Case Of Wernicke's Encephalopathy Research Articles

A RARE CASE OF WERNICKE'S ENCEPHALOPATHY INDUCED BY HYPEREMESIS GRAVIDARUM: A DIAGNOSTIC DILEMMA

A RARE CASE OF WERNICKE'S ENCEPHALOPATHY INDUCED BY HYPEREMESIS GRAVIDARUM: A DIAGNOSTIC DILEMMA

Acute Dizziness Treated With Thiamine Supplement: A Case of Wernicke Encephalopathy

Wernicke encephalopathy (WE) is an uncommon but severe neurological disorder caused by thiamine (vitamin B1) deficiency. It is characterized by the sudden onset of altered consciousness, ophthalmoplegia, and ataxia. Apart from chronic alcoholism, a lot of other conditions causing malnutrition and decreasing thiamine absorption must be considered as predisposing factors. Due to its low prevalence and clinical heterogeneity, WE is often misdiagnosed, resulting in persistent dysfunctions or death. Therefore, early diagnosis and prompt treatment with intravenous thiamine supplement might prevent encephalopathy and other neurologic or systemic complications of thiamine depletion. We hereby report of our experience of a WE patient who presented with predominantly vestibular symptoms and signs; the patient was successfully diagnosed and treated with high-dose intravenous thiamine repletion.

Spectrum of Neurological Complications of Pregnancy on Magnetic Resonance Imaging

Introduction: Catastrophic neurological decline, although exceedingly rare, takes a huge toll on pregnant population. In view of varied symptomatology and risks to the fetus, diagnosis and management of the neurological disorders in pregnancy is always a challenging task. The evaluation and management should be performed in a stepwise fashion and requires a multidisciplinary approach. Radiological imaging, especially magnetic resonance imaging (MRI), has revolutionized the diagnosis of these disorders, thereby exacerbating maternal and fetal outcome. Aim: The present study was conducted with the aim to characterize some of the significant neurological disorders complicating pregnancy and puerperium and to study the role of imaging, especially MRI, in differentiation and exclusion of various neurologic conditions, which helps an obstetrician to point to a specific diagnosis and management. Materials and Methods: Our study was an observational study conducted in the Department of Obstetrics and Gynecology in collaboration with the Department of Radiodiagnosis of GMC, Srinagar, from June 2018 to January 2020. The images were obtained with MRI and subjected for radiological interpretation. Results: A total of 750 patients were included in the study out of which 25 patients had neurological complications. Out of 25 patients, 13 were in the antenatal period and 12 were in the puerperium. There were 10 (40.0%) cases of posterior reversible encephalopathy syndrome (PRES), 6 (24%) cases of cerebral venous thrombosis (CVT), 3 (12.0%) cases of embolic infarcts, 2 (8.0%) cases of status epilepticus, 2 (8.0%) cases of pituitary apoplexy, 1 (4.0%) case of Wernicke encephalopathy, and 1 (4.0%) case of metastasis to brain (choriocarcinoma). Conclusion: Diagnosis of neurological complications of pregnancy and postpartum plays a crucial role in reducing fetomaternal morbidity and mortality. MRI stands above all imaging modalities in early diagnosis of these neurological complications, simultaneously taking care of fetal safety as well. The most common neurological complications that cause increased maternal mortality are PRES and CVT. Hence, early imaging can help in early and appropriate management of serious pregnancy-related neurological catastrophes.

A rare case of Wernicke encephalopathy in stage IV gastric cancer

ABSTRACT A 38-year-old male with stage IV gastric adenocarcinoma presented with abdominal pain, nausea, bilious non-bloody vomiting, and lethargy. He was found to have an ileus and was treated appropriately with bowel rest and nasogastric tube decompression. However, the patient was also noted to have confusion and nystagmus. While he was abstinent from alcohol for 20 years, he was found to have Wernicke Encephalopathy (WE) as a result of malnutrition from the underlying malignancy.

Non-alcoholic Wernicke's encephalopathy with atypical brain MRI in setting of severe subacute malnutrition

Wernicke encephalopathy (WE) classically presents as encephalopathy, oculomotor dysfunction, and gait ataxia. WE usually occurs in the setting of chronic alcohol use and thiamine insufficiency. MRI imaging generally demonstrates edema of the periaqueductal region of the midbrain, mammillary bodies, and thalamus. Basal ganglia (BG) involvement, more commonly seen in pediatric WE, is classically thought to differentiate pediatric versus adult WE. However, we report a case of adult non-alcoholic WE with both thalamic and BG involvement.

A Fortunate Escape After Falling into a Ravine: a Case of Wernicke Encephalopathy, Polyneuropathy and Optic Neuropathy Following Sleeve Gastrectomy

A Fortunate Escape After Falling into a Ravine: a Case of Wernicke Encephalopathy, Polyneuropathy and Optic Neuropathy Following Sleeve Gastrectomy

SUN-596 A Rare Presentation of Early Onset Wernicke Encephalopathy Following Sleeve Gastrectomy

Background: Wernicke encephalopathy (WE) has been reported after malabsorptive bariatric surgeries but is an uncommon complication of sleeve gastrectomy. Since 2011, the number of patients receiving a sleeve gastrectomy has tripled, with almost 60% of patients undergoing bariatric surgery receiving a sleeve gastrectomy in 2017 (1). We present a case of WE in a young woman as a rare and early complication of sleeve gastrectomy. Clinical Case: A 32-year old female with a past medical history significant for hypertension, pseudotumor cerebri, and morbid obesity status post sleeve gastrectomy two months prior presented to the emergency department with complaints of blurry vision and lower extremity numbness. Physical examination showed sluggish light reflex and decreased extraocular movements. Given history of pseudotumor cerebri, patient underwent a therapeutic lumbar puncture with removal of 13 ml of CSF. Opening pressure was 20 cm of water and patient experienced no relief of her symptoms. Ophthalmology consult did not offer an explanation for the blurry vision. MRI-brain with and without contrast showed findings highly suggestive of WE. It showed faint linear symmetric hyperintensities along the bilateral mesial thalamus, dorsal midbrain and periaqueductal gray matter, which were determined to be acute in nature in comparison with a MRI performed three weeks prior. Upon further investigation, thiamine level was low at 43.6 nmol/L [66.5 – 200] confirming the diagnosis of WE. Thiamine supplementation was started immediately and patient reported improvement of her vision the next day with return to baseline in 3 days. Conclusion: There have been a handful of cases of WE reported in literature as a complication of sleeve gastrectomy. Zheng, L also reported a case of WE 7 weeks after sleeve gastrectomy (2). Although sleeve gastrectomy does not directly affect the primary absorptive pathway of thiamine in the gastrointestinal tract, it is imperative to consider WE in patients presenting with suspicious neurologic symptoms after a recent sleeve gastrectomy. WE was suspected in our case due to typical MRI findings and neurological presentation after bariatric surgery, which was later confirmed by low serum thiamine level. Early detection and thiamine supplementation resulted in complete reversal of symptoms in our patient. WE is a rare but severe and preventable consequence of bariatric surgery that warrants attention given its rapid onset and detrimental course. Reference: (1) Estimate of Bariatric Surgery Numbers, 2011-2017. (2018, June 26). Retrieved from https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. (2) Zheng, L. (2016).Wernicke Encephalopathy and Sleeve Gastrectomy. American Journal of Therapeutics, 23(6).

A Case of Wernicke Encephalopathy with Disordered Eye Movements

A Case of Wernicke Encephalopathy with Disordered Eye Movements

Refeeding Syndrome and Non-Alcoholic Wernicke’s Encephalopathy in a Middle-aged Male Initially Presenting with Gallstone Pancreatitis: A Clinical Challenge

Wernicke’s Encephalopathy (WE) is a neurological condition characterized by ophthalmoplegia, ataxic gait, and altered mental status. It is an underdiagnosed yet severely limiting disease process precipitated by thiamine deficiency. Often times, it can occur in conjunction with other disease states like refeeding syndrome in which the underlying etiology is prolonged periods of malnutrition. We present a unique case of non-alcoholic WE in a middle-aged male who initially presented with gallstone pancreatitis complicated with severe metabolic derangements. This ultimately resulted in the development of non-alcoholic WE. Prevention of this condition is a clinical challenge for most physicians as the classic features associated with thiamine deficiency lack diagnostic sensitivity and specificity in critically ill patients. As a result, early recognition and prompt management of this can dramatically decrease morbidity and mortality. Our case highlights and emphasizes the importance of maintaining a high index of suspicion for WE and refeeding syndrome in the setting of altered sensorium and metabolic derangements.

A case of Wernicke encephalopathy with hypoacusia and MR high intensity of the inferior colliculi that normalized after thiamine administration

A 61-year-old man was admitted to our institution with progressive hypoacusia, double vision, and lightheadedness. Neurological examination on day 6 of his illness showed severe hypoacusia, mild confusion, ocular motility disorder, truncal ataxia and absence of a deep tendon reflex. MRI fluid-attenuated inversion recovery imaging revealed symmetrical high intensities in the tectum of the midbrain, involving the bilateral inferior colliculi and the bilateral medial thalami, which suggested Wernicke encephalopathy (WE). Thiamine was administered immediately after completion of the MRI, and the patients' hearing and other abnormal neurologic signs improved rapidly within a few days, except for the absence of the deep tendon reflex. Whole blood examination at admission revealed very low levels of vitamin B1. The patient was discharged on day 19, and MRI on day 39 showed the disappearance of the abnormal high intensities involving the bilateral inferior colliculi. The present case indicates that hypoacusia and abnormal MRI signal due to WE might be normalized by administration of thiamine a few days after the onset of symptoms.

Adolescent Bariatric Surgery and Thiamine Deficiency: What Do We Know So Far?

We read with great interest the recent article by Armstrong-Javors et al1 published in the December 2016 issue of Pediatrics that describes a case of Wernicke encephalopathy (WE) 2 months after Roux-en-Y gastric bypass (RYGB). The authors report a rare case of WE resulting from thiamine deficiency in a 15-year-old white girl who underwent RYGB. According to the article, WE was suspected because of the progressive neurologic symptoms (nystagmus, irritability, ataxia) and frequent vomiting. The aforementioned case is important because it reports not only a rare but also an acute complication after bariatric surgery with notably increased mortality and morbidity. Furthermore, … E-mail: antwnis_athanasiou{at}hotmail.com

Wernicke’s Encephalopathy in a Patient Without Chronic Alcohol Abuse

Wernicke’s encephalopathy (WE) is traditionally seen in the emergency department in patients with chronic alcohol abuse. WE can result in significant morbidity and mortality if untreated, making early diagnosis and intervention paramount. We discuss a case of WE in a 63-year-old female with no history of chronic alcohol abuse, who presented with bilateral opthalmoplegia that resolved after intravenous thiamine administration. This case report highlights the varied clinical settings other than chronic alcohol abuse in which the diagnosis of WE should be considered.

Miller Fisher Sendromu Düşünülen Wernicke Ensefalopati Olgusu

Miller Fisher Sendromu Düşünülen Wernicke Ensefalopati Olgusu

Wernicke Encephalopathy after Endoscopic Necrosectomy in Acute Necrotizing Pancreatitis with WOPN: A Case Report

Infected walled-off pancreatic necrosis (WOPN) is dangerous complication of acute pancreatitis. Open necrosectomy and post-operative irrigation of necrotic cavity have been conventional treatment for infected pancreatic necrosis, however, recently minimally invasive techniques such as endoscopic necrosectomy has been regarded as preferred treatment method for infected WOPN. Endoscopic necrosectomy provides a targeted approach with a reduction in the systemic inflammatory response and avoidance of wound complications. Non alcohol related Wernicke encephalopathy is rare disease caused by thiamine deficiency due to intravenous feeding, and presented an encephalopathy, oculomotor dysfunction, gait ataxia. We report herein a case of Wernicke encephalopathy after successful endoscopic necrosectomy for infected WOPN. Korean J Pancreatobiliary 2016;21(1):34-39

Thyrotoxicosis With Development of Wernicke Encephalopathy in an Adolescent

ABSTRACT Objective: Wernicke encephalopathy (WE) is a rare disorder resulting from deficiency of thiamine (vitamin B1). It is precipitated by conditions including thyrotoxicosis, hyperemesis gravidarum, and alcoholism. The disease is not always suspected in pediatric patients, and its presentation can be atypical, so it is often underdiagnosed. Methods: We present a case of severe WE in a 13-year-old female that was precipitated by malnutrition secondary to vomiting, abdominal pain, and weight loss due to gastritis. Features of WE were induced by concomitant untreated hyperthyroidism. The patient showed the classical triad of WE clinically and had typical brain magnetic resonance imaging features. Results: Encephalopathy was dramatically improved after thiamine replacement. Her disease course ended with full reversal of neurologic deficits and radiologic abnormalities within 7 weeks. Conclusion: WE is a debilitating condition that can be life-threatening if not treated. It is underdiagnosed in children but can present with classical clinical and radiological features that should prompt the diagnosis. As with adults, untreated hyperthyroidism with a malnutrition state can lead to WE in children, and thiamine replacement can reverse the condition. Abbreviations: MRI = magnetic resonance imaging NR = normal range WE = Wernicke encephalopathy

Coexisting cytotoxic and vasogenic edema in Wernicke encephalopathy

Wernicke encephalopathy (WE) is caused by a thiamine deficiency and typically results in symmetrical lesions in areas of the brain including the paraventricular regions of the thalamus and hypothalamus, the mammillary bodies, the periaqueductal region of the midbrain, the floor of the fourth ventricle and the superior cerebellar vermis. We observed a case of WE that exhibited simultaneous cytotoxic and vasogenic edema. Although cytotoxic edema and vasogenic edema are typical findings of Wernicke encephalopathy, it is very rare for both pathogenic findings to be observed together. A 52-year-old woman with a history of total colectomy was admitted for management of epigastric discomfort, nausea and vomiting 7 days in duration. The patient suffered from recurrent paralytic ileus due to systemic sclerosis. Three months prior to admission, the patient underwent a total colectomy due to colon obstruction. The patient had no prior history of hypertension, diabetes, or cerebrovascular diseases. She did not have a history of smoking or alcohol consumption (Fig. 1). Despite administration of antiemetics, vomiting persisted. The patient was treated with intravenous glucose and electrolyte solution without vitamin supplementation. After 15 days of hospitalization, the patient was referred to the Neurology Department for evaluation of convulsive movement, diplopia, and ataxia. On examination, the patient was alert, but disoriented. There was complete ophthalmoplegia with coarse spontaneous nystagmus. The upper and lower limbs were symmetrically hypotonic and weak. The patient was unable to maintain a sitting position or standing position without support due to truncal ataxia, and deep tendon reflexes were slightly depressed. Laboratory studies revealed anemia, leukocytosis and elevated liver enzymes. The serum thiamine level was below the normal range (14.5 lg/L, normal 28–85). Magnetic resonance imaging (MRI) performed on the referral day showed high signal intensity lesions in both medial thalami, the mammillary bodies, the periaqueductal region, the tectum of the midbrain and the medullary tegmentum in T2-weighted and fluid-attenuated inversion recovery (FLAIR) MR imaging. Diffusion-weighted images (DWI) showed more extensive symmetrical high signal intensities in the aforementioned areas, and also in both the central and precentral sulcus. Apparent diffusion coefficient (ADC) mapping showed low intensity areas in both cortical sulcal lesions, the most medial part of the thalami, the mammillary bodies, and the dorsal and upper part of the midbrain tectum, and simultaneous high or iso intensities in the rest of the medial thalamus, midbrain tectum and medullary tegmentum. The patient was given 100 mg of thiamine per day intravenously. Seven days after thiamine supplementation, her ocular motor function had improved, and 21 days after thiamine treatment began, the patient was able to walk without titubation. Many case investigations using DWI to examine patients with Wernicke encephalopathy have S. Kim S.-H. Kim J.-S. Kim (&) Department of Neurology, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 505, Banpo-dong, Seocho-gu, Seoul 137-701, South Korea e-mail: neuronet@catholic.ac.kr

Unfortunate Consequences of Losing Weight – A Case of Wernicke Encephalopathy and Bariatric Beriberi after Gastric Bypass Surgery (P06.209)

Unfortunate Consequences of Losing Weight – A Case of Wernicke Encephalopathy and Bariatric Beriberi after Gastric Bypass Surgery (P06.209)

A Novel Scoring System to Guide Risk Assessment of Wernicke's Encephalopathy

Thiamine deficiency in patients who abuse alcohol can cause Wernicke's encephalopathy (WE). Thiamine supplements are given to prevent this complication. Guidelines exist for giving thiamine supplementation in the inpatient population. However, similar guidelines are not available for clinicians detoxifying patients in the community, and consequently, assessment of risk of WE and prophylaxis can be inconsistent. A scoring system to assess risk of WE was developed and evaluated by comparing practice before and after introduction of the system. One hundred and twenty-six cases requiring alcohol detoxification were examined: 94 before introduction of the scoring system and 32 afterward. Before introduction of the scoring system, a risk assessment for developing WE was performed in 30% of patients and parenteral thiamine prescribed in 32%. After introduction of the scoring system, risk assessment and administration of parenteral thiamine increased to 100 and 75%, respectively. There was 1 probable case of WE before introduction of the scoring system and none afterward. We conclude that assessment of WE is often inadequate, leading to inadequate thiamine administration. The new scoring system allows simple, structured risk assessment for WE and thus guides appropriate thiamine administration. This is of most value to clinicians treating the consequences of alcohol dependence in the community.

Thiamine Deficiency Following Umbilical Cord Blood Transplant

A case of Wernicke encephalopathy (WE) in the setting of umbilical cord blood transplant is reported. The patient, originally diagnosed with Philadelphia chromosome-positive acute lymphoblastic leukemia, proceeded to an umbilical cord blood transplant. He presented with altered mental status 149 days following transplant. Prompt magnetic resonance imaging, baseline thiamine level, and immediate intravenous replacement allowed for recovery of most symptoms. Accompanying this case is a review of the known cases of WE in hematopoietic cell transplants and their causative factors. This is the first known adult case of WE independent of parenteral nutrition use in the setting of umbilical cord transplant.

Wernicke encephalopathy with atypical magnetic resonance imaging

Wernicke encephalopathy (WE) is a medical emergency caused by thiamine (vitamin B1) deficiency. Typical clinical manifestations are mental change, ataxia, and ocular abnormalities. Wernicke encephalopathy is an important differential diagnosis in all patients with acute mental change. However, the disorder is greatly underdiagnosed. Clinical suspicion, detailed history taking, and neurologic evaluations are important for early diagnosis. Magnetic resonance imaging (MRI) is currently considered the diagnostic method of choice. Typical MRI findings of WE are symmetrical involvement of medial thalamus, mammillary body, and periaqueductal gray matter. Prompt thiamine supplement is important in avoiding unfavorable outcomes. Here, we report a case of alcoholic WE with typical clinical presentation but with atypical MRI. Axial fluid-attenuated inversion recovery images showing symmetrical hyperintensity lesions in dentate nuclei of cerebellum, olivary bodies, and dorsal pons. Although atypical MRI findings are more common in nonalcoholic WE, it can also occur in alcoholic WE. This article is aimed to highlight the potential pitfalls in diagnosing acute mental change, the importance of clinical suspicion, and early treatment in WE.