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Slagle BM, Meece T, Foster C, Campbell A, Tong L, Drake P. Altered Mental Status and Cardiac Failure Due to Thiamine Deficiency in an Overweight Teen. Pediatrics 2024; 153:e2022060958. [PMID: 38449424 DOI: 10.1542/peds.2022-060958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 03/08/2024] Open
Abstract
We describe an overweight but otherwise previously healthy 17-year-old female who presented with altered mental status and rapidly progressive weakness. She was ultimately diagnosed with Wernicke encephalopathy and wet beriberi resulting from severe thiamine deficiency. She required admission to the pediatric ICU because of hypoventilation with progressive weakness and worsening encephalopathy and was found to have impaired cardiac function as assessed by echocardiography. Her heart function and encephalopathy improved on initiation of thiamine repletion. She remained in inpatient rehabilitation for 10 months but still remained weak at discharge. Thiamine deficiency is not commonly considered in the United States as a diagnosis other than in patients with severe alcohol use disorder. However, thiamine may be depleted in as little as 2 weeks if nutrition is inadequate. In such a setting, thiamine deficiency is an important etiology to consider early in the pediatric patient with altered mentation especially because it can be readily and safely treated.
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Affiliation(s)
- Brittany M Slagle
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Arkansas Children's Hospital, Little Rock, Arkansas
| | - Trevor Meece
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Arkansas Children's Hospital, Little Rock, Arkansas
| | - Claire Foster
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Arkansas Children's Hospital, Little Rock, Arkansas
| | - Andrew Campbell
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Lauren Tong
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Paul Drake
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Arkansas Children's Hospital, Little Rock, Arkansas
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2
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Cantu-Weinstein A, Branning R, Alamir M, Weleff J, Do M, Nero N, Anand A. Diagnosis and treatment of Wernicke's encephalopathy: A systematic literature review. Gen Hosp Psychiatry 2024; 87:48-59. [PMID: 38306946 DOI: 10.1016/j.genhosppsych.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Wernicke's encephalopathy (WE) is a serious neurological disorder that is underdiagnosed. Despite limited clinical guidelines, the standard use of intravenous (IV) thiamine is underutilized and remains an area of research deserving much attention. OBJECTIVES We conducted a systematic review using Medline, Embase, and CENTRAL databases to identify and summarize the literature on IV thiamine treatment in WE. Human studies with WE patients who received ≥100 mg of thiamine IV met inclusion criteria. Randomized controlled trials, cross-sectional studies, and case reports were included. RESULTS A total of 27 studies were included: 20 case reports, five retrospective studies, one prospective study and one randomized control trial. Of the case reports, 11 (55%) cases were female, and the average age of all cases was 45 years (SD = 15). The other seven studies included 688 patients; the average age was 52 years (SD = 9), and 266 (38.7%) were female. Among the case reports, neurological and clinical findings were used to diagnose WE in 16 (80%) cases. MRI was utilized to diagnose 15 (75%) cases. 500 mg IV thiamine TID was reported in 12 case reports (60%). 18 (90%) of case reports had partial or complete resolution of symptoms following IV thiamine. CONCLUSION IV thiamine can alleviate neurological symptoms, cognitive dysfunction, and brain imaging lesions associated with WE. We found key limitations in the evidence for IV thiamine and diagnostic standards for WE. Future targeted research should establish clear diagnostic and treatment guidelines for WE to prevent this serious condition from being underdiagnosed or undertreated.
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Affiliation(s)
- Ashley Cantu-Weinstein
- Case Western Reserve University School of Medicine, Cleveland, OH, United States of America
| | - Rachel Branning
- Department of Psychiatry, University Hospitals Medical Center, Cleveland, OH, United States of America
| | - Maria Alamir
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH, United States of America
| | - Jeremy Weleff
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States of America
| | - Molly Do
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, United States of America
| | - Neil Nero
- Education Institute, Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, OH, United States of America
| | - Akhil Anand
- Department of Psychiatry, University Hospitals Medical Center, Cleveland, OH, United States of America; Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, United States of America.
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3
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Thompson JP, Rittenberry JC, Lawton AW, Kirchner KR. Wernicke's Encephalopathy From Gastrointestinal Disease After Remote Roux-en-Y. J Neuroophthalmol 2024; 44:e147-e148. [PMID: 36729906 DOI: 10.1097/wno.0000000000001776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- John P Thompson
- Louisiana State University at New Orleans (JPT, JCR, KRK), New Orleans, Louisiana; and Ochsner Medical Center Ophthalmology (AL), New Orleans, Louisiana
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Louis AM, Chen AH, Pakravan M, Charoenkijkajorn C, Lee AG. Wernicke's Encephalopathy Secondary to Chronic Total Parenteral Nutrition. J Neuroophthalmol 2024; 44:e149-e150. [PMID: 36729907 DOI: 10.1097/wno.0000000000001777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Abigail M Louis
- McGovern Medical School (AML), Houston, Texas; Baylor College of Medicine (AHC), Houston, Texas; Department of Ophthalmology (MP, CC, AGL), Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas; Departments of Ophthalmology, Neurology, and Neurosurgery (AGL), Weill Cornell Medicine, New York, New York; Department of Ophthalmology (AGL), University of Texas Medical Branch, Galveston, Texas; University of Texas MD Anderson Cancer Center (AGL), Houston, Texas; Texas A and M College of Medicine (AGL), Bryan, Texas; and Department of Ophthalmology (AGL), The University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Oudman E, Wijnia JW, Severs D, Oey MJ, van Dam M, van Dorp M, Postma A. Wernicke's Encephalopathy in Acute and Chronic Kidney Disease: A Systematic Review. J Ren Nutr 2024; 34:105-114. [PMID: 37838073 DOI: 10.1053/j.jrn.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/02/2023] [Accepted: 10/08/2023] [Indexed: 10/16/2023] Open
Abstract
Thiamine (vitamin B1) deficiency is relatively common in patients with kidney disease. Wernicke's encephalopathy (WE) is caused by vitamin B1 deficiency. Our aim was to systematically review the signs and symptoms of WE in patients with kidney disease. We conducted a systematic literature review on WE in kidney disease and recorded clinical and radiographic characteristics, treatment and outcome. In total 323 manuscripts were reviewed, which yielded 46 cases diagnosed with acute and chronic kidney disease and WE published in 37 reports. Prodromal characteristics of WE were loss of appetite, vomiting, weight loss, abdominal pain, and diarrhea. Parenteral thiamine 500 mg 3 times per day often led to full recovery, while Korsakoff's syndrome was found in those receiving low doses. To prevent WE in kidney failure, we suggest administering high doses of parenteral thiamine in patients with kidney disease who present with severe malnutrition and (prodromal) signs of thiamine deficiency.
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Affiliation(s)
- Erik Oudman
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands.
| | - Jan W Wijnia
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands
| | - David Severs
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Misha J Oey
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands
| | - Mirjam van Dam
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands
| | - Maaike van Dorp
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands
| | - Albert Postma
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands
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Vasantha Shekar Reddy H, S Nagabushana D, Kattamanchi D, Dakappa A. Nystagmus in a child with nephrotic syndrome. BMJ Case Rep 2024; 17:e259734. [PMID: 38417935 PMCID: PMC10900356 DOI: 10.1136/bcr-2024-259734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024] Open
Abstract
We report a child with steroid-dependent nephrotic syndrome presenting with excessive irritability, double vision and inability to walk for 5 days. On examination, the child was irritable with Glasgow coma sccale (GCS of 12/15, had bilateral convergent squint (R>L), vertical nystagmus, ataxia without any focal neurological deficits and normal fundus. MRI brain with venogram showed bilateral symmetric FLAIR hyperintensity in the medial thalamus and periaqueductal grey matter showing diffuse restriction with normal venogram. A possibility of Wernicke encephalopathy (WE) was considered and the child was started on thiamine supplementation, following which he had significant improvement in his symptoms. His irritability reduced with significant improvement in the range of eye movements and vertical nystagmus. At 3-month follow-up, the child is asymptomatic with normal gait. Although WE is uncommon in children with nephrotic syndrome, the possibility has to be kept in mind when a child presents with atypical neurological symptoms.
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Affiliation(s)
| | | | | | - Ahish Dakappa
- Pediatrics, MS Ramaiah Medical College Hospital, Bangalore, India
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Ibrahim T, El Ansari W, Abusabeib A, Yousaf Z, Elhag W. Infrequent but serious? Beriberi And Thiamine deficiency among adolescents and young adults after bariatric surgery. Surg Obes Relat Dis 2024; 20:115-126. [PMID: 37620168 DOI: 10.1016/j.soard.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/19/2023] [Accepted: 06/23/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Thiamine deficiency (TD) among adolescents following metabolic and bariatric surgery (MBS) has not been assessed. OBJECTIVE We assessed TD among adolescents following MBS. SETTING University Hospital. METHODS A retrospective chart review was conducted for all adolescents and young adults (aged 10-25 years) who had MBS and subsequently presented with TD at our institution (n = 30). Diagnosis used clinical, laboratory, brain imaging, and neurophysiology criteria. Of 1575 patients, 7 subsequently had TD. Another 23 adolescents had MBS at private hospitals or overseas and presented at our institution with TD. RESULTS Based on MBS undertaken at our institution, TD prevalence was .45 cases per 100 MBS. The mean age of patients was 19.5 ± 3.23 years, 53.3% were male, 96.7% had sleeve gastrectomy, and time from MBS to admission averaged 4.97 ± 11.94 months. Mean weight loss from surgery to admission was 33.68 ± 10.90 kg. Associated factors included poor oral intake (90%), nausea and vomiting (80%), and noncompliance with multivitamins (71%). Signs and symptoms included generalized weakness, nystagmus, numbness, and paraparesis (83.3%-80%). Seven patients had Wernicke encephalopathy full triad; 16 displayed a mixed picture of Wernicke encephalopathy and dry beriberi; and there were no cases of wet beriberi. Half the patients achieved complete resolution of symptoms, whereas 47% and 40% had residual weakness or persistent sensory symptoms, respectively. There was no mortality. Most common concurrent nutritional deficiencies were of vitamins K, D, and A. CONCLUSIONS This is the first in-depth study of TD among adolescents after MBS. Although TD is uncommon among adolescents after MBS, it is serious, requiring diligent suspicion and prompt treatment. Bariatric teams should emphasize compliance with multivitamin regimens and follow it up.
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Affiliation(s)
- Tawheeda Ibrahim
- Department of Bariatric Surgery/Bariatric Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Walid El Ansari
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar; College of Medicine, Qatar University, Doha, Qatar; Weill Cornell Medicine - Qatar, Doha, Qatar.
| | - Alyaa Abusabeib
- Department of Bariatric Surgery/Bariatric Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Zohaib Yousaf
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Wahiba Elhag
- Department of Bariatric Surgery/Bariatric Medicine, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine - Qatar, Doha, Qatar
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Bentahar A, Boubga T, Bellamlih H, Chafi K, Salek M, Belabbes S, Zinoun B, Africha T. [Hyperemesis gravidarum leading to Gayet-Wernicke encephalopathy]. Rev Prat 2024; 74:174-175. [PMID: 38415422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Amine Bentahar
- Service de radiologie, hôpital militaire Moulay-Ismail, Meknès, université Sidi Mohamed Ben Abdellah, Fès, Maroc
| | - Taoufik Boubga
- Service de neurologie, hôpital militaire Moulay-Ismail, Meknès, université Sidi Mohamed Ben Abdellah, Fès, Maroc
| | - Habib Bellamlih
- Service de radiologie, hôpital militaire Moulay-Ismail, Meknès, université Sidi Mohamed Ben Abdellah, Fès, Maroc
| | - Khalil Chafi
- Service de radiologie, hôpital militaire Moulay-Ismail, Meknès, université Sidi Mohamed Ben Abdellah, Fès, Maroc
| | - Monsif Salek
- Service de radiologie, hôpital militaire Moulay-Ismail, Meknès, université Sidi Mohamed Ben Abdellah, Fès, Maroc
| | - Soufiane Belabbes
- Service de radiologie, hôpital militaire Moulay-Ismail, Meknès, université Sidi Mohamed Ben Abdellah, Fès, Maroc
| | - Brahim Zinoun
- Service de radiologie, hôpital militaire Moulay-Ismail, Meknès, université Sidi Mohamed Ben Abdellah, Fès, Maroc
| | - Taoufik Africha
- Service de radiologie, hôpital militaire Moulay-Ismail, Meknès, université Sidi Mohamed Ben Abdellah, Fès, Maroc
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9
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Akbar A, Lowther J, Creeden S, Frese W. Atypical Wernicke's encephalopathy without mental status changes following bariatric surgery in an adolescent patient. BMJ Case Rep 2024; 17:e255507. [PMID: 38296505 PMCID: PMC10831428 DOI: 10.1136/bcr-2023-255507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2024] Open
Abstract
Morbid obesity is a systemic disease which can result in chronic complications, including hypertension, diabetes mellitus, depression, osteoarthritis and low self-esteem in the adolescent population.Bariatric surgery can be indicated to treat more severe forms of obesity, but these procedures are not without long-term risks. Therefore, adequate preoperative and postoperative care, which includes preoperative psychosocial evaluation for compliance, ongoing nutrition counselling and vitamin and micronutrient supplementation, is required for all patients, especially adolescent patients, who generally may not comply with medical therapies and/or be able to developmentally fully appreciate or comprehend the health consequences of their behaviours, prior to as well as after bariatric surgery to prevent complications.Thiamine pyrophosphate, an active form of thiamine (also known as vitamin B1, a water-soluble vitamin), which functions as a coenzyme in glucose and energy metabolism, is one such vitamin that requires supplementation postoperatively. It is mandatory for glucose to be administered concomitantly with thiamine, as glucose alone can precipitate Wernicke's encephalopathy (WE) in thiamine-deficient individuals. WE is a medical emergency, with a mortality rate of up to 20%. WE is best understood as a classic triad of mental confusion, gait ataxia and eye movement abnormalities, and atypical WE or Wernicke's syndrome (WS) is seen when the classic triad is not present. Cases that meet some, but do not necessarily meet all three criteria, are referred to as atypical WE or WS which can lead to delayed diagnosis. Atypical WE has an incidence of 19% which can lead to misdiagnosis of a preventable medical emergency with fatal complications.The following case reviews the consequences of post-bariatric thiamine supplementation therapy non-adherence and resulting in a deficiency in an adolescent patient.
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Affiliation(s)
- Asra Akbar
- Pediatric Neurology, University of Illinois college of medicine in peoria, Peoria, Illinois, USA
| | - Jason Lowther
- University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Sean Creeden
- University of Illinois Chicago College of Medicine at Peoria, Peoria, Illinois, USA
| | - William Frese
- University of Illinois Chicago College of Medicine at Peoria, Peoria, Illinois, USA
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Bravetti GE, Steffen H, Bouthour W. Infrequent but Important Fundus Findings in Wernicke's Encephalopathy. Ophthalmology 2023; 130:1357. [PMID: 37086242 DOI: 10.1016/j.ophtha.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/23/2023] Open
Affiliation(s)
| | - Heimo Steffen
- Department of Ophthalmology, Geneva University Hospitals, Geneva, Switzerland
| | - Walid Bouthour
- Department of Ophthalmology, Geneva University Hospitals, Geneva, Switzerland
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11
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Nachbor KM, Adams OE, Liaboe CA, Abel AS. Acute Bilateral Optic Neuropathy: A Rare Presentation of Wernicke Encephalopathy. J Neuroophthalmol 2023; 43:e177-e179. [PMID: 35421056 DOI: 10.1097/wno.0000000000001527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Kristine M Nachbor
- Department of Ophthalmology (KMN, OEA, ASA), Hennepin Healthcare, Minneapolis, Minnesota; Department of Ophthalmology and Visual Neurosciences (OEA, ASA), University of Minnesota, Minneapolis, Minnesota; and Minnesota Eye Consultants (CAL), Bloomington, Minnesota
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12
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Supahiah P, Thomas BHI, Zhen PC, Aris AM, Abdul-Jalil F, Din NM. Wernicke Encephalopathy as the First Presentation of Neuromyelitis Optica Spectrum Disorder With Horizontal Nerve Palsy. J Neuroophthalmol 2023; 43:e293-e295. [PMID: 34924530 DOI: 10.1097/wno.0000000000001444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Prakash Supahiah
- Departments of Internal Medicine & Neurology (AMA), Ophthalmology (PS, BHIT, A-JF), and Radiology (PCZ), Melaka General Hospital, Melaka, Malaysia; and Department of Ophthalmology (PS, NMD), Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaakob Latiff, Kuala Lumpur, Malaysia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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.
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González MF, Facchini R, McGinley J, Bronshteyn D, Stimmel M, Weiss EF. A - 89 Cognitive Evaluation of Suspected Wernicke- Korsakoff's Encephalopathy in a Woman with Complicated Hyperemesis Gravidarum. Arch Clin Neuropsychol 2023; 38:1254. [PMID: 37807224 DOI: 10.1093/arclin/acad067.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVE Wernicke-Korsakoff syndrome (WKS) is a neurological disorder caused by the lack of thiamine (vitamin B1) and includes Wernicke encephalopathy and the later stage of Korsakoff amnesic syndrome. WKS could be secondary to malnutrition, including Hyperemesis Gravidarum (HEG), which is characterized by severe vomiting during pregnancy. We present a case of HEG resulting in suspected WKS where neuropsychological evaluation clarified cognitive status with complex cultural, language, and educational factors. METHOD Repeat evaluations of a 29-year-old West-African* woman with mental status change, decreased verbal output, agitation, and inability to walk in the context of HEG. Initially referred for inpatient neuropsychological evaluation at 21 weeks gestation. MRI demonstrated mild diffuse cerebral atrophy and symmetric foci of T2 FLAIR hyperintensities in periaqueductal gray matter, hypothalamus, bilateral thalami, perirolandic cortex, and bilateral mammillary bodies. RESULTS Initial inpatient testing with a face-to-face language congruent interpreter demonstrated notable multidomain impairment. Possible Intellectual Disability was considered by the referring team and test performances. Attempts at re-evaluation were limited by medical complications and prolonged hospitalization. Repeat inpatient evaluation 5 months later following birth of healthy child and initiation of stimulant medication, demonstrated profound memory impairment but otherwise improved cognitive capacity and engagement. Results aided in discharge planning including cognitive remediation with goal of improving functional independence. CONCLUSIONS Wernicke-Korsakoff syndrome due to Hyperemesis Gravidarum is an uncommon but known complication that can have profound acute and long-term consequences. This case demonstrates that repeat neuropsychological evaluations can clarify cognitive status in complex medical/cultural/language situations. *(country of origin and primary language not provided for patient privacy).
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Laique A, Breting LG. A - 102 Neuropsychological Findings in a Patient Diagnosed with Wernicke's Encephalopathy Due to Chemoradiation and Malnutrition: a Case Presentation. Arch Clin Neuropsychol 2023; 38:1269. [PMID: 37807222 DOI: 10.1093/arclin/acad067.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVE Wernicke's Encephalopathy (WE) is a rare neuropsychiatric syndrome caused by thiamine deficiency. WE is characterized by inattention, incoherence, confusion, eye-movement disorders, and ataxia. However, scarce information exists on neurocognitive outcomes, particularly stemming from oncology-related etiologies, (e.g., malnutrition caused by chemoradiation). In hopes of elucidating consequential deficits, a case presenting the neurocognitive profile of WE in a 71-year-old female cancer survivor is reported. METHOD Patient underwent standard chemoradiation for squamous cell carcinoma of the oropharynx in 2021 followed by frequent nutritional deficiency resulting from decreased appetite, mouth sores, and nausea/vomiting. She developed increased weakness, confusion, difficulty walking, nystagmus, and altered mental state. Completion of chemoradiation and onset of WE saw her experience altered mental status, confusion, gait instability, dysarthric speech, and memory difficulties. Imaging indicated a linear chronic infarct in the left cerebellar hemisphere and frontal predominant brain volume loss. RESULTS Patient was referred for neuropsychological evaluation after beginning treatment for WE and psychotherapy to assess barriers to improving nutrition. Primary deficits were observed on verbal learning and memory, verbal fluency, executive functioning, attention, and visuomotor functioning. Comprehension and visual memory skills were intact. Both basic and higher order cognitive processes were impacted resulting in declining quality of life and activities of daily living. CONCLUSION This study highlights the need to consider chemoradiation as an etiological risk factor for the development of WE and associated neurocognitive sequelae. Neuropsychological dysfunction is an important consideration given the acute nature of this life-threatening disease. The key elements in treatment involve thiamine replacement, nutrition, appropriate rehabilitation, and medical follow-up.
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Basouny N, Spigos J, Khvolis D, McFarlane-Ferreira Y, Lee A. Wernicke Encephalopathy in a Pediatric Patient with Avoidant Restrictive Food Intake Disorder: A Rare Presentation of Thiamine Deficiency. Am J Case Rep 2023; 24:e940717. [PMID: 37632134 PMCID: PMC10467509 DOI: 10.12659/ajcr.940717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/17/2023] [Accepted: 07/11/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Wernicke encephalopathy is traditionally associated with chronic alcoholism, nutritional imbalance, prolonged intravenous feeding, hyperemesis, anorexia nervosa, and malabsorption syndromes. We report a case of Wernicke's encephalopathy in a 12-year-old girl with avoidant restrictive food intake disorder. CASE REPORT The patient had lost 45.4 kg of body weight due to self-imposed changes to her diet, before presenting with decreased oral intake for 2-3 weeks, intermittent nausea, crampy epigastric pain, and post-prandial emesis. Her weight on admission was 78.2 kg. She received intravenous fluids of dextrose 5% with normal saline while she initially attempted to eat, but the post-prandial emesis persisted. She developed a fear of vomiting, which led to even more severe food intake restriction. After a week, she began to report double vision and blurred peripheral vision, with physical findings of nystagmus and an ataxic gait. She was empirically started on thiamine after negative neurology workup, with improvement of her gait, blurry vision, and nystagmus. Thiamine deficiency was later confirmed. CONCLUSIONS In patients with large amounts of weight loss presenting with neurological symptoms, Wernicke's encephalopathy must be considered in the differential diagnosis. Avoidant restrictive food intake disorder is rarely reported to cause Wernicke's encephalopathy. To the best of our knowledge, this is the first pediatric case demonstrating that Wernicke encephalopathy can occur in this type of eating disorder and not just in anorexia nervosa.
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Affiliation(s)
- Noha Basouny
- Department of Pediatrics, NewYork Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - John Spigos
- Department of Pediatrics, NewYork Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Dmitri Khvolis
- Department of Pediatrics, NewYork Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | | | - Ada Lee
- Department of Pediatrics, Stony Brook Children’s Hospital, Stony Brook, NY, USA
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Fraenkel E, Orlický M, Fedičová M, Gdovinová Z, Lazúrová I. Concomitant occurrence of Wernicke's encephalopathy and sarcopenia due to vitamin D depletion in patients with alcohol use disorder: a case report. J Int Med Res 2023; 51:3000605231182262. [PMID: 37340718 PMCID: PMC10288397 DOI: 10.1177/03000605231182262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/30/2023] [Indexed: 06/22/2023] Open
Abstract
Individuals with alcohol use disorder frequently suffer from vitamin D deficiency, in addition to deficiencies in vitamins B12, folic acid and B1. This is due to inadequate dietary intake and behavioural changes. Each of these deficiencies results in different clinical symptoms. Subacute spinal cord degeneration, together with radicular and sensorimotor peripheral neuropathy, arises from B12 vitamin and folic acid deficiencies. B1 vitamin deficiency leads to Wernicke's encephalopathy, which can include the classical triad of symptoms (i.e. cognitive changes, ataxia and ophthalmoplegia). Sarcopenia is a consequence of a long-term deficiency of vitamin D. This current case report describes a 43-year-old female patient with alcohol use disorder who complained of dizziness, postural disturbance and episodes of intermittent paraesthesia. She was subsequently shown to have concomitant Wernicke's encephalopathy and sarcopenia due to vitamin D deficiency. This case report presents the diagnostic process undertaken to exclude conditions related to ataxia and paraparesis other than vitamins D and B1 deficiencies. It also emphasizes the importance of concomitant replacement of the depleted vitamins because the vitamin deficiency may occur simultaneously, which causes the accompanying manifestations of several clinical syndromes.
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Affiliation(s)
- Emil Fraenkel
- First Department of Internal Medicine, Univerzita Pavla Jozefa Šafárika v Košiciach, Košice, Slovakia
| | - Michal Orlický
- Department of Neurosurgery, Univerzita Pavla Jozefa Šafárika v Košiciach, Košice, Slovakia
| | - Miriam Fedičová
- Department of Neurology, Univerzita Pavla Jozefa Šafárika v Košiciach, Košice, Slovakia
| | - Zuzana Gdovinová
- Department of Neurology, Univerzita Pavla Jozefa Šafárika v Košiciach, Košice, Slovakia
| | - Ivica Lazúrová
- First Department of Internal Medicine, Univerzita Pavla Jozefa Šafárika v Košiciach, Košice, Slovakia
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Bouladi M, Lajmi H, Ben Othmen A, El Fekih L. Uncommon bilateral optic neuropathy in Wernicke's encephalopathy complicating gravidarum hyperemesis. Tunis Med 2023; 101:530-532. [PMID: 38372521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/15/2023] [Indexed: 02/20/2024]
Abstract
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.
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Affiliation(s)
- Mejda Bouladi
- Ophthalmology Department, Mongi Slim University Hospital, La Marsa, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia
| | - Houda Lajmi
- Ophtalmology Department, Security Forces Hospital, La Marsa, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia
| | - Amal Ben Othmen
- Ophthalmology Department, Mongi Slim University Hospital, La Marsa, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia
| | - Lamia El Fekih
- Ophthalmology Department, Mongi Slim University Hospital, La Marsa, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia
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Affiliation(s)
- Marsel Mesulam
- Mesulam Center for Cognitive Neurology and Alzheimer's Disease, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Cynthia Thompson
- Mesulam Center for Cognitive Neurology and Alzheimer's Disease, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Sandra Weintraub
- Mesulam Center for Cognitive Neurology and Alzheimer's Disease, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Emily Rogalski
- Mesulam Center for Cognitive Neurology and Alzheimer's Disease, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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21
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Martins Carvalho M, Proença T, Alves Pinto R, Pinto R, Macedo F. Wernicke encephalopathy and beriberi disease presenting as STEMI-equivalent. Monaldi Arch Chest Dis 2023; 93. [PMID: 36806824 DOI: 10.4081/monaldi.2023.2513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/02/2023] [Indexed: 02/23/2023] Open
Abstract
Thiamine deficiency is commonly associated with malnutrition, alcoholism and bariatric surgery. Thiamine deficiency can manifest in different ways, especially in developing countries: as peripheric neuropathy, as Wernicke encephalopathy or as beriberi disease. The authors present the case of a 72-year-old male, with a hiatal hernia that led to thiamine deficiency due to malnutrition. The initial clinical manifestation was an ST-elevation myocardial infarct equivalent, an ECG with a shark-fin pattern that evolved to a Wellens type B pattern. The patient evolved with severe altered mental status. A Wernicke encephalopathy diagnosis was confirmed by MRI; the patient was medicated with high-dose thiamine, with quick recovery, both neurologic and cardiac. The clinical history and response to treatment confirm the diagnosis of Wernicke encephalopathy and beriberi disease.
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Affiliation(s)
- Miguel Martins Carvalho
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto; Cardiovascular R&D Center, Faculty of Medicine, University of Porto.
| | - Tânia Proença
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto.
| | - Ricardo Alves Pinto
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto.
| | - Roberto Pinto
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto.
| | - Filipe Macedo
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto; Cardiovascular R&D Center, Faculty of Medicine, University of Porto.
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Sani E, Da Prato G, Gremes V, Valletta F, Bariani M, Zenti MG. A Case of Wernicke's Encephalopathy After Sleeve Gastrectomy. Endocr Metab Immune Disord Drug Targets 2023; 23:1548-1551. [PMID: 37157214 DOI: 10.2174/1871530323666230508152340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Wernicke's encephalopathy, resulting from thiamine deficiency, is a rare but serious neurological complication of bariatric procedures. A clinical and radiologic diagnosis is often difficult, and thiamine blood tests are not broadly available. Only a few cases of Wernicke's encephalopathy after sleeve gastrectomy have been reported in the literature, nonetheless, subjects can be underdiagnosed, and their cases can be underreported. CASE PRESENTATION We present the case of a 20-year-old female patient who developed Wernicke's encephalopathy after sleeve gastrectomy for grade II obesity with metabolic complications. She was presented to the Emergency Department showing confusion, gait ataxia and horizontal nystagmus two months after surgery. Persistent vomiting and lack of compliance with vitamin intake were reported. Cerebral MRI showed acute bilateral lesions in the periaqueductal and periventricular regions. Parenteral thiamine supplementation was administered, obtaining a progressive resolution of altered mental status, motor ataxia, and nystagmus. She was discharged on oral thiamine supplementation and underwent a multidisciplinary rehabilitation program, since anterograde, retrograde, and working memory impairment persisted. After a 2-year follow-up, she was compliant with a balanced fractionated diet and vitamin supplementation. A new cerebral MRI showed regression of the neuroradiological findings, but minimal memory impairment remained. CONCLUSION Wernicke's encephalopathy is a concrete possibility after sleeve gastrectomy and should always be suspected in patients with recurrent vomiting, poor nutritional intake, and non-compliance to vitamin supplementation. Immediate and aggressive thiamine supplementation is mandatory to prevent patients from irreversible neurological impairment, even though full recovery is not always achieved.
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Affiliation(s)
- Elena Sani
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Verona, Verona, Italy
| | - Giuliana Da Prato
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Verona, Verona, Italy
| | - Veronica Gremes
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Verona, Verona, Italy
| | - Francesco Valletta
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Matilde Bariani
- Department of Radiology, University of Verona, Verona, Italy
| | - Maria Grazia Zenti
- Diabetes and Metabolism Unit, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
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Hidaka M, Kumamoto M, Suenaga T, Itsuji A, Kanazawa Y, Goto S, Takaba H, Kitazono T. Wernicke-Korsakoff Syndrome in a Young Adult on Dialysis Who Showed Bilateral Ganglia Lesions. Intern Med 2023; 62:113-118. [PMID: 35598991 PMCID: PMC9876722 DOI: 10.2169/internalmedicine.8910-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A 30-year-old man admitted with renal dysfunction (serum creatinine, 8.19 mg/dL) was diagnosed with immunoglobulin A nephritis through a renal biopsy. He was treated with intravenous methylprednisolone pulse therapy and urgent hemodialysis, and eventually, he underwent maintenance hemodialysis. On day 108, he developed amnesia. Magnetic resonance imaging revealed bilateral basal ganglia lesions. Wernicke encephalopathy (WE) was diagnosed based on decreased serum thiamine concentration (12.8 μg/dL; reference range, 24-66 μg/dL). Thiamine replacement therapy was initiated, but the Wernicke-Korsakoff syndrome persisted. Careful monitoring of thiamine is required in patients undergoing dialysis. In addition, patients with WE may exhibit bilateral basal ganglia lesions.
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Affiliation(s)
- Masaoki Hidaka
- Department of Cerebrovascular Medicine and Neurology, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Japan
| | - Masaya Kumamoto
- Department of Cerebrovascular Medicine and Neurology, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Japan
| | - Tatsuya Suenaga
- Department of Nephrology, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Japan
| | - Ayaka Itsuji
- Department of Cerebrovascular Medicine and Neurology, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Japan
| | - Yuka Kanazawa
- Department of Cerebrovascular Medicine and Neurology, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Japan
| | - Seiji Goto
- Department of Cerebrovascular Medicine and Neurology, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Japan
| | - Hitonori Takaba
- Department of Cerebrovascular Medicine and Neurology, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
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Cornea A, Lata I, Simu M, Rosca EC. Wernicke Encephalopathy Presenting with Dysphagia: A Case Report and Systematic Literature Review. Nutrients 2022; 14:nu14245294. [PMID: 36558453 PMCID: PMC9788281 DOI: 10.3390/nu14245294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Wernicke encephalopathy (WE) is a well-known neurological condition caused by thiamine (vitamin B1) deficiency that occurs in both alcoholic and non-alcoholic populations. We aimed to report a case of a patient with WE who presented with dysphagia and dysphonia and later developed typical symptoms of thiamine deficiency and to conduct a systematic review of the literature on this rare presentation of WE. We searched two databases (PubMed and Scopus) and included publications up to November 2022. We found 12 cases of WE and dysphagia, aged between 12 and 81 years; swallowing problems presented at the onset in nine patients (including the current case report). Our findings suggest that thiamine deficiency should be suspected in patients with dysphagia of unknown cause, even in the absence of alcohol abuse. In contrast to most WE patients, the majority of patients included in this review presented with dysphagia at the onset of their disease, even in the absence of the classic triad of cognitive impairment, ataxia, and oculomotor abnormalities, indicating that there could be varying susceptibilities to clinical manifestations of thiamine deficiency in different brain regions.
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Affiliation(s)
- Amalia Cornea
- Department of Neurology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania
- Department of Neurology, Clinical Emergency County Hospital Timisoara, Bd. Losif Bulbuca No. 10, 300736 Timisoara, Romania
| | - Irina Lata
- Department of Neurology, Clinical Emergency County Hospital Timisoara, Bd. Losif Bulbuca No. 10, 300736 Timisoara, Romania
| | - Mihaela Simu
- Department of Neurology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania
- Department of Neurology, Clinical Emergency County Hospital Timisoara, Bd. Losif Bulbuca No. 10, 300736 Timisoara, Romania
| | - Elena Cecilia Rosca
- Department of Neurology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania
- Department of Neurology, Clinical Emergency County Hospital Timisoara, Bd. Losif Bulbuca No. 10, 300736 Timisoara, Romania
- Correspondence: or ; Tel.: +40-746-173794
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Koca O, Demir B, Derin S, Turna ZH. A case report of Wernicke Korsakoff syndrome in a patient with cholangiocellular carcinoma: An underestimated cause of encephalopathy in cancer patients. Medicine (Baltimore) 2022; 101:e31904. [PMID: 36482648 PMCID: PMC9726370 DOI: 10.1097/md.0000000000031904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Wernicke's encephalopathy, a disorder caused by thiamin deficiency, is characterized by a classical triad of encephalopathy, ataxia, and ophthalmoplegia. Although alcoholism is the most common predisposing factor, it can also be associated with nonalcoholic states (hyperemesis gravidarum, intestinal obstruction, bariatric surgery, and others). This work presents a case of nonalcoholic Wernicke-Korsakoff syndrome diagnosed in a cholangiocellular carcinoma patient and literature review. CASE REPORT A 65-year-old male patient with a history of cholangiocellular carcinoma (Klatskin tumor) was treated with radiotherapy at the operation site after Roux-en-Y hepaticojejunostomy. During follow-up, the patient developed gastric outlet obstruction and was diagnosed with peritoneal carcinomatosis after a palliative gastrojejunostomy. As the patient could not tolerate oral nutrition during hospitalization, total parenteral nutrition was administered. After 10 days of admission, the patient showed decreased response to verbal stimuli as well as bilateral horizontal nystagmus, lethargy, and disorientation. Furthermore, the patient displayed confabulation. Clinical and imaging findings were consistent with Wernicke's encephalopathy. Therefore, treatment with intravenous thiamin replacement was initiated. The patient's encephalopathy regressed on the second day after treatment, and he recovered the place-person-time orientation. In the following month, the abnormal imaging findings were almost entirely resolved. CONCLUSION In order to prevent irreversible brain damage induced by chronic thiamin deficiency, thiamin replacement therapy with parenteral nutrition solutions should be included as a treatment for hospitalized cancer patients unable to receive enteral nutrition for a long time.
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Affiliation(s)
- Oguzhan Koca
- Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Bilal Demir
- Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sumeyra Derin
- Division of Medical Oncology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Zeynep Hande Turna
- Division of Medical Oncology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Kuzume D, Morimoto Y, Yamasaki M, Hosomi N. [Wernicke encephalopathy with lesions in the bilateral abducens nuclei: a case report]. Rinsho Shinkeigaku 2022; 62:869-872. [PMID: 36288967 DOI: 10.5692/clinicalneurol.cn-001783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
A 35-year-old Japanese man had been treated for alcoholism until 6 months before coming to our hospital, after which he discontinued treatment for alcoholism. He noticed dizziness from two weeks ago. He visited our hospital because his dizziness was worsened and he noticed diplopia from two days ago. Physical examination revealed bilateral abducens nerve palsy, decreased limb tendon reflex, and ataxia. His blood vitamin B1 level was 16 ng/ml (normal range 24-66 ng/ml). FLAIR images on brain MRI showed high signal intensity lesions in the bilateral abducens nuclei and mammillary body. We diagnosed him as Wernicke encephalopathy (WE) with lesions in the bilateral abducens nuclei. Treatment with thiamine rapidly resulted in improvement of his neurological symptoms and MRI findings. He was discharged from our department on the 10th hospitalization day. Previous reports have shown that abducens nerve palsy and horizontal gaze evoked nystagmus may occur in the early state of WE. This case report highlights the importance to comprehend the atypical MRI findings of WE to treat a patient at the early stage.
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Abstract
Vitamin B1 also known as thiamin is an essential vitamin assuring body functioning and comes exclusively from food. Vitamin B1 deficiency is an under-diagnosed disease because it is less frequently suspected in high income countries. However, its risk factors, like alcohol and malnutrition, are common in the general population. Thiamin deficiency can lead to three clinical entities, Gayet-Wernicke encephalopathy, which can progress to Korsakoff encephalopathy, wet Beriberi and its dry form. These diseases are associated with high mortality and heavy long-term sequelae. Rapid diagnosis enables timely treatment.
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Affiliation(s)
- Sabrina Silhadi
- Service de médecine interne générale, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Simon Édouard Pinaud
- Service de médecine interne générale, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Mathieu Nendaz
- Service de médecine interne générale, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Jérôme Stirnemann
- Service de médecine interne générale, Hôpitaux universitaires de Genève, 1211 Genève 14
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Ohira M. [Neurological Symptoms Associated With Vitamin Deficiency and Excess: Past and Present Findings]. Brain Nerve 2022; 74:1205-1210. [PMID: 36198646 DOI: 10.11477/mf.1416202210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Vitamin deficiencies and excesses are known to cause various types of brain or peripheral nerve injuries. Improved nutritional status and dietary patterns have led to reduced prevalence, and at least some of these conditions are rare in recent times. However, delayed diagnosis (For example, in patients with Wernicke's encephalopathy) may worsen patient prognosis even in current times. Recent studies have reported an association between cognitive function and some vitamins. In this article, we summarize past and present research focused on neurological symptoms that occur secondary to vitamin deficiencies and excesses.
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Affiliation(s)
- Masayuki Ohira
- Department of Clinical Laboratory, National Center Hospital, National Center of Neurology and Psychiatry
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Hernandez L, Brockman T, Mehta T. Identification of Wernicke Encephalopathy in a Patient Presenting With Altered Mental Status and Dehydration. WMJ 2022; 121:E10-E14. [PMID: 35442587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Providing glucose before thiamine can cause or exacerbate Wernicke encephalopathy, a potentially life-threatening condition associated with a variety of neurological impairments. CASE PRESENTATION An emaciated, middle-aged woman with a longstanding history of alcohol abuse and an undifferentiated seizure disorder presented to a local emergency department with altered mental status of unknown duration. Initial labs showed signs of acute kidney injury and she could not tolerate oral intake. Overnight, dextrose-containing maintenance fluids were started. The next day, she had an acute deterioration of mental status. Empiric therapy for Wernicke encephalopathy was begun, resulting in resolution of most of her symptoms over a matter of days. DISCUSSION It is generally recommended to administer thiamine treatment prior to glucose in patients with suspected thiamine deficiency. The Caine criteria can assist in the decision to start empiric treatment to prevent delays in thiamine therapy. CONCLUSION Wernicke encephalopathy is a disease with high morbidity that is usually treated with the generally benign therapy of thiamine. Given the risk of harm of untreated Wernicke encephalopathy and the benign nature of treatment, clinicians should have a low threshold to provide thiamine therapy.
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Affiliation(s)
- Leilani Hernandez
- Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin,
| | - Taylor Brockman
- Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tej Mehta
- Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
- Interventional Radiology, Johns Hopkins University, Baltimore, Maryland
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Kalbi D, Al Sbihi A, Parekh H, Chaudhary AJ. Wernicke encephalopathy after Roux-en-Y gastric bypass in a young patient. BMJ Case Rep 2022; 15:e247710. [PMID: 35321913 PMCID: PMC8943737 DOI: 10.1136/bcr-2021-247710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 11/03/2022] Open
Abstract
We report a case of Wernicke encephalopathy (WE) in a woman in her 20s who had Roux-en-Y gastric bypass surgery for severe obesity, which resulted in a severe depletion of the patient's thiamine reserve and development of WE syndrome, we also emphasise the importance of prompt diagnosis of this serious complication in addition to the importance of adequate therapy.
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Affiliation(s)
- Deepak Kalbi
- Nuclear Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Ali Al Sbihi
- Internal Medicine, Wayne State University, Detroit, Michigan, USA
- Internal Medicine, Sinai Grace Hospital, Detroit, Michigan, USA
| | - Harsh Parekh
- School of Medicine, Wayne State University, Detroit, Michigan, USA
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Kora C, Rockson O, El Arabi S, Skiker I. [Gayet Wernicke encephalopathy]. Rev Prat 2021; 71:1104. [PMID: 35147368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
| | - Obed Rockson
- Service de radiologie, CHU Mohammed-VI, Oujda, Maroc
| | | | - Imane Skiker
- Service de radiologie, CHU Mohammed-VI, Oujda, Maroc
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Palmer G, Inman KL, Abdalla A, Ahmed M. Visual Disturbances in a Grave's Disease Patient After Sleeve Gastrectomy. S D Med 2021; 74:457-462. [PMID: 34995426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Wernicke encephalopathy (WE) is a neuropsychiatric disorder that results from untreated severe thiamine deficiency, frequently described as a triad of ophthalmoplegia, ataxia, and confusion. While this triad is commonly used to describe WE, all three symptoms are observed in less than 20 percent of individuals with this diagnosis. Most commonly, WE is observed in individuals with significant alcohol use and associated malnutrition resulting in thiamine deficiency. However, this condition can also be diagnosed in patients with other sources of malnutrition, and less frequently in hypermetabolic states such as those with hyperthyroidism. Due to its broad clinical presentation and numerous causes, Wernicke encephalopathy can be difficult to diagnose. Diagnosis of WE guides management, as glucose before IV thiamine administration can be detrimental. Therefore, it is essential to understand the complexities of WE. In this paper, we discuss a patient who presented to the emergency department complaining of central vision loss, change in color perception, tinnitus, and difficulty walking two months post gastric sleeve and a recently diagnosed and, possibly inadequately treated, hyperthyroidism. The combination of recent sleeve gastrectomy and hyperthyroidism likely led to thiamine malabsorption and hypermetabolism, resulting in WE.
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Affiliation(s)
- Geralyn Palmer
- University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Kristin L Inman
- University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | | | - Mohammad Ahmed
- Avera McKennan, Sioux Falls, South Dakota
- University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
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Affiliation(s)
- Yuki Kubota
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
| | - Hiroshi Hori
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
| | - Hitoshi Sugawara
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
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Mittal A, Tiwari S, Sureka B, Singh K. Wernicke's encephalopathy - An oddball complication of nephrotic syndrome. Saudi J Kidney Dis Transpl 2021; 32:1456-1460. [PMID: 35532717 DOI: 10.4103/1319-2442.344767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
Metabolic encephalopathies are a common cause of altered mental status in various states of malnutrition. However, a high index of suspicion is required to recognize them and differentiate Metabolic Disorders from other causes of altered mental status such as infections. A 6-year old with steroid-resistant nephrotic syndrome (NS), peritonitis, and prolonged diarrhea and vomiting, developed a brief episode of altered mental status six days after starting tacrolimus. On imaging, there were features suggestive of Wernicke's encephalopathy and it ruled out other causes of seizure in the given scenario. The child was treated with thiamine supplementation and the changes reversed four weeks after treatment. This is to emphasize that although an uncommonly reported complication of nephrotic state, one should have a high index of suspicion for these metabolic encephalopathies, especially in the setting of malnutrition, where these children are highly predisposed to multivitamin deficiency.
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Affiliation(s)
- Aliza Mittal
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Binit Sureka
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Kuldeep Singh
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Abstract
Thiamine is an essential cofactor in the process of nucleic acid synthesis. Neuronal tissues are especially sensitive to thiamine deficiency, manifesting as Wernicke's encephalopathy (WE). The typical triad of WE, encephalopathy, oculomotor dysfunction and gait ataxia, is only present in less than one-third of the cases. We present the case of a middle-aged man with hypoactive delirium due to presumed thiamine deficiency, who had a prolonged hospital course and a delayed diagnosis of the cause of altered mental status. The presentation of this disorder solely as a decreased level of consciousness is uncommon but has been reported in the literature. It is essential to recognise WE as a treatable condition that may manifest only as a hypoactive delirium. The delay in the diagnosis and treatment may lead to coma and death.
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Affiliation(s)
- Tiffany Truong
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Fredrick Hetzel
- MetroHealth Medical Center, Department of Internal Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Katherine M Stiff
- Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
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36
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Yoshioka A, Sato I, Onishi H, Ishida M. Subclinical thiamine deficiency identified by pretreatment evaluation in an esophageal cancer patient. Eur J Clin Nutr 2021; 75:564-566. [PMID: 32895510 PMCID: PMC7943416 DOI: 10.1038/s41430-020-00735-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/18/2020] [Accepted: 08/21/2020] [Indexed: 12/13/2022]
Abstract
Despite the fact that both thiamine deficiency (TD) and Wernicke encephalopathy (WE) have been observed to some degree in cancer patients, such cases of TD and/or WE reported to date have all been diagnosed after the initiation of treatment. We here report a case of TD that presented without the commonly accepted triad of WE symptoms based on a total nutritional evaluation prior to the onset of treatment for cancer. The patient was a 71-year-old man with esophageal cancer who was referred to the oncology outpatient clinic for evaluation to determine the treatment plan. Although he did not present with delirium, cerebellar signs, or ocular symptoms, TD was suspected based on a reduction in appetite lasting 2 months as thiamine stores in the body are depleted in as few as 18 days. Blood findings showed a marked decline in serum thiamine level supported, which the diagnosis of TD. This case revealed the existence of a cancer patient with subclinical TD prior to the onset of treatment for cancer. Due to the fact that TD can occur without the characteristic symptoms as in this case, we believe it is important that total nutritional evaluation of cancer patients always be considered.
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Affiliation(s)
- Akira Yoshioka
- Department of Clinical Oncology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Izumi Sato
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Hideki Onishi
- Departments of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka City, Japan
| | - Mayumi Ishida
- Departments of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka City, Japan.
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Affiliation(s)
- Kojiro Ikeda
- Department of Medicine, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
| | - Hiroyuki Yano
- Department of Medicine, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
| | - Tetsushi Higa
- Department of Medicine, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
| | - Mitsuyo Kinjo
- Department of Medicine, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
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38
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Jdidia NB, Halima SB, Hakim H, Kebaili S, Koubaa I, Chelly H, Chaabane K. Reversible Wernicke encephalopathy caused by hyperemesis gravidarum in the second trimester of pregnancy: a case report. Pan Afr Med J 2021; 40:240. [PMID: 35178151 PMCID: PMC8817192 DOI: 10.11604/pamj.2021.40.240.30245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 12/14/2021] [Indexed: 11/18/2022] Open
Abstract
Wernicke encephalopathy is a potentially life-threatening neurologic syndrome caused by acute thiamine (vitamin B1) deficiency. It is usually associated with excessive alcohol consumption. Less frequently, this syndrome can be caused by persistent vomiting. This is a case report of a 33-year-old woman diagnosed with Wernicke encephalopathy (WE) during the second trimester of pregnancy. The presence of neurological and ophthalmological symptoms in the context of hyperemesis gravidarum led us to evoke the diagnosis of WE, and it was confirmed when specific lesions were found in the brain magnetic resonance imaging (MRI). Luckily for our patient, WE was diagnosed promptly and the signs were reversible after thiamine supplementation. In conclusion, any first line care taker or midwife must know the symptoms of Wernicke encephalopathy because prompt diagnosis and treatment can lead to recovery
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Affiliation(s)
- Nadia Ben Jdidia
- Department of Gynecology and Obstetrics, University of Medicine of Sfax, Hedi Chaker Hospital, 3029, Sfax, Tunisia
- Corresponding author: Nadia Ben Jdidia, Department of Gynecology and Obstetrics, University of Medicine of Sfax, Hedi Chaker Hospital, 3029, Sfax, Tunisia.
| | - Sawssan Ben Halima
- Department of Gynecology and Obstetrics, University of Medicine of Sfax, Hedi Chaker Hospital, 3029, Sfax, Tunisia
| | - Hana Hakim
- Department of Gynecology and Obstetrics, University of Medicine of Sfax, Hedi Chaker Hospital, 3029, Sfax, Tunisia
| | - Sahbi Kebaili
- Department of Gynecology and Obstetrics, University of Medicine of Sfax, Hedi Chaker Hospital, 3029, Sfax, Tunisia
| | - Ines Koubaa
- Department of Radiology, University of Medicine of Sfax, Hedi Chaker Hospital, 3029, Sfax, Tunisia
| | - Hedi Chelly
- Department of Intensive Care, University of Medicine of Sfax, Habib Bourguiba Hospital, 3029, Sfax, Tunisia
| | - Kais Chaabane
- Department of Gynecology and Obstetrics, University of Medicine of Sfax, Hedi Chaker Hospital, 3029, Sfax, Tunisia
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Miyanaga R, Hisahara S, Ohhashi I, Yamamoto D, Matsumura A, Suzuki S, Tanimoto K, Hirakawa M, Kawamata J, Kato J, Shimohama S. Hyperemesis-induced Wernicke-Korsakoff Syndrome due to Hypergastrinemia during Long-term Treatment with Proton Pump Inhibitors. Intern Med 2020; 59:2783-2787. [PMID: 32669503 PMCID: PMC7691029 DOI: 10.2169/internalmedicine.5168-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
We herein report a patient with Wernicke-Korsakoff syndrome (WKS) who had neither a history of alcoholism or of history of gastric surgery. A 56-year-old woman was transferred to our hospital because of the loss of consciousness and she was diagnosed to have Wernicke encephalopathy. She showed proton pump inhibitor-induced refractory hypergastrinemia with the subsequent development of hyperemesis and a vitamin B1 deficiency.
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Affiliation(s)
- Rei Miyanaga
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Shin Hisahara
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Ikkei Ohhashi
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Daisuke Yamamoto
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Akihiro Matsumura
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Syuuichirou Suzuki
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Katsumasa Tanimoto
- Department of Orthopedics, Chitose City Hospital, Japan
- Department of Orthopedics, School of Medicine, Sapporo Medical University, Japan
| | - Masahiro Hirakawa
- Department of Medical Oncology, Department of Hematology, School of Medicine, Sapporo Medical University, Japan
| | - Jun Kawamata
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Junji Kato
- Department of Medical Oncology, Department of Hematology, School of Medicine, Sapporo Medical University, Japan
| | - Shun Shimohama
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
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40
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Dihn D, Chien K, Ma L. Case Report: Wernicke Encephalopathy Following Roux-en-Y Gastric Bypass. Am Fam Physician 2020; 102:197-198. [PMID: 32803937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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41
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Meng H, Zhou Q, Chen S. Anti-Ma encephalitis masquerading as Wernicke encephalopathy. J Clin Neurosci 2020; 79:160-162. [PMID: 33070888 DOI: 10.1016/j.jocn.2020.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/16/2020] [Accepted: 06/29/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Anti-Ma encephalitis is a disease usually associated with testicular cancer in young male patients. Anti-Ma encephalitis presented as Wernicke encephalopathy-like symptoms and with gastric cancer is rare. Here, we report a case of anti-Ma encephalitis with gastric cancer in an elderly patient, which has been misdiagnosed of Wernicke encephalopathy. CASE REPORT A 71-year old male with a history of alcohol abuse was admitted to the hospital because of progressive dizziness, diplopia and anorexia lasted for 1 month. He was initially diagnosed as Wernicke encephalopathy. However, this patient failed in the treatment of VitB1. The blood and cerebrospinal fluid examination found the presence of anti-Ma1/2 antibodies. 18F-FDG PET-MR showed symmetrical hypermetabolic changes on the bilateral hypothalamus, basal ganglion and brainstem, as well as gastric neoplasms with liver metastasis. The patient was finally diagnosed with anti-Ma encephalitis. CONCLUSION Anti-Ma encephalitis should be suspected in patient with Wernicke encephalopathy-like symptoms but failed VitB1 treatment.
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Affiliation(s)
- Huanyu Meng
- Ruijin Hospital, Department of Neurology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qinming Zhou
- Ruijin Hospital, Department of Neurology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sheng Chen
- Ruijin Hospital, Department of Neurology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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42
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Besci T, Evren G, Köroðlu TF. Wernicke Encephalopathy and Lactic Acidosis in Thiamine Deficiency. Indian Pediatr 2020; 57:369-370. [PMID: 32284483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Thiamine deficiency can cause encephalopathy (Wernicke) and lactic acidosis. Herein we report a 6-year-old girl on total parenteral nutrition (TPN) who developed lactic acidosis and neurological symptoms due to improper vitamin replacement, which responded to thiamine injection. The MRI brain findings were not typical for Wernicke encephalopathy.
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Affiliation(s)
- Tolga Besci
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Dokuz Eylül University School of Medicine, Izmir, Turkey.
| | - Gultac Evren
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Tolga Fikri Köroðlu
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Dokuz Eylül University School of Medicine, Izmir, Turkey
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Foucher JR, Gawlik M, Roth JN, de Crespin de Billy C, Jeanjean LC, Obrecht A, Mainberger O, Clauss JME, Elowe J, Weibel S, Schorr B, Cetkovich M, Morra C, Rebok F, Ban TA, Bollmann B, Roser MM, Hanke MS, Jabs BE, Franzek EJ, Berna F, Pfuhlmann B. Wernicke-Kleist-Leonhard phenotypes
of endogenous psychoses: a review of their validity
. Dialogues Clin Neurosci 2020; 22:37-49. [PMID: 32699504 PMCID: PMC7365293 DOI: 10.31887/dcns.2020.22.1/jfoucher] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
While the ICD-DSM paradigm has been a major advance in clinical psychiatry, its usefulness for biological psychiatry is debated. By defining consensus-based disorders rather than empirically driven phenotypes, consensus classifications were not an implementation of the biomedical paradigm. In the field of endogenous psychoses, the Wernicke-Kleist-Leonhard (WKL) pathway has optimized the descriptions of 35 major phenotypes using common medical heuristics on lifelong diachronic observations. Regarding their construct validity, WKL phenotypes have good reliability and predictive and face validity. WKL phenotypes come with remarkable evidence for differential validity on age of onset, familiality, pregnancy complications, precipitating factors, and treatment response. Most impressive is the replicated separation of high- and low-familiality phenotypes. Created in the purest tradition of the biomedical paradigm, the WKL phenotypes deserve to be contrasted as credible alternatives with other approaches currently under discussion.
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Affiliation(s)
- Jack R Foucher
- ICube - CNRS UMR 7357, neurophysiology, FMTS, University of Strasbourg, France ; CEMNIS - Noninvasive Neuromodulation Center, University Hospital Strasbourg, France
| | - Micha Gawlik
- Department of Psychiatry and Psychotherapy, University of Würzburg, Würzburg, Germany
| | - Julian N Roth
- Department of Psychiatry and Psychotherapy, University of Würzburg, Würzburg, Germany
| | - Clément de Crespin de Billy
- ICube - CNRS UMR 7357, neurophysiology, FMTS, University of Strasbourg, France; CEMNIS - Noninvasive Neuromodulation Center, University Hospital Strasbourg, France
| | - Ludovic C Jeanjean
- IICube - CNRS UMR 7357, neurophysiology, FMTS, University of Strasbourg, France; CEMNIS - Noninvasive Neuromodulation Center, University Hospital Strasbourg, France
| | - Alexandre Obrecht
- ICube - CNRS UMR 7357, neurophysiology, FMTS, University of Strasbourg, France; Pôle de Psychiatrie, Santé Mentale et Addictologie, University Hospital Strasbourg, France
| | - Olivier Mainberger
- ICube - CNRS UMR 7357, neurophysiology, FMTS, University of Strasbourg, France. CEMNIS - Noninvasive Neuromodulation Center, University Hospital Strasbourg, France
| | - Julie M E Clauss
- Pôle de Psychiatrie, Santé Mentale et Addictologie, University Hospital Strasbourg, France. SAGE - CNRS UMR 7363, FMTS, University of Strasbourg, France
| | - Julien Elowe
- Department of Psychiatry, Prangins Psychiatric Hospital (CHUV), Route de Benex, Prangins, Switzerland
| | - Sébastien Weibel
- IPôle de Psychiatrie, Santé Mentale et Addictologie, University Hospital Strasbourg, France; Physiopathologie et Psychopathologie Cognitive de la Schizophrénie - INSERM 1114, FMTS, University of Strasbourg, France
| | - Benoit Schorr
- Pôle de Psychiatrie, Santé Mentale et Addictologie, University Hospital Strasbourg, France; Physiopathologie et Psychopathologie Cognitive de la Schizophrénie - INSERM 1114, FMTS, University of Strasbourg, France
| | - Marcelo Cetkovich
- Institute of Translational and Cognitive Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina; National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - Carlos Morra
- ICube - CNRS UMR 7357, neurophysiology, FMTS, University of StInstitute of Translational and Cognitive Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina; National Scientific and Technical Research Council (CONICET), Sanatorio Morra, Córdoba, Argentina
| | - Federico Rebok
- "Servicio de Emergencia", Acute Inpatient Unit, Moyano Neuropsychiatric Hospital, Buenos Aires, Argentina
| | - Thomas A Ban
- International Network for the History of Neuropsychopharmacology (INHN), Córdoba, Argentina
| | - Barbara Bollmann
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Berlin, Germany
| | - Mathilde M Roser
- Department of Psychiatry, Mondor Hospital France, Creteil, France
| | - Markus S Hanke
- Universitäre psychiatrische Dienste Bern, Spiez, Switzerland
| | - Burkhard E Jabs
- Klinik für Psychiatrie and Psychotherapie, Städtisches Klinikum Dresden, Dresden, Germany
| | - Ernst J Franzek
- Yes We Can Clinics, Department of Research and Development, Eindhoven, The Netherlands
| | - Fabrice Berna
- Department of Psychiatry and Psychotherapy, University of Würzburg, Würzburg, Germany; Department of Psychiatry, Prangins Psychiatric Hospital (CHUV), Route de Benex, Prangins, Switzerland
| | - Bruno Pfuhlmann
- IKlinik für Psychiatrie and Psychotherapie, Städtisches Klinikum Dresden, Dresden, Germany
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Heesterbeek MJAB, Swolfs SN, de Waardt DA, Veth CPM. [The knowledge of resident doctors on diagnostics, etiology and treatment of Wernicke encephalopathy]. Tijdschr Psychiatr 2020; 62:853-859. [PMID: 33184816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Wernicke encephalopathy (we) is a severe, acute neuropsychiatric disorder caused by a deficiency in thiamine. There have been indications that we is undertreated, which can lead to the Korsakoff syndrome, delirium or death. Treatment according to protocol is simple and effective. The knowledge of physicians about we has not been researched before.<br/> AIM: To test the knowledge of resident doctors on diagnosis, etiology and treatment of we. <br/> METHOD: The knowledge of 70 resident doctors in different medical specialties was examined through two clinical cases: the first with we due to hyperemesis gravidarum and the second due to alcohol abuse. Both open and multiple-choice questions were asked. Cues of the classical triad of we (cognitive disorder, eye movement disorder and gait disorder) were given accumulatively.<br/> RESULTS: The classical triad of we was not recognized by 73% of the resident doctors in the case of hyperemesis gravidarum and they missed we in the case of alcohol abuse. Many of the resident doctors were not able to name the thiamin deficiency, the triad of we, more than three causes of we or the correct treatment with thiamine sufficiently. 67% of resident doctors indicated that their knowledge of we was insufficient and 76% expressed a need for more information about we.<br/> CONCLUSION: The knowledge of resident doctors about the diagnostics, etiology and management of we is insufficient. Moreover, the resident doctors evaluate their knowledge about we to be insufficient. Medical school and postgraduate specialization have to focus more on this common and severe syndrome, which can appear in different medical areas.
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45
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Sinha S, Kataria A, Kolla BP, Thusius N, Loukianova LL. Wernicke Encephalopathy-Clinical Pearls. Mayo Clin Proc 2019; 94:1065-1072. [PMID: 31171116 DOI: 10.1016/j.mayocp.2019.02.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 02/05/2019] [Accepted: 02/21/2019] [Indexed: 12/16/2022]
Abstract
Wernicke encephalopathy (WE) was first described by Carl Wernicke in 1881. WE is caused by thiamine deficiency. Alcoholism is the most common etiologic factor associated with WE in the United States, but it can occur in any patient with a nutritional deficiency state such as hyperemesis gravidarum, intestinal obstruction, and malignancy. WE is a clinical diagnosis. The common findings include mental status changes, ocular dysfunction, and a gait apraxia, present in only 10% of cases. Only a few cases of WE are diagnosed before death. Approximately 80% of patients with untreated WE have development of Korsakoff syndrome, which is characterized by memory impairment associated with confabulation. The initial clinical diagnosis of WE is critical, keeping in mind that the classic triad of symptoms is often absent. Recognition of nutritional deficiency and any portion of the classic triad should prompt treatment. Additionally, hypothermia, hypotension, and coma should raise clinical suspicion for the disease. Primary treatment includes timely administration of thiamine, for which the route and dosage remain controversial. Clinical judgment should be exercised in diagnosis and treatment (dosage, frequency, route of administration and duration) in all cases of WE. Overdiagnosis and overtreatment may be preferred to prevent prolonged or persistent neurocognitive impairments given the excellent safety profile of thiamine. Further prospective research is warranted to better understand the disease biology, risk factors, and treatment recommendations.
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Affiliation(s)
- Shirshendu Sinha
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN.
| | - Archish Kataria
- Division of Gastroenterology, Department of Internal Medicine, University of Texas Health Science Center, San Antonio, TX
| | - Bhanu Prakash Kolla
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Nuria Thusius
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Larissa L Loukianova
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN
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Abstract
RATIONALE Wernicke encephalopathy (WE) is a syndrome characterized by an acute or subacute onset of ataxia, ophthalmoplegia, and mental status changes. To our knowledge, hypothalamic syndrome is rare in WE. PATIENT CONCERNS A 73-year-old female patient with acute cerebral infarct, who showed initial symptoms of vomiting, nausea, ataxia, and subsequent anorexia, was treated with parenteral nutritional supplement for 20 days. Nevertheless, the patient still developed refractory hyponatremia despite the appropriate sodium supplement given for a week following parenteral nutritional supplement. In fact, after 14 days of parenteral nutritional supplement, the patient gradually showed hypotension and apathy. Hyponatremia, hypotension, anorexia and apathy were signs of hypothalamic syndrome. DIAGNOSES Finally, the patient was diagnosed as WE by head magnetic resonance imaging, which showed symmetrical lesions in T2-weighted imaging images and FLAIR high signal intensity in the periaqueduct, hypothalamus, thalamus, mammiliary bodies, medulla oblongata, and vermis cerebelli. INTERVENTIONS The patient was given thiamine supplementation. OUTCOMES The patient regained consciousness within 3 days. The sings of hyponatremia, hypotension, and apathy were relieved subsequently. LESSONS When patients develop unexplained hypothalamic syndrome, we should think of the possibility of WE. The concomitant presence of hyponatremia, hypotension, anorexia, and apathy in WE is rare. Therefore, this case is reported here for discussion.
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Affiliation(s)
- Sha Zhu
- Department of Neurology, Peking University International Hospital
| | - Jun Qiang
- Department of Neurology, Peking University International Hospital
| | - Qing Xia
- Department of Neurology, Peking University International Hospital
| | - Yanshu Wang
- Department of Neurology, Peking University International Hospital
| | - Jun Zhang
- Department of Neurology, Peking University People's Hospital, Beijing, China
| | - Xianzeng Liu
- Department of Neurology, Peking University International Hospital
- Department of Neurology, Peking University People's Hospital, Beijing, China
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López Zúñiga MÁ, Andreo Jiménez FJ, Barrero Hernández FJ. When a stroke is not a stroke. Emergencias 2019; 30:136-137. [PMID: 29547242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Abstract
RATIONALE Bariatric surgery is the recommended treatment for morbid obesity because of its rapid and sustained body weight loss effect. Nutrient deficiency-related neurological complications after bariatric surgery are often disabling. Thus, early recognition of these complications is important. Neurological complications involving the central and peripheral nerve system after bariatric surgery were reported. However, the report on the clinical course of the concurrent involvement of central and peripheral nervous system is limited. We present a rare case of a patient who developed Wernicke encephalopathy concurrent with polyradiculoneuropathy after receiving bariatric surgery. PATIENT CONCERNS A 22-year-old man with a history of morbid obesity presented progressive bilateral lower limbs weakness, blurred vision, and gait disturbance 2 months after receiving laparoscopic sleeve gastrectomy. Bilateral lower limb numbness and cognition impairment were also noted. DIAGNOSIS Brain magnetic resonance imaging and electrophysiologic studies confirmed the diagnosis of Wernicke encephalopathy concurrent with acute polyradiculoneuropathy. INTERVENTIONS Vitamin B and folic acid were given since admission. He also received regular intensive rehabilitation program. OUTCOMES The subject's cognitive impairment and diplopia improved 1 week after admission under medical treatments, yet lower limb weakness and gait disturbance were still noted. After a month of intensive inpatient rehabilitation, he was able to ambulate with a walker for 30 munder supervision. LESSONS Nutrient deficiency-related neurological complications after bariatric surgery are often disabling and even fatal. Prevention of neurological complications can be improved through close postsurgical follow-up of the nutritional status. Recognizing the signs and symptoms and evaluating the medical history are critical to the early diagnosis and treatment of this potentially serious yet treatable condition.
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Affiliation(s)
- Heng-Wei Chang
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital
| | - Pei-Yu Yang
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Ting-I Han
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital
| | - Nai-Hsin Meng
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital
- School of Medicine, China Medical University, Taichung, Taiwan
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Salzer J, Zizka J, Karlberg M. [Bilateral loss of the horizontal vestibulo-ocular reflex in Wernicke encephalopathy - a specific and early clinical sign]. Lakartidningen 2019; 116:FEP4. [PMID: 30694522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Wernicke encephalopathy is a condition in which thiamine deficiency causes cognitive dysfunction, ataxia and eye motor abnormalities. The condition is potentially reversible if treated with high doses of intravenous thiamine (vitamin B1). The video head impulse test, in which the vestibulo-ocular reflex is tested, can reveal an early specific sign of selective dysfunction in the medial vestibular nuclei by demonstrating selective dysfunction of the horisontal vestibulo-ocular reflex. We present two cases with clinical and neuroradiological findings consistent with Wernicke encephalopathy where such oculomotor findings were detected.
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Affiliation(s)
- Jonatan Salzer
- Institutionen för farmakologi och klinisk neurovetenskap - Sektionen för neurologi Sweden, Sweden Institutionen för farmakologi och klinisk neurovetenskap - Sektionen för neurologi Sweden, Sweden
| | - Jan Zizka
- Norrlands universitetssjukhus - Bild- och funktionsmedicin, Neuroradiologi Umeå, Sweden Norrlands universitetssjukhus - Bild- och funktionsmedicin, Neuroradiologi Umeå, Sweden
| | - Mikael Karlberg
- Skane's University Hospital - Ear, nose and throat clinic Lund, Sweden - Lund, Sweden
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Ajob L, Brännström I, Ott M, Werneke U. [Not Available]. Lakartidningen 2018; 114:ELZT. [PMID: 30536232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Leath Ajob
- Sunderby sjukhus - Psykiatri Lulea, Sweden Sunderby sjukhus - Psykiatri Lulea, Sweden
| | - Ingrid Brännström
- Sunderby sjukhus - Verksamhetsavdelningen Lulea, Sweden Sunderby sjukhus - Verksamhetsavdelningen Lulea, Sweden
| | - Michael Ott
- Umea Universitet Medicinska fakulteten - Institutionen för folkshälsa och klinisk medicin - medicin Umea, Sweden Umea Universitet Medicinska fakulteten - Institutionen för folkshälsa och klinisk medicin - medicin Umea, Sweden
| | - Ursula Werneke
- Umea Universitet Medicinska fakulteten - Institutionen för klinisk vetenskap - psykiatri, Sunderby Forskningsenhet Umea, Sweden Umea Universitet Medicinska fakulteten - Institutionen för klinisk vetenskap - psykiatri, Sunderby Forskningsenhet Umea, Sweden
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