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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] [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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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] [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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Abstract
Half a million bariatric procedures are performed annually worldwide. Our aim was to review the signs and symptoms of Wernicke's encephalopathy (WE) after bariatric surgery. We included 118 WE cases. Descriptions involved gastric bypass (52%), but also newer procedures like the gastric sleeve. Bariatric WE patients were younger (median = 33 years) than those in a recent meta-analysis of medical procedures (mean = 39.5 years), and often presented with vomiting (87.3%), ataxia (84.7%), altered mental status (76.3%), and eye movement disorder (73.7%). Younger age seemed to protect against mental alterations and higher BMI against eye movement disorders. The WE treatment was often insufficient, specifically ignoring low parenteral thiamine levels (77.2%). In case of suspicion, thiamine levels should be tested and treated adequately with parenteral thiamine supplementation.
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Affiliation(s)
- Erik Oudman
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands.
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands.
| | - Jan W Wijnia
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
| | - Mirjam van Dam
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
| | - Laser Ulas Biter
- Department of Bariatric Surgery, Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Albert Postma
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
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Liu YL, Xiao WM, Liang MQ, Wu ZQ, Wang YZ, Qu JF, Chen YK. Clinical characteristics and magnetic resonance imaging findings in nine patients with nonalcoholic Wernicke's encephalopathy: a retrospective study. Neuropsychiatr Dis Treat 2019; 15:2433-2441. [PMID: 31692555 PMCID: PMC6716582 DOI: 10.2147/ndt.s217237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/03/2019] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Wernicke's encephalopathy (WE) is a severe neurological disorder caused by thiamine deficiency. The most common cause of WE is alcoholism. However, there is a significant paucity of information in the existing literature relating to nonalcoholic WE. In this study, we investigated the clinical characteristics and neuroimaging findings of nine patients with nonalcoholic WE. PATIENTS AND METHODS We retrospectively collated clinical data from nine patients who had been diagnosed with WE in accordance with established criteria including age, gender, risk factors and clinical manifestations. We also collated initial hematological and neuroimaging findings. RESULTS The mean age of the nine patients was 54.0±17.1 years; four of these patients (44.4%) were male. All nine patients had a history of fasting (range, 5-47 days) prior to WE. Four of the nine patients (44.4%) exhibited the classical triad, and eight (88.9%) showed alterations in mental status. Magnetic resonance imaging (MRI) scans showed that all nine patients had symmetric lesions of the medial thalamus. MRI also revealed other WE-related lesions in mammillary bodies (22.2%), the periaqueductal region (55.6%), the tectal plate of the midbrain (77.8%), cranial nerve nuclei (77.8%) and in the symmetric subcortical white matter (11.1%). CONCLUSION Our analysis showed that fasting is a common cause of WE in nonalcoholic patients and that MRI is a useful tool for the diagnosis of WE. The most common MRI findings were symmetrical lesions of the medial thalamus lesions, followed by the tectal plate of the midbrain and cranial nerve nuclei.
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Affiliation(s)
- Yong-Lin Liu
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Wei-Min Xiao
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Man-Qiu Liang
- Department of Radiology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Zhi-Qiang Wu
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Ya-Zhi Wang
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Jian-Feng Qu
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
| | - Yang-Kun Chen
- Department of Neurology, Affiliated Dongguan People's Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong Province, People's Republic of China
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Pourhassan M, Biesalski HK, Angersbach B, Lueg G, Klimek C, Wirth R. Prevalence of thiamine deficiency in older hospitalized patients. Clin Interv Aging 2018; 13:2247-2250. [PMID: 30464433 PMCID: PMC6220429 DOI: 10.2147/cia.s183102] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Despite some reports of high prevalence of thiamine deficiency in elderly people, the reported prevalence is controversial mainly due to the methods used in assessing thiamin concentrations. In this study, we sought to investigate the prevalence of vitamin B1 deficiency, using the high-performance liquid chromatography (HPLC) method, among older hospitalized patients. Patients and methods This cross-sectional study retrospectively analyzed the results of routine measurements of vitamin B1 of 238 older patients who were consecutively hospitalized to a geriatric acute care ward. Whole blood vitamin B1 concentrations were measured using the HPLC method at hospital admission, and the whole blood vitamin B1 level of <20 ng/mL was considered as deficiency. Results Of 238 patients, with a mean age of 82.1±7.1 years, 63% of patients were women. In total, the mean whole blood vitamin B1 level was 66.1±24.8 ng/mL (range 29.5-215 ng/mL), indicating no vitamin B1 deficiency in the entire population. In addition, no significant differences in the mean whole blood vitamin B1 concentrations between sexes were observed (P=0.356). Conclusion This study indicates that the mean whole blood vitamin B1 concentrations using the HPLC method were within the normal range in older hospitalized patients suggesting that thiamine deficiency appears to be rather uncommon among these patients.
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Affiliation(s)
- Maryam Pourhassan
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany,
| | - Hans Konrad Biesalski
- Institute of Biological Chemistry and Nutritional Science, University of Hohenheim, Stuttgart, Germany
| | - Bjoern Angersbach
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany,
| | - Gero Lueg
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany,
| | - Christiane Klimek
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany,
| | - Rainer Wirth
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany,
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Herman CK, Hoschander AS, Wong A. Post-Bariatric Body Contouring. Aesthet Surg J 2015; 35:672-87. [PMID: 25902949 DOI: 10.1093/asj/sjv008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The "epidemic" of obesity has recently been accompanied by a new "epidemic" of massive weight loss. The demand for post-bariatric contouring is rising and, as such, it is extremely important for plastic surgeons to be well versed in the treatment of these patients. Unfortunately, the problem is not solely surgical. OBJECTIVES The aim of this article is to understand the nutritional and psychological complications that can occur in patients following massive weight loss, to understand the anatomic deformities in massive weight loss as a means to correct those deformities surgically, and to understand the complications from post-bariatric contouring procedures in an effort to avoid them. METHODS This article discusses the nutritional and psychological considerations in the massive weight loss patient, anatomical considerations in this patient group, and the surgical techniques designed to address these anatomic concerns. Important pertinent studies are reviewed and discussed. RESULTS Anatomical changes are encountered in each region of the body: there are surgical options available to correct them, although potential complications are associated with these surgical procedures. These surgical options are reviewed as well as the risk and benefits associated with them. CONCLUSIONS There are many problems that need to be addressed in the massive weight loss patient prior to embarking on surgical treatment. Additionally, surgery on massive weight loss patients has unique considerations that distinguish these operations from those performed on the non-bariatric population.
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Affiliation(s)
- Charles K Herman
- Dr Herman is the Chief Medical Executive, Chairman of the Department of Surgery and Chief of the Division of Plastic and Reconstructive Surgery, Pocono Health Systems, East Stroudsburg, PA; Clinical Professor of Surgery, The Commonwealth Medical College, Scranton, PA; and Assistant Clinical Professor of Surgery, Albert Einstein College of Medicine, New York, NY. Dr. Hoschander is the Chief Resident and Dr. Wong is a Resident in the Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, FL
| | - Ari S Hoschander
- Dr Herman is the Chief Medical Executive, Chairman of the Department of Surgery and Chief of the Division of Plastic and Reconstructive Surgery, Pocono Health Systems, East Stroudsburg, PA; Clinical Professor of Surgery, The Commonwealth Medical College, Scranton, PA; and Assistant Clinical Professor of Surgery, Albert Einstein College of Medicine, New York, NY. Dr. Hoschander is the Chief Resident and Dr. Wong is a Resident in the Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, FL
| | - Anselm Wong
- Dr Herman is the Chief Medical Executive, Chairman of the Department of Surgery and Chief of the Division of Plastic and Reconstructive Surgery, Pocono Health Systems, East Stroudsburg, PA; Clinical Professor of Surgery, The Commonwealth Medical College, Scranton, PA; and Assistant Clinical Professor of Surgery, Albert Einstein College of Medicine, New York, NY. Dr. Hoschander is the Chief Resident and Dr. Wong is a Resident in the Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, FL
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Arslan EA, Ekinci S, Akkuş PZ, Göçmen R, Haliloğlu G. Wernicke encephalopathy due to thiamine deficiency after surgery on a child with duodenal stenosis. Pediatr Neurol 2014; 51:840-2. [PMID: 25303868 DOI: 10.1016/j.pediatrneurol.2014.08.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/29/2014] [Accepted: 08/30/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wernicke encephalopathy is rare in children and is caused by thiamine deficiency. It is characterized by acute or subacute ataxia, altered consciousness, and ophthalmoparesis. Gastroenterological surgery, total parenteral nutrition for short bowel syndrome, and alcoholism are common risk factors for Wernicke encephalopathy. Typical magnetic resonance imaging features include selective symmetrical signal changes in the mammillary bodies, medial thalamus, tectum, periaqueductal region, cranial nerves, cerebellum, red nucleus, dentate nucleus, fornix, splenium, cerebral cortex, and putamen. If left undiagnosed and untreated, the disease may be fatal. PATIENT DESCRIPTION We describe a 13-year-old boy who developed acute cerebellar findings while receiving total parenteral nutrition after gastroduodenostomy for duodenal stenosis. RESULTS The diagnosis of Wernicke encephalopathy was based on his clinical history, neurological examination, and imaging results. We immediately started intravenous thiamine replacement therapy. Two weeks later, the patient's clinical signs had resolved except for mild clumsiness, which was observed during his tandem gait examination. CONCLUSION Our report emphasizes the importance of clinical and magnetic resonance imaging pattern recognition in timely diagnosis, as well as the importance of prompt thiamine replacement therapy. We also demonstrate the importance of thiamine supplementation during total parenteral nutrition after gastrointestinal surgery.
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Affiliation(s)
- Elif Acar Arslan
- Department of Pediatric Neurology, Hacettepe University Children's Hospital, Ankara, Turkey.
| | - Saniye Ekinci
- Department of Pediatric Surgery, Hacettepe University Children's Hospital, Ankara, Turkey
| | - Pınar Zengin Akkuş
- Department of Pediatric Neurology, Hacettepe University Children's Hospital, Ankara, Turkey
| | - Rahşan Göçmen
- Department of Radiology, Hacettepe University, Ankara, Turkey
| | - Göknur Haliloğlu
- Department of Pediatric Neurology, Hacettepe University Children's Hospital, Ankara, Turkey
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Isenberg-Grzeda E, Kutner HE, Nicolson SE. Wernicke-Korsakoff-syndrome: under-recognized and under-treated. PSYCHOSOMATICS 2013; 53:507-16. [PMID: 23157990 DOI: 10.1016/j.psym.2012.04.008] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 04/11/2012] [Accepted: 04/12/2012] [Indexed: 01/12/2023]
Abstract
BACKGROUND Wernicke-Korsakoff syndrome (WKS) is a well described syndrome of neurological and cognitive problems that comprises both Wernicke's encephalopathy (WE) and Korsakoff syndrome (KS). WE is an acute neuropsychiatric disorder caused by thiamine deficiency. KS is a chronic consequence of thiamine deficiency with prominent impairment in memory formation. METHOD The authors review the literature on the pathophysiology, presentation, and treatment of WKS, focusing on the acute identification and treatment of WE. RESULTS Most cases of WE are missed by clinicians, likely because patients do not present with the classic signs associated with the condition. Attaining high serum levels of thiamine during treatment may be important to restore cognitive function as quickly as possible, though the exact dosing and route needed for effective treatment is unknown. Data indicates that the administration of intravenous (IV) thiamine has little risk. CONCLUSION In order to prevent this potentially devastating disease, physicians should have a high index of suspicion for WKS and dose thiamine accordingly.
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Affiliation(s)
- Elie Isenberg-Grzeda
- Dept. of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
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Jung YC, Chanraud S, Sullivan EV. Neuroimaging of Wernicke's encephalopathy and Korsakoff's syndrome. Neuropsychol Rev 2012; 22:170-80. [PMID: 22577003 PMCID: PMC4728174 DOI: 10.1007/s11065-012-9203-4] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 04/23/2012] [Indexed: 11/27/2022]
Abstract
There is considerable evidence that neuroimaging findings can improve the early diagnosis of Wernicke's encephalopathy (WE) in clinical settings. The most distinctive neuroimaging finding of acute WE are cytotoxic edema and vasogenic edema, which are represented by bilateral symmetric hyperintensity alterations on T2-weighted MR images in the periphery of the third ventricle, periaqueductal area, mammillary bodies and midbrain tectal plate. An initial bout of WE can result in Korsakoff's syndrome (KS), but repeated bouts in conjunction with its typical comorbidity, chronic alcoholism, can result in signs of tissue degeneration in vulnerable brain regions. Chronic abnormalities identified with neuroimaging enable examination of brain damage in living patients with KS and have expanded the understanding of the neuropsychological deficits resulting from thiamine deficiency, alcohol neurotoxicity, and their comorbidity. Brain structure and functional studies indicate that the interactions involving the thalamus, mammillary bodies, hippocampus, frontal lobes, and cerebellum are crucial for memory formation and executive functions, and the interruption of these circuits by WE and chronic alcoholism can contribute substantially to the neuropsychological deficits in KS.
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Affiliation(s)
- Young-Chul Jung
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, South Korea.
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Abstract
Millions of individuals in the United States and around the world are overweight or obese. Bariatric surgery is now considered an evidenced-based choice for sustainable long-term weight loss and may reduce obesity-related comorbidities such as diabetes and obstructive sleep apnea. As bariatric surgical procedures increase, it can be expected that intensive care unit (ICU) admissions will increase as well. An emerging ICU population includes postbariatric patients either immediately after undergoing bariatric surgery or returning for subsequent surgical procedures. Massive weight loss following surgery leads to an excess of lax, overstretched skin, causing physical discomfort and psychosocial problems. It is important to understand the complex pathophysiological changes that occur in order to care for this growing population of patients. This review addresses the growing and evolving issues related to the complex nature of the postbariatric ICU patients.
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Altinyazar V, Kiylioglu N, Salkin G. Anorexia nervosa and Wernicke Korsakoff's syndrome: atypical presentation by acute psychosis. Int J Eat Disord 2010; 43:766-9. [PMID: 19950117 DOI: 10.1002/eat.20783] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 16-year-old girl was admitted to the emergency department because of acute changes in mental state such as paranoid and nihilistic delusions, confabulations, and distortions of body schema perception. Her history was compatible with anorexia nervosa in that she had lost more than 17 kg in weight over one and a half years. Her body mass index was 14. She was diagnosed with Wernicke Korsakoff's syndrome and was given intravenous thiamine at 250 mg/day. Response was dramatic for nystagmus and gait incoordination but not for other symptoms. After dosage was increased to 750 mg/day all symptoms including psychosis improved. With her increase in food consumption, secondary deterioration was observed and diagnosed as refeeding syndrome. After proper replacements she was completely normal in the 9th month, and her weight was 55 kg. This patient was interesting for the presenting symptoms (psychosis), and improvement by high doses of thiamine replacement, and also for refeeding syndrome during this period.
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Affiliation(s)
- Vesile Altinyazar
- Department of Psychiatry, Adnan Menderes University, Aydin, Türkiye.
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Micronutrient-responsive cerebral dysfunction other than Wernicke's encephalopathy after malabsorptive surgery. Surg Obes Relat Dis 2010; 6:171-80. [DOI: 10.1016/j.soard.2009.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 04/04/2009] [Accepted: 04/10/2009] [Indexed: 11/18/2022]
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Abstract
Optimal functioning of the central and peripheral nervous system is dependent on a constant supply of appropriate nutrients. The first section of this review discusses neurologic manifestations related to deficiency of key nutrients such as vitamin B(12), folate, copper, vitamin E, thiamine, and others. The second section addresses neurologic complications related to bariatric surgery. The third sections includes neurologic presentations caused by nutrient deficiencies in the setting of alcoholism. The concluding section addresses neurologic deficiency diseases that have a geographic predilection.
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Affiliation(s)
- Neeraj Kumar
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA.
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Abstract
PURPOSE To report a case of Wernicke encephalopathy after gastric bypass surgery resulting in vision loss, ophthalmoplegia, and ataxia, all of which reversed with a single dose of IV thiamine. METHODS Observational case report. RESULTS A 34-year-old woman presented with decreased vision and intermittent diplopia after gastric bypass surgery. She was found to have bilateral limitation of horizontal gaze, decreased vision with bilateral central scotoma and mild disc edema OU. Her cranial magnetic resonance imaging (MRI) was normal. A presumptive diagnosis of Wernicke encephalopathy was made. The patient was admitted, and a single dose of IV thiamine reversed the ophthalmoplegia and vision loss within 24 hours. CONCLUSION Wernicke encephalopathy should be considered in patients with vision loss after gastric bypass surgery. The classic triad of confusion, ataxia, and ophthalmoplegia may not be present and, although uncommon, the findings of optic disc edema and vision loss should not deter the clinician from making the diagnosis. Replacement thiamine if given promptly may rapidly reverse the findings.
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Affiliation(s)
- Reid Longmuir
- The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Walker J, Kepner A. Wernicke's encephalopathy presenting as acute psychosis after gastric bypass. J Emerg Med 2009; 43:811-4. [PMID: 19406605 DOI: 10.1016/j.jemermed.2009.03.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2008] [Revised: 01/29/2009] [Accepted: 03/26/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients frequently present to the Emergency Department (ED) with psychiatric complaints. The differential diagnosis for acute psychosis is extensive, and determining a possible etiology requires a thorough history and physical. Small details can help the physician in differentiating organic disease from non-organic disease. Many times patients are thought to be "crazy" without a thorough history and physical being done. CASE REPORT In this case, the diagnosis hinged on the history of having gastric bypass surgery. A thorough physical examination was performed, and the patient had neurologic findings suggestive of severe thiamine deficiency. The patient's thiamine level was low. The patient was started on i.v. thiamine and slowly began to recover. CONCLUSION Cerebral beriberi, more commonly known as Wernicke's encephalopathy, is a difficult diagnosis to make in the ED. A thorough neurologic examination is difficult to perform in the ED environment, but it is necessary when trying to determine the etiology of the patient's altered mental status. The number of patients with Wernicke's encephalopathy may increase with bariatric surgery becoming more common. This disease can present with a wide variety of findings, and the classic triad is not very common. With this in mind, the physician should have a low threshold for administering thiamine intravenously.
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Affiliation(s)
- Jonathan Walker
- Emergency Medicine Residency, York Hospital, York, Pennsylvania 17404, USA
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Velasco MV, Casanova I, Sanchez-Pernaute A, Pérez-Aguirre E, Torres A, Puerta J, Cabrerizo L, Rubio MA. Unusual Late-Onset Wernicke’s Encephalopathy Following Vertical Banded Gastroplasty. Obes Surg 2009; 19:937-40. [DOI: 10.1007/s11695-009-9841-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Accepted: 04/01/2009] [Indexed: 11/29/2022]
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Abstract
OBJECTIVE To review the clinical essentials of Wernicke encephalopathy (WE) after bariatric surgery. SUMMARY BACKGROUND DATA An estimated 205,000 bariatric surgical procedures were performed in the United States in 2007. Such procedures may potentially lead to severe nutritional complications. METHODS Literature searches were performed in Medline, Embase, and abstract collections. Inclusion criteria were WE after bariatric surgery, diagnosed by the presence of two or more of the following signs: mental status changes, eye movement abnormalities, cerebellar dysfunction, and dietary deficiency. RESULTS Of 104 reported cases of WE after bariatric surgery, 84 cases were included. Gastric bypass or a restrictive procedure had been performed in 80 cases (95%). Admission to hospital for WE occurred within 6 months of surgery in 79 cases (94%). Frequent vomiting was a risk factor in 76 cases (90%) and had lasted for a median of 21 days at admission. Intravenous glucose administration without thiamine was a risk factor in 15 cases (18%). Brain magnetic resonance imaging identified lesions characteristic of WE in 14 of 30 cases (47%). Incomplete recovery was observed in 41 cases (49%); memory deficits and gait difficulties were frequent sequela. The recent increase in the use of bariatric surgery in the United States was associated with an increase in reported WE cases. CONCLUSIONS The number of WE cases after bariatric surgery is substantially higher than previously reported. Surgeons, allied health providers, and patients need to be aware of the predisposing factors and symptoms to prevent and optimize the management of this condition.
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ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis 2008; 4:S73-108. [PMID: 18490202 DOI: 10.1016/j.soard.2008.03.002] [Citation(s) in RCA: 286] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Accepted: 03/12/2008] [Indexed: 12/13/2022]
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Fei GQ, Zhong C, Jin L, Wang J, Zhang Y, Zheng X, Zhang Y, Hong Z. Clinical characteristics and MR imaging features of nonalcoholic Wernicke encephalopathy. AJNR Am J Neuroradiol 2008; 29:164-9. [PMID: 18192344 DOI: 10.3174/ajnr.a0827] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Nonalcoholic Wernicke encephalopathy (WE) is prone to be underestimated in clinical practice. The purpose of this study was to improve its awareness and early accurate diagnosis. MATERIALS AND METHODS We conducted a retrospective review of the cases of 12 patients with nonalcoholic WE, consisting of clinical characteristics and MR imaging features as well as follow-up after administration of thiamine. RESULTS Patients with mild coma or lethargy (7/12) exhibited typical MR features of symmetric brain paraventricular damage. Patients without disturbances of consciousness or who only had drowsiness (3/12) exhibited a lesion of the periaqueductal area only. In addition to typical MR manifestations, symmetric cortical involvement was observed in 2 of 12 patients with deep coma. Gadolinium enhancement of the mammillary bodies was observed in 2 of 3 patients. No atrophy of the mammillary bodies and cerebellar vermis was found in any patients. Of 10 patients without deep coma and cortical damage, 2 missed the follow-up and 8, who recovered clinically, also showed accordant resolution of abnormal hyperintense signal intensity on T2-weighted and fluid-attenuated inversion recovery images within 2 weeks to 1 year after thiamine supplementation. Two patients with deep coma and cortical damage showed a poor prognosis:1 patient died 15 days after being diagnosed with WE, and the other entered a persistent vegetative state during a follow-up of 2 years. CONCLUSION Typical symmetric damage of the mammillary bodies and brain paraventricular regions may permit a specific diagnosis of nonalcoholic WE. In all patients, no atrophy of the mammillary bodies and cerebellar vermis was found. Cortical involvement in patients with nonalcoholic WE may be indicative of irreversible lesions and a poor prognosis.
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Affiliation(s)
- G-Q Fei
- Department of Neurology, Zhongshan Hospital and Shanghai Medical College, Fudan University, Shanghai, China
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Makarewicz W, Kaska L, Kobiela J, Stefaniak T, Krajewski J, Stankiewicz M, Wujtewicz MA, Lachinski AJ, Sledzinski Z. Wernicke’s Syndrome after Sleeve Gastrectomy. Obes Surg 2007; 17:704-6. [PMID: 17658035 DOI: 10.1007/s11695-007-9114-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We report a case of Wernicke's encephalopathy after sleeve gastrectomy, which had been complicated by stomach wall edema and aggravated by dietary non-compliance. Despite intense parenteral nutrition, thiamine deficiency became clinically evident. It suggests that nutritional preparations used were unable to cover the increased thiamine requirement. After intense thiamine supplementation, gradual improvement occurred during the 6 months after the diagnosis, without permanent cognitive impairment. Clinicians involved in postoperative management of bariatric surgery patients must consider Wernicke's syndrome in hyper-emetic patients, who show unclear neurological deterioration. Early diagnosis and treatment can instantly improve the patient's condition without permanent sequelae.
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Affiliation(s)
- Wojciech Makarewicz
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Poland.
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Sechi G, Serra A. Wernicke's encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol 2007; 6:442-55. [PMID: 17434099 DOI: 10.1016/s1474-4422(07)70104-7] [Citation(s) in RCA: 694] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Wernicke's encephalopathy is an acute neuropsychiatric syndrome resulting from thiamine deficiency, which is associated with significant morbidity and mortality. According to autopsy-based studies, the disorder is still greatly underdiagnosed in both adults and children. In this review, we provide an update on the factors and clinical settings that predispose to Wernicke's encephalopathy, and discuss the most recent insights into epidemiology, pathophysiology, genetics, diagnosis, and treatment. To facilitate the diagnosis, we classify the common and rare symptoms at presentation and the late-stage symptoms. We emphasise the optimum dose of parenteral thiamine required for prophylaxis and treatment of Wernicke's encephalopathy and prevention of Korsakoff's syndrome associated with alcohol misuse. A systematic approach helps to ensure that patients receive a prompt diagnosis and adequate treatment.
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Abstract
Nutritional deficiencies are already present in many morbidly obese patients before weight-loss surgery. Appropriate preoperative detection and correction is essential. The severity and pattern of deficiencies is dependent on the presence of preoperative uncorrected deficiency, the type of procedure performed varying with the degree of restriction or the length of bypassed small intestine, the modification of eating behavior, the development of complications, compliance with oral multivitamin and mineral supplementation, and compliance with follow-up. Rigorous control of fluids and electrolytes with establishment of adequate oral nutrition is important in the immediate postoperative period. Regular follow-up of the metabolic and nutritional status of the patient is essential, with life-long multivitamin and mineral supplementation.
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Affiliation(s)
- Olga N Tucker
- The Bariatric Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
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