Neuro-ophthalmic Manifestations of Wernicke Encephalopathy

Sudden vision loss in pregnancy: Wernicke's encephalopathy in a patient with hyperemesis gravidarum

Wernicke's encephalopathy, the acute phase of Wernicke-Korsakoff syndrome, is characterised as a triad of altered mental status, ocular signs and ataxia. Our patient presented with hyperemesis gravidarum, which is a rare aetiology of Wernicke's encephalopathy. The patient did not have any oculomotor abnormalities, which are more common and classically described in Wernicke's triad. The sudden visual loss in both eyes can be attributed to acute optic neuropathy. Our case highlights a unique ophthalmic presentation with retinal haemorrhages and optic disc oedema as unusual manifestations of Wernicke's encephalopathy. The dramatic and complete reversal of visual symptoms within 48 hours after starting parenteral thiamine retrospectively supports the diagnosis.

Reversible Bilateral Vision Loss: An Unusual Presentation of Wernicke-Korsakoff Syndrome

Neuro-ophthalmic manifestations of Wernicke encephalopathy (WE) are uncommon and vary from nystagmus, oculomotor palsies, anisocoria, and optic disc edema to vision loss. We describe a case of a 53-year-old woman presenting with subacute bilateral painless vision decline, lower-extremities weakness with impaired ambulation, headache, and abdominal pain. Neurological examination was pertinent for confabulation, bilateral decreased visual acuity with an absent blink to threat, absent afferent pupillary defect and fundus abnormalities, and significant allodynia in bilateral lower extremities. Besides elevated inflammatory marker with an erythrocyte sedimentation rate (ESR) of 130 mm/hr, her infectious, autoimmune, paraneoplastic, and neuromyelitis optica work-up was overall unremarkable. Brain MRI showed abnormal fluid-attenuated inversion recovery (FLAIR) signaling in bilateral mammillary bodies and around periaqueductal gray matter concerning WE. Due to concerns of Wernicke-Korsakoff syndrome (WKS), parenteral high-dose thiamine was initiated with significant clinical improvement. The patient was also later found to have a positive anti-myelin oligodendrocyte glycoprotein (MOG) antibody, which was deemed false positive given the atypical phenotype and symptomatic improvement with thiamine supplementation. This case encourages the consideration of vision loss as a manifestation of WKS, especially in patients who have risk factors. Testing serum levels of thiamine is strongly encouraged; however, initiating empiric treatment is advocated for high clinical suspicion due to its reversible nature and minimal risk for side effects.

Wernicke Encephalopathy Associated With Semaglutide Use

A patient presenting to the emergency room with neurological symptoms is more commonly found to have manifestations of stroke, transient ischemic attack, or nervous system injury. Alcoholic Wernicke encephalopathy (WE) is also another common manifestation of neurological dysfunction; however, the prevalence of non-alcoholic WE is relatively uncommon. We discuss a 37-year-old male who presented to the ED with dysphagia, slurred speech, word-finding difficulty, and restricted extraocular movements from non-alcoholic WE in the setting of semaglutide use.

Wernicke encephalopathy with atypical imaging findings in a depressed patient: A case report

This case report highlights the rare occurrence of Wernicke encephalopathy caused by malnutrition in a depressed patient with atypical imaging findings. A 60-year-old female with depression developed a disturbance of consciousness owing to Wernicke encephalopathy. Magnetic resonance imaging showed abnormal signals in the thalamus and mammillary bodies around the third ventricle, cerebral aqueduct, and fourth ventricle. Abnormal signals were also present in the cerebral cortex around the central sulcus, and an intracranial hemorrhage from the thalamus was observed. Therefore, clinicians should consider Wernicke encephalopathy in the differential diagnosis of altered consciousness in depressed patients. Early assessment of nutritional status and prompt intervention are crucial in cases of prolonged depression-related malnutrition.

Ocular manifestations of liver disease: an important diagnostic aid

PURPOSE

This review examined existing literature to determine various ocular manifestations of liver pathologies, with a focus on metabolic deficiencies as well as viral and immune liver conditions.

METHODS

Recent data were compiled from PubMed from 2000 to 2020 using keywords that were relevant to the assessed pathologies. Ocular presentations of several liver pathologies were researched and then summarized in a comprehensive form.

RESULTS

Several ocular manifestations of liver disease were related to vitamin A deficiency, as liver disease is associated with impaired vitamin A homeostasis. Alcoholic liver cirrhosis can result in vitamin A deficiency, presenting with Bitot spots, xerosis, and corneal necrosis. Congenital liver diseases such as mucopolysaccharidoses and peroxisomal disorders are also linked with ocular signs. Viral causes of liver disease have associations with conditions like retinal vasculitis, keratoconjunctivitis sicca, retinopathies, Mooren's ulcer, and Sjogren's syndrome. Autoimmune hepatitis has been linked to peripheral ulcerative keratitis and uveitis.

CONCLUSIONS

Building strong associations between ocular and liver pathology will allow for early detection of such conditions, leading to the early implementation of management strategies. While this review outlines several of the existing connections between hepatic and ophthalmic disease, further research is needed in the area in order to strengthen these associations.

Wernicke's Encephalopathy and Serotonin Syndrome: A Case Report of Overlapping Pathologies

Objective: Acute encephalopathy is a common symptom encountered in critically ill patients and may be associated with Wernicke's encephalopathy (WE) or serotonin syndrome (SS). We describe a patient who presented with clinical manifestations of both WE and SS and who responded to treatment for both pathologies. Case: A 56-year-old male presented after being found unresponsive and in a questionable tonic-clonic state. Past medical history was significant for depression managed with fluoxetine 20 mg by mouth daily and alcohol use disorder. A physical exam revealed severe clonus in the bilateral lower extremities; diffuse hyperreflexia along with akinesia on the left upper extremity; ophthalmoplegia; and persistent tachycardia despite pharmacologic interventions. It was learned that the patient had been taking his fluoxetine 3 times per day rather than daily as prescribed. Oral cyproheptadine was administered at a 12 mg initial dose followed by 4 mg every 6 hours. A thiamine regimen of 500 mg intravenous (IV) every 8 hours in addition to folic acid 1 mg IV every 24 hours was initiated to treat WE. Physical symptoms of both WE and SS resolved within 48 hours, and the patient was ultimately discharged to home in stable condition. Discussion/Conclusions: The clinical diagnosis of both WE and SS in this case is supported by the Caine and Hunter criteria, respectively, as well as the resolution of symptoms with accepted treatment modalities for each. It is important for clinicians to be cognizant of potential overlapping pathologies when patients present with nonspecific symptoms, especially acute encephalopathy, in the intensive care unit.

Association Between Vitamin Deficiencies and Ophthalmological Conditions

Vitamin deficiencies can have adverse effects on health, including on the visual system. The ocular manifestations of a vitamin deficiency are related to the underlying biochemical function of the particular nutrient. While vitamin deficiencies are not common in developed counties, they are still prevalent in parts of the developing world and in specific, vulnerable populations. Vitamin deficiencies can cause or contribute to many ophthalmological conditions and eye diseases may even be the first presenting finding of a vitamin deficiency. As such, it is important for ophthalmologists to be aware of the ocular manifestations of vitamin deficiencies, especially given that the complications can be severe and effectively treated if identified early. This review summarizes the literature on the main vitamins known to have characteristic ocular manifestations: vitamins A, B1, B2, B9, B12, C, D, E and K. The function, epidemiology, manifestations, workup, and management of each vitamin is discussed in detail.

Uncommon bilateral optic neuropathy in Wernicke's encephalopathy complicating gravidarum hyperemesis

Wernicke encephalopathy (WE) is a rare neurological disorder that results from vitamin B1 (Thiamin) deficiency, classically characterized by the triad of ophtalmoplagia, altered consciousness, and ataxia. WE is often associated with alcoholism, malnutrition, or gastrointestinal diseases with malabsorption. The association of «gravidarum hyperemesis» and WE seems to be underestimated. We report a 24-year-old pregnant woman with hyperemesis gravidarum, who presented with decreased visual acuity of both eyes. Fundus examination showed a bilateral stage 2 papillary edema. brain magnetic resonance imaging (MRI) showed bilateral and symmetrical hyper intense lesions on T2-weighted and FLAIR sequences in periaqueductal gray matter, thalamus, and mammillary bodies, which confirmed WE complicated by bilateral optic neuropathy. Her symptoms resolved after thiamine treatment. This case raises of the possibility of optic neuropathy in WE, which is a diagnostic emergency requiring early treatment to prevent complications.

Thiamine deficiency in pregnancy and lactation: implications and present perspectives

During pregnancy, many physiologic changes occur in order to accommodate fetal growth. These changes require an increase in many of the nutritional needs to prevent long-term consequences for both mother and the offspring. One of the main vitamins that are needed throughout the pregnancy is thiamine (vitamin B1) which is a water-soluble vitamin that plays an important role in many metabolic and physiologic processes in the human body. Thiamine deficiency during pregnancy can cause can have many cardiac, neurologic, and psychological effects on the mother. It can also dispose the fetus to gastrointestinal, pulmonological, cardiac, and neurologic conditions. This paper reviews the recently published literature about thiamine and its physiologic roles, thiamine deficiency in pregnancy, its prevalence, its impact on infants and subsequent consequences in them. This review also highlights the knowledge gaps within these topics.

Clinical and imaging clues to the diagnosis and follow-up of ptosis and ophthalmoparesis

Ophthalmoparesis and ptosis can be caused by a wide range of rare or more prevalent diseases, several of which can be successfully treated. In this review, we provide clues to aid in the diagnosis of these diseases, based on the clinical symptoms, the involvement pattern and imaging features of extra-ocular muscles (EOM). Dysfunction of EOM including the levator palpebrae can be due to muscle weakness, anatomical restrictions or pathology affecting the innervation. A comprehensive literature review was performed to find clinical and imaging clues for the diagnosis and follow-up of ptosis and ophthalmoparesis. We used five patterns as a framework for differential diagnostic reasoning and for pattern recognition in symptomatology, EOM involvement and imaging results of individual patients. The five patterns were characterized by the presence of combination of ptosis, ophthalmoparesis, diplopia, pain, proptosis, nystagmus, extra-orbital symptoms, symmetry or fluctuations in symptoms. Each pattern was linked to anatomical locations and either hereditary or acquired diseases. Hereditary muscle diseases often lead to ophthalmoparesis without diplopia as a predominant feature, while in acquired eye muscle diseases ophthalmoparesis is often asymmetrical and can be accompanied by proptosis and pain. Fluctuation is a hallmark of an acquired synaptic disease like myasthenia gravis. Nystagmus is indicative of a central nervous system lesion. Second, specific EOM involvement patterns can also provide valuable diagnostic clues. In hereditary muscle diseases like chronic progressive external ophthalmoplegia (CPEO) and oculo-pharyngeal muscular dystrophy (OPMD) the superior rectus is often involved. In neuropathic disease, the pattern of involvement of the EOM can be linked to specific cranial nerves. In myasthenia gravis this pattern is variable within patients over time. Lastly, orbital imaging can aid in the diagnosis. Fat replacement of the EOM is commonly observed in hereditary myopathic diseases, such as CPEO. In contrast, inflammation and volume increases are often observed in acquired muscle diseases such as Graves' orbitopathy. In diseases with ophthalmoparesis and ptosis specific patterns of clinical symptoms, the EOM involvement pattern and orbital imaging provide valuable information for diagnosis and could prove valuable in the follow-up of disease progression and the understanding of disease pathophysiology.

Bilateral papilledema with vision loss due to post-COVID-19-induced thiamine deficiency: illustrative case

BACKGROUND

Bilateral papilledema with vision loss is considered a neurosurgical emergency due to high intracranial pressure. However, it may not be the only cause of papilledema. The authors reported an association among coronavirus disease 2019 (COVID-19), bilateral papilledema, blindness, and Wernicke's encephalopathy (WE).

OBSERVATIONS

An 18-year-old woman presented to the neurosurgery service with rapid profound vision loss and bilateral papilledema. She had COVID-19 3 months earlier with subsequent loss of smell (anosmia) and taste (ageusia), which resulted in hyperemesis and a 43-lb weight loss. Examination revealed ataxia, horizontal nystagmus, and blindness. Magnetic resonance imaging and magnetic resonance venography of her brain were normal. Presumptive diagnosis of WE was made, and she was treated with intravenous thiamine with restoration of vision within 48 hours. Patient's thiamine level was less than half the normal value.

LESSONS

Neurosurgeons should be aware of this unique correlation between papilledema and vision loss and its association with WE due to post-COVID-19 hyperemesis and weight loss from anosmia and ageusia.

Chronic Posterior Tibiofemoral Dislocation of a Cruciate Retaining Total Knee Arthroplasty in the Setting of Wernicke-Korsakoff Syndrome: A Case Report

Introduction

Knee dislocations are an uncommon complication following total knee arthroplasty (TKA). There are many causes of TKA dislocation; however, Wernicke-Korsakoff syndrome is one uncommon neurologic condition that increases the risk of TKA dislocation.

Case Report

A 71-year-old male with presented to a local community hospital with knee pain due to advanced osteoarthritis of the knee and subsequently underwent an uncomplicated TKA with a cruciate retaining prosthesis. He eventually returned to the hospital due to infection, medical instability, chronic knee instability, and posterior tibiofemoral dislocation. A revision process was required. Throughout the course of management, the patient had altered mental status and was admitted to the intensive care unit. The first procedure involved removing the cruciate retaining prosthesis and replacing it with a static cement antibiotic spacer. This prosthesis was eventually dislocated through the tibia and a second procedure requiring the placement of an intercalary fusion was needed. The patient has not followed up after the hospital admission.

Conclusion

Wernicke-Korsakoff Syndrome is an uncommon condition that affects alcoholics and complicates treatment with joint replacement surgery. Patients with Wernicke-Korsakoff syndrome provide a unique set of challenges that may require multiple surgeries and varying prostheses. Chronic posterior tibiofemoral dislocation is one specific complication that may affect the management of these patients. As orthopedic surgeons, it is important to consider alcohol use disorder and Wernicke-Korsakoff Syndrome when treating patients with total joint replacement.

Therapeutic potential of vitamin B1 derivative benfotiamine from diabetes to COVID-19

Benfotiamine (S-benzoylthiamine-O-monophosphate), a unique, lipid-soluble derivative of thiamine, is the most potent allithiamine found in roasted garlic, as well as in other herbs of the genus Allium. In addition to potent antioxidative properties, benfotiamine has also been shown to be a strong anti-inflammatory agent with therapeutic significance to several pathological complications. Specifically, over the past decade or so, benfotiamine has been shown to prevent not only various secondary diabetic complications but also several inflammatory complications such as uveitis and endotoxemia. Recent studies also demonstrate that this compound could be used to prevent the symptoms associated with various infectious diseases such as HIV and COVID-19. In this review article, the authors discuss the significance of benfotiamine in the prevention of various pathological complications.

Gaze-evoked nystagmus in Wernicke encephalopathy

Wernicke encephalopathy is caused by vitamin B1 deficiency. It presents as a triad consisting of altered mental status, oculomotor dysfunction, and gait ataxia. Early vitamin B1 administration alleviates symptoms. We present a video of gaze-evoked nystagmus in an elderly patient with Wernicke encephalopathy.

Vitamin B1, eye and brain

Vitamin B1 (aneurin, thiamine) is a water-soluble vitamin necessary for the normal function of the nervous system, visual system and heart and is part of important enzymes in the body. Thiamine enables the normal use of glucose, other carbohydrates and proteins, and enables the supply of energy to the organism. The main sources of thiamine are exogenous and small amounts are synthesized by microorganisms of the human intestinal microbiome. Vitamin B1 cannot accumulate in the body, so signs of deficiency are quickly manifested. Hypovitaminosis B1 is seen in chronic ethyl abuse, persistent vomiting (as in some pregnant women) or after bariatric surgical procedures, but in a mild form it is present in the general population. Normal daily needs for vitamin B1 depend on calorie intake, and 0.4 mg should be ingested for every 1000 kcal.

Clinical diagnosis, outcomes and treatment of thiamine deficiency in a tertiary hospital

BACKGROUND

Acute thiamine deficiency can occur in patients with or without history of alcohol abuse and can lead to life-threatening complications. Clinical diagnosis is challenging, often resulting in delayed recognition and treatment. Patients may present with heterogenous symptoms, more diverse than the historical neurological description. Cerebral MRI can contribute to the diagnosis in patients with neurological signs but it is not always feasible in emergency settings. Prompt parenteral supplementation is required to obtain the improvement of symptoms and avoid chronic complications.

AIMS

To describe the clinical presentation of reported cases of thiamine deficiency, assess prescription and results of cerebral imaging, review treatments that had been prescribed in accordance or not with available guidelines, and study the short-term outcome of these patients.

METHODS

This is a monocentric retrospective analysis of all reported cases of thiamine deficiency in a French tertiary hospital between January 1st 2008 and December 31st 2018.

RESULTS

Fifty-six cases were identified during the study period. Forty-five (80%) patients had a history of alcohol abuse. Most patients were diagnosed based on neurological symptoms but non-specific and digestive symptoms were frequent. Thirty-four percent of patients fulfilled clinical criteria for malnutrition. A brain MRI was performed in 54% of patients and was abnormal in 63% of these cases. Eighty-five percent of patients were treated by parenteral thiamine administration and the supplementation was continued orally in 55% of them. The majority of patients initially received 1000 mg daily of IV thiamine but the dose and duration of thiamine supplementation were variable. At the time of discharge, partial or complete improvement of symptoms was noted in 59% of patients.

CONCLUSION

This study highlights the clinical and radiological heterogeneity of thiamine deficiency. These observations should encourage starting thiamine supplementation early in patients with risk factors or suggestive symptoms even in non-alcoholic patients, and underline the importance of early nutritional support.