Hallucinations and psychosis in Guillain-Barré syndrome: case report

Abstract

Introduction: Guillain-Barré syndrome (GBS) is an acute inflammatory peripheral neuropathy that occurs after infection or immunization. Wernicke’s encephalopathy (WE) is caused by thiamine deficiency that classically presents with altered mental status, ataxic gait and ophthalmoplegia. Case report: Male, 64 years old, presented with diarrhea, vomiting and hyporexia. Three weeks later, he developed concomitant acute tetraparesis and cognitive impairment. On examination, he presented with persecutory delusions, hallucinations, tetraparesis with global areflexia. The cerebrospinal fluid analysis showed important albuminocytological dissociation. Treatment with intravenous immunoglobulin associated with thiamine was started. The electroneuromyography was compatible with demyelinating sensorimotor polyneuropathy. Brain Magnetic resonance imaging showed FLAIR (Fluid-Attenuated Inversion Recovery) hyperintensities in mamillary bodies and periaqueductal gray matter. The patient was diagnosed with GBS and WE. He was discharged after two weeks with complete resolution of the cognitive impairment and improvement of tetraparesis. Altered mental status in a patient with GBS is not common. There are some reports of patients who presented cognitive disturbances related to autonomic dysfunction and more severe cases, which developed a few days after the onset of the motor condition. The reported patient had a change in mental status concomitantly with a motor condition, reported prolonged gastrointestinal symptoms, in addition to having received intravenous glucose. WE may occur after a short period of thiamine absorption/intake deficiency and may be precipitated by glucose administration. The patient showed rapid cognitive improvement after thiamine supplementation, and had typical EW changes on the brain MRI confirming the diagnosis of WE. Conclusions: We must be aware of changes in mental status as this may indicate thiamine deficiency. The case elucidates the importance of thiamine replacement in patients at risk of vitamin deficiency.