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Hiraga A, Kojima K, Kuwabara S. Typical and atypical MRI abnormalities in Wernicke's encephalopathy: Correlation with blood vitamin B1 levels. J Neurol Sci 2024; 461:123045. [PMID: 38749282 DOI: 10.1016/j.jns.2024.123045] [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] [Received: 03/21/2024] [Accepted: 05/08/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Clinical features of Wernicke's encephalopathy (WE) confirmed strictly through the low blood vitamin B1 (VB1) levels are limited. This study aimed to analyse magnetic resonance imaging (MRI) findings, and clinical characteristics, in patients with WE who have confirmed low blood VB1 levels. METHODS Clinical and laboratory records of 12 consecutive patients with WE admitted to our hospital during the past 11 years were reviewed. The WE diagnosis was confirmed based on low blood VB1 levels and the presence of at least one of the classical triad. RESULTS Ophthalmoplegia and nystagmus were recorded in 75% and 50% of the patients, respectively. Eleven of 12 patients presented with consciousness disturbance/memory loss. All patients experienced gait disturbances. Eight of the 12 patients exhibited MRI abnormalities at typical sites (the dorsal midbrain [n = 7], medial thalamus [n = 6], mammillary bodies [n = 5], and dorsal pons [n = 5]). Of the 12 patients, six showed abnormalities at atypical sites (the splenium of the corpus callosum [n = 4], fornix [n = 3], cerebral cortex [n = 2], cerebellar vermis [n = 2], and dorsal medulla [n = 1]). Patients with positive MRI abnormalities had significantly lower blood VB1 levels than those without abnormalities (9.5 vs. 16.0 ng/mL). CONCLUSIONS In cases of confirmed WE with low blood VB1 levels, the corpus callosum, fornix, and cerebral cortex were more frequently involved than in previous studies. MRI abnormalities at both typical and atypical sites were correlated with low blood VB1 levels in WE, suggesting that lower blood VB1 levels are associated with more severe brain damage in patients with WE.
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Affiliation(s)
- Akiyuki Hiraga
- Department of Neurology, Chiba Rosai Hospital, Chiba, Japan.
| | - Kazuho Kojima
- Department of Neurology, Chiba Rosai Hospital, Chiba, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Jophlin L, Liu TY, McClain CJ. Nutritional deficiencies in alcohol use disorder/alcohol-associated liver disease. Curr Opin Gastroenterol 2024; 40:112-117. [PMID: 38193343 DOI: 10.1097/mog.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW To delineate common and uncommon dietary and nutritional deficiencies in individuals with chronic heavy alcohol use and alcohol use disorder and to highlight important advances in the nutrition field in patients ranging from those with alcohol use disorder (AUD) and no liver disease to those with decompensated alcohol-associated liver disease (ALD). RECENT FINDINGS Patients with AUD may have nutritional deficiencies, especially isolated nutrient deficiencies, such as thiamine or zinc deficiencies. This should not be surprising, as alcohol is a major source of "empty calories." It is devoid of critical macronutrients, such as protein, and micronutrients including important vitamins and minerals. Patients with AUD frequently drink much more than often appreciated (10-20 drinks a day). Patients with AUD and early ALD often begin to develop more apparent nutritional deficiencies. Healthcare providers need to be aware of the presenting features of individual nutrient deficiencies, such as thiamine deficiency, and to provide prompt treatment. In patients with more advanced liver disease, malnutrition correlates with severity of liver disease. It is important to understand the value of nutritional support throughout the spectrum of AUD. SUMMARY We review nutritional deficiencies in the spectrum of patients with AUD and ALD and highlight new information and recommendations.
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Affiliation(s)
- Loretta Jophlin
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tzu-Yu Liu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Craig J McClain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
- Robley Rex VAMC, Louisville KY, USA
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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] [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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A Clinician's View of Wernicke-Korsakoff Syndrome. J Clin Med 2022; 11:jcm11226755. [PMID: 36431232 PMCID: PMC9693280 DOI: 10.3390/jcm11226755] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/06/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022] Open
Abstract
The purpose of this article is to improve recognition and treatment of Wernicke-Korsakoff syndrome. It is well known that Korsakoff syndrome is a chronic amnesia resulting from unrecognized or undertreated Wernicke encephalopathy and is caused by thiamine (vitamin B1) deficiency. The clinical presentation of thiamine deficiency includes loss of appetite, dizziness, tachycardia, and urinary bladder retention. These symptoms can be attributed to anticholinergic autonomic dysfunction, as well as confusion or delirium, which is part of the classic triad of Wernicke encephalopathy. Severe concomitant infections including sepsis of unknown origin are common during the Wernicke phase. These infections can be prodromal signs of severe thiamine deficiency, as has been shown in select case descriptions which present infections and lactic acidosis. The clinical symptoms of Wernicke delirium commonly arise within a few days before or during hospitalization and may occur as part of a refeeding syndrome. Wernicke encephalopathy is mostly related to alcohol addiction, but can also occur in other conditions, such as bariatric surgery, hyperemesis gravidarum, and anorexia nervosa. Alcohol related Wernicke encephalopathy may be identified by the presence of a delirium in malnourished alcoholic patients who have trouble walking. The onset of non-alcohol-related Wernicke encephalopathy is often characterized by vomiting, weight loss, and symptoms such as visual complaints due to optic neuropathy in thiamine deficiency. Regarding thiamine therapy, patients with hypomagnesemia may fail to respond to thiamine. This may especially be the case in the context of alcohol withdrawal or in adverse side effects of proton pump inhibitors combined with diuretics. Clinician awareness of the clinical significance of Wernicke delirium, urinary bladder retention, comorbid infections, refeeding syndrome, and hypomagnesemia may contribute to the recognition and treatment of the Wernicke-Korsakoff syndrome.
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Moya M, Escudero B, Gómez-Blázquez E, Rebolledo-Poves AB, López-Gallardo M, Guerrero C, Marco EM, Orio L. Upregulation of TLR4/MyD88 pathway in alcohol-induced Wernicke’s encephalopathy: Findings in preclinical models and in a postmortem human case. Front Pharmacol 2022; 13:866574. [PMID: 36225571 PMCID: PMC9549119 DOI: 10.3389/fphar.2022.866574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Wernicke’s encephalopathy (WE) is a neurologic disease caused by vitamin B1 or thiamine deficiency (TD), being the alcohol use disorder its main risk factor. WE patients present limiting motor, cognitive, and emotional alterations related to a selective cerebral vulnerability. Neuroinflammation has been proposed to be one of the phenomena that contribute to brain damage. Our previous studies provide evidence for the involvement of the innate immune receptor Toll-like (TLR)4 in the inflammatory response induced in the frontal cortex and cerebellum in TD animal models (animals fed with TD diet [TDD] and receiving pyrithiamine). Nevertheless, the effects of the combination of chronic alcohol consumption and TD on TLR4 and their specific contribution to the pathogenesis of WE are currently unknown. In addition, no studies on TLR4 have been conducted on WE patients since brains from these patients are difficult to achieve. Here, we used rat models of chronic alcohol (CA; 9 months of forced consumption of 20% (w/v) alcohol), TD hit (TDD + daily 0.25 mg/kg i.p. pyrithiamine during 12 days), or combined treatment (CA + TDD) to check the activation of the proinflammatory TLR4/MyD88 pathway and related markers in the frontal cortex and the cerebellum. In addition, we characterized for the first time the TLR4 and its coreceptor MyD88 signature, along with other markers of this proinflammatory signaling such as phospo-NFκB p65 and IκBα, in the postmortem human frontal cortex and cerebellum (gray and white matter) of an alcohol-induced WE patient, comparing it with negative (no disease) and positive (aged brain with Alzheimer’s disease) control subjects for neuroinflammation. We found an increase in the cortical TLR4 and its adaptor molecule MyD88, together with an upregulation of the proinflammatory signaling molecules p-NF-ĸB and IĸBα in the CA + TDD animal model. In the patient diagnosed with alcohol-induced WE, we observed cortical and cerebellar upregulation of the TLR4/MyD88 pathway. Hence, our findings provide evidence, both in the animal model and the human postmortem brain, of the upregulation of the TLR4/MyD88 proinflammatory pathway in alcohol consumption–related WE.
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Affiliation(s)
- Marta Moya
- Department of Psychobiology and Methods in Behavioral Science, Faculty of Psychology, Complutense University of Madrid, Madrid, Spain
| | - Berta Escudero
- Department of Psychobiology and Methods in Behavioral Science, Faculty of Psychology, Complutense University of Madrid, Madrid, Spain
| | | | | | | | - Carmen Guerrero
- Biobanco of Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | - Eva M. Marco
- Department of Genetics, Physiology and Microbiology, Faculty of Biology, Complutense University of Madrid, Madrid, Spain
| | - Laura Orio
- Department of Psychobiology and Methods in Behavioral Science, Faculty of Psychology, Complutense University of Madrid, Madrid, Spain
- Research Network in Primary Care in Addictions (Red de Investigación en Atención Primaria en Adicciones), Riapad, Spain
- *Correspondence: Laura Orio,
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Mateos-Díaz AM, Marcos M, Chamorro AJ. Wernicke-Korsakoff syndrome and other diseases associated with thyamine deficiency. Med Clin (Barc) 2022; 158:431-436. [PMID: 35039171 DOI: 10.1016/j.medcli.2021.11.015] [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] [Received: 10/05/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 11/17/2022]
Abstract
Wernicke-Korsakoff syndrome is the best known consequence of thiamine deficiency, frequently associated with patients with chronic and excessive alcohol consumption, but it can be produced by any cause that produces thiamine deficiency. The disease is underdiagnosed so it is essential to have a high clinical suspicion, mainly in patients who do not have alcohol consumption as a risk factor. For this, the diagnosis continues to be eminently clinical, with the difficulty of high clinical variability. Complementary tests are used to support the diagnosis and rule out other causes that can produce similar symptoms, with magnetic resonance imaging being the most cost-effective imaging test. Treatment is based on the administration of thiamine, which should be started early, and parenterally at the appropriate doses, in all patients with compatible symptoms, without waiting to confirm the diagnosis.
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Affiliation(s)
- Ana-María Mateos-Díaz
- Servicio de Medicina Interna, Hospital Virgen del Puerto, Plasencia, Cáceres, España
| | - Miguel Marcos
- Servicio de Medicina Interna, Hospital Universitario de Salamanca-IBSAL, Universidad de Salamanca, Salamanca, España
| | - Antonio-Javier Chamorro
- Servicio de Medicina Interna, Hospital Universitario de Salamanca-IBSAL, Universidad de Salamanca, Salamanca, España.
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