation and Impaired Frontotemporal Connectivity. Front Psychiatry 2018; 9:204. [PMID: 29910747 PMCID: PMC5992887 DOI: 10.3389/fpsyt.2018.00204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/02/2018] [Indexed: 12/14/2022] Open
Abstract
Background: Non-alcoholic Wernicke's encephalopathy and Korsakoff syndrome are greatly underdiagnosed. There are very few reported cases of neuropsychologically documented non-alcoholic Korsakoff syndrome, and diffusion tensor imaging (DTI) data are scarce. Methods: We report clinical characteristics and neuropsychological as well as radiological findings from three psychiatric patients (one woman and two men) with a history of probable undiagnosed non-alcoholic Wernicke's encephalopathy and subsequent chronic memory problems. Results: All patients had abnormal neuropsychological test results, predominantly in memory. Thus, the neuropsychological findings were compatible with Korsakoff syndrome. However, the neuropsychological findings were not uniform. The impairment of delayed verbal memory of the first patient was evident only when the results of the memory tests were compared to her general cognitive level. In addition, the logical memory test and the verbal working memory test were abnormal, but the word list memory test was normal. The second patient had impaired attention and psychomotor speed in addition to impaired memory. In the third patient, the word list memory test was abnormal, but the logical memory test was normal. All patients had intrusions in the neuropsychological examination. Executive functions were preserved, except for planning and foresight, which were impaired in two patients. Conventional MRI examination was normal. DTI showed reduced fractional anisotropy values in the uncinate fasciculus in two patients, and in the corpus callosum and in the subgenual cingulum in one patient. Conclusions: Non-alcoholic Korsakoff syndrome can have diverse neuropsychological findings. This may partly explain its marked underdiagnosis. Therefore, a strong index of suspicion is needed. The presence of intrusions in the neuropsychological examination supports the diagnosis. Damage in frontotemporal white matter tracts, particularly in the uncinate fasciculus, may be a feature of non-alcoholic Korsakoff syndrome in psychiatric patients.
Collapse
Affiliation(s)
- Georgios Nikolakaros
- "Specialists in Psychiatry" Medical Center, Turku, Finland.,Satakunta Hospital District, Psychiatric Care Division, General Psychiatry Outpatient Clinic, Pori, Finland.,Turku University Central Hospital, Salo Psychiatry Outpatient Clinic, Salo, Finland
| | - Timo Kurki
- Terveystalo Pulssi Medical Center, Turku, Finland.,Department of Radiology, University of Turku, Turku, Finland
| | - Janina Paju
- Department of Psychiatry, University of Turku, Turku, Finland
| | - Sokratis G Papageorgiou
- Cognitive Disorders/Dementia Unit, 2nd University Department of Neurology, Medical School, National and Kapodistrian University of Athens, University General Hospital "ATTIKON", Athens, Greece
| | - Risto Vataja
- Division of Neuropsychiatry, Helsinki University Hospital, Helsinki, Finland
| | - Tuula Ilonen
- Department of Psychiatry, University of Turku, Turku, Finland
| |
Collapse
|
32
|
Shigekiyo T, Tani H, Nakajima H, Kimura F. Antecedent diffuse cerebellar lesions on diffusion-weighted MRI in nonalcoholic Wernicke's encephalopathy. Neurol Sci 2017; 39:789-790. [PMID: 29143148 DOI: 10.1007/s10072-017-3190-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/06/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Taro Shigekiyo
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| | - Hiroki Tani
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| | - Hideto Nakajima
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan.
| | - Fumiharu Kimura
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| |
Collapse
|
33
|
Sanvisens A, Zuluaga P, Fuster D, Rivas I, Tor J, Marcos M, Chamorro AJ, Muga R. Long-Term Mortality of Patients with an Alcohol-Related Wernicke–Korsakoff Syndrome. Alcohol Alcohol 2017; 52:466-471. [DOI: 10.1093/alcalc/agx013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 02/24/2017] [Indexed: 12/17/2022] Open
Abstract
Abstract
Aims
To characterize a series of contemporary patients with alcohol-related Wernicke's encephalopathy (WE) or Korsakoff's syndrome (KS) and to update the current prognosis of disease.
Methods
Retrospective and prospective study of patients diagnosed with an alcohol-related WE or KS between 2002 and 2011 in a tertiary hospital. Socio-demographic, alcohol use characteristics, signs and symptoms, co-morbidity and blood parameters were obtained at admission. Patients were followed up until 2013 and causes of death were ascertained through the review of charts.
Results
Sixty-one patients were included (51 with WE and 10 with KS). Among patients with WE, 78% were men and age at diagnosis was 57 years (interquartile range (IQR): 49–66). Twenty-three percent fulfilled the classic WE triad. Regarding Caine's criteria for WE, 70.6% presented with at least two out of four signs or symptoms. Median follow-up of patients with WE syndrome was 5.3 years (IQR: 2.6–8.8), the cumulated mortality was 45% and death rate of 7.4 × 100 person-years (95% confidence interval (CI): 4.8–10.9). Overall, 50% of patients would be expected to die within 8 years of WE episode and main causes of death included serious bacterial infections (44.5%) and cancer (33.3%).
Conclusions
Survival of patients with an alcohol-related Wernicke–Korsakoff syndrome is poor; pursuing treatment of alcohol use disorder and early diagnosis of thiamine deficiency is a priority for improving clinical outcomes.
Collapse
Affiliation(s)
- Arantza Sanvisens
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Ctra. Canyet s/n, 08916 Badalona, Spain
| | - Paola Zuluaga
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Ctra. Canyet s/n, 08916 Badalona, Spain
| | - Daniel Fuster
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Ctra. Canyet s/n, 08916 Badalona, Spain
| | - Inmaculada Rivas
- Municipal Centre for Substance Abuse Treatment (Centro Delta), IMSP-Badalona, C/Termes Romanes 12, 08911 Badalona, Spain
| | - Jordi Tor
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Ctra. Canyet s/n, 08916 Badalona, Spain
| | - Miguel Marcos
- 3Department of Internal Medicine, Alcoholism Unit, Hospital Universitario de Salamanca, Paseo de San Vicente, 88-182, 37007 Salamanca, Spain
| | - Antonio J. Chamorro
- 3Department of Internal Medicine, Alcoholism Unit, Hospital Universitario de Salamanca, Paseo de San Vicente, 88-182, 37007 Salamanca, Spain
| | - Roberto Muga
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Ctra. Canyet s/n, 08916 Badalona, Spain
| |
Collapse
|
34
|
Abstract
In this review, we present a survey on Korsakoff's syndrome (KS), a residual syndrome in patients who suffered from a Wernicke encephalopathy (WE) that is predominantly characterized by global amnesia, and in more severe cases also by cognitive and behavioral dysfunction. We describe the history of KS and its definition, its epidemiology, and the lack of consensus criteria for its diagnosis. The cognitive and behavioral symptoms of KS, which include anterograde and retrograde amnesia, executive dysfunction, confabulation, apathy, as well as affective and social-cognitive impairments, are discussed. Moreover, recent insights into the underlying neurocognitive mechanisms of these symptoms are presented. In addition, the evidence so far on the etiology of KS is examined, highlighting the role of thiamine and alcohol and discussing the continuity hypothesis. Furthermore, the neuropathology of KS is reviewed, focusing on abnormalities in the diencephalon, including the mammillary bodies and thalamic nuclei. Pharmacological treatment options and nonpharmacological interventions, such as those based on cognitive rehabilitation, are discussed. Our review shows that thiamine deficiency (TD) is a crucial factor in the etiology of KS. Although alcohol abuse is by far the most important context in which TD occurs, there is no convincing evidence for an essential contribution of ethanol neurotoxicity (EN) to the development of WE or to the progression of WE to KS. Future research on the postmortem histopathological analysis of brain tissues of KS patients is crucial for the advancement of our knowledge of KS, especially for associating its symptoms with lesions in various thalamic nuclei. A necessary requirement for the advancement of studies on KS is the broad acceptance of a comprehensive definition and definite diagnostic criteria. Therefore, in this review, we propose such a definition of KS and draft outlines for prospective diagnostic criteria.
Collapse
Affiliation(s)
- Nicolaas Jm Arts
- Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, Venray.,Neuropsychiatry Center Thalamus, Institution for Integrated Mental Health Care Pro Persona, Wolfheze
| | - Serge Jw Walvoort
- Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, Venray
| | - Roy Pc Kessels
- Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, Venray.,Department of Neuropsychology and Rehabilitation Psychology, Donders Institute for Brain, Cognition and Behaviour, Radboud University.,Department of Medical Psychology, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|