1
|
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.
Collapse
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
| |
Collapse
|
2
|
Bathobakae L, Ozgur SS, Lombardo D, Mekheal N, Michael P. “Bariatric Beriberi”: A Rare Case of Wernicke Encephalopathy Two Weeks After Laparoscopic Sleeve Gastrectomy. Cureus 2023; 15:e37056. [PMID: 37153253 PMCID: PMC10155465 DOI: 10.7759/cureus.37056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/05/2023] Open
Abstract
Wernicke encephalopathy (WE) is an acute neurological syndrome caused by thiamine (vitamin B1) deficiency. This disorder manifests as a triad of gait ataxia, confusion, and vision abnormalities. The absence of a full triad does not rule out WE. Because of its vague presentation, WE is commonly missed in patients with no history of alcohol abuse. Other risk factors for WE include bariatric surgery, hemodialysis, hyperemesis gravidarum, and malabsorption syndromes. WE is a clinical diagnosis that can be confirmed with an MRI of the brain as hyperintensities in the mammillary bodies, periaqueductal area, thalami, and hippocampus. If suspected in a patient, WE must be immediately treated with intravenous thiamine to prevent evolution into Korsakoff syndrome, coma, or death. Currently, there is no consensus in the medical community as to how much thiamine must be given and for how long. Therefore, there is a need for more research in the diagnosis and management of WE after bariatric surgery. Herein, we report a rare case of a 23-year-old female with a history of morbid obesity who developed WE two weeks after a laparoscopic sleeve gastrectomy.
Collapse
|
3
|
Cetera GE, D'Ambrosi F, Di Martino DD, Landi L, Criscuolo S, Caschera L, Cesano N, Ossola MW. An uncommon presentation of Wernicke-Korsakoff's syndrome in pregnancy: Case report. Radiol Case Rep 2022; 18:921-925. [PMID: 36593922 PMCID: PMC9803690 DOI: 10.1016/j.radcr.2022.11.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 12/25/2022] Open
Abstract
Wernicke's encephalopathy is an acute neuropsychiatric syndrome resulting from severe thiamine (vitamin B1) deficiency. Symptoms occur with an acute onset and may vary according to the brain area involved. Altered consciousness is the most common clinical feature, together with ocular abnormalities and ataxia. We report the case of a pregnant women affected by pre-gestational hyperthyroidism that caused an uncommon presentation of Wernicke's encephalopathy. Symptoms differed from the classic triad and diagnosis was made possible by a thorough analysis of anamnestic factors and brain MRI. Alongside thiamine supplementation, a multidisciplinary approach which included physiokinesis and a phoniatric support was fundamental for the patient's recovery.
Collapse
Affiliation(s)
- Giulia Emily Cetera
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, Milan 20122 , Italy
| | - Francesco D'Ambrosi
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, Milan 20122 , Italy,Corresponding author.
| | - Daniela Denis Di Martino
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, Milan 20122 , Italy
| | - Laura Landi
- Department of Pediatric anesthesia and resuscitation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Criscuolo
- Postgraduational School of Radiodiagnostic, Università degli Studi di Milano, Milan, Italy
| | - Luca Caschera
- Department of Neuroradiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Cesano
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, Milan 20122 , Italy
| | - Manuela Wally Ossola
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, Milan 20122 , Italy
| |
Collapse
|
4
|
Ehsanian R, Anderson S, Schneider B, Kennedy D, Mansourian V. Prevalence of Low Plasma Vitamin B1 in the Stroke Population Admitted to Acute Inpatient Rehabilitation. Nutrients 2020; 12:nu12041034. [PMID: 32290066 PMCID: PMC7230706 DOI: 10.3390/nu12041034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/01/2020] [Accepted: 04/07/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To determine the prevalence of vitamin B1 (VitB1) deficiency in the stroke population admitted to acute inpatient rehabilitation. DESIGN Retrospective cohort study. SETTING Acute inpatient rehabilitation facility at an academic medical center. PARTICIPANTS 119 consecutive stroke patients admitted to stroke service from 1 January 2018 to 31 December 2018. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Plasma VitB1 level. RESULTS There were 17 patients (14%; 95% CI 9-22%) with low VitB1 with a range of 2-3 nmol/L, an additional 58 (49%; CI 40-58%) patients had normal low VitB1 with a range of 4-9 nmol/L, twenty-five patients (21%; CI 15-29%) had normal high VitB1 with a range of 10-15 nmol/L, and nineteen patients (16%; CI 10-24%) had high VitB1 with a range of 16-43 nmol/L. CONCLUSIONS In this cohort of patients admitted to the stroke service at an acute rehabilitation facility, there is evidence of thiamine deficiency. Moreover, the data suggest that there is inadequate acute intake of VitB1. Given the role of thiamine deficiency in neurologic function, further study of the role of thiamine optimization in the acute stroke rehabilitation population is warranted.
Collapse
Affiliation(s)
- Reza Ehsanian
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, TN 37212, USA; (R.E.); (S.A.); (B.S.); (D.K.)
- Department of Neurosurgery, Stanford University, Palo Alto, CA 34304, USA
- Division of Physical Medicine and Rehabilitation, Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Sean Anderson
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, TN 37212, USA; (R.E.); (S.A.); (B.S.); (D.K.)
| | - Byron Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, TN 37212, USA; (R.E.); (S.A.); (B.S.); (D.K.)
| | - David Kennedy
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, TN 37212, USA; (R.E.); (S.A.); (B.S.); (D.K.)
| | - Vartgez Mansourian
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, TN 37212, USA; (R.E.); (S.A.); (B.S.); (D.K.)
- Correspondence: ; Tel.: +615-936-7708
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Thota D, Rudinsky S. Wernicke’s Encephalopathy in a Patient Without Chronic Alcohol Abuse. Clin Pract Cases Emerg Med 2017; 1:95-97. [PMID: 29849420 PMCID: PMC5965427 DOI: 10.5811/cpcem.2016.12.32769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 12/08/2016] [Accepted: 12/12/2016] [Indexed: 11/25/2022] Open
Abstract
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.
Collapse
|
7
|
Psychiatric Emergencies for Clinicians: Emergency Department Management of Wernicke-Korsakoff Syndrome. J Emerg Med 2016; 51:401-404. [PMID: 27553920 DOI: 10.1016/j.jemermed.2016.05.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 04/15/2016] [Accepted: 05/17/2016] [Indexed: 12/27/2022]
|
8
|
Erick M. Hyperemesis gravidarum: A case of starvation and altered sensorium gestosis (ASG). Med Hypotheses 2014; 82:572-80. [DOI: 10.1016/j.mehy.2014.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Revised: 11/01/2013] [Accepted: 02/13/2014] [Indexed: 12/24/2022]
|
9
|
Levinson R, Silverman JB, Catella JG, Rybak I, Jolin H, Isom K. Pharmacotherapy prevention and management of nutritional deficiencies post Roux-en-Y gastric bypass. Obes Surg 2014; 23:992-1000. [PMID: 23558789 DOI: 10.1007/s11695-013-0922-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Roux-en-Y gastric bypass is the most commonly performed bariatric procedure. It is associated with nutritional deficiencies due to gastric reduction, intestinal bypass, reduced caloric intake, avoidance of nutrient-rich foods, noncompliance with supplementation and poor food tolerability. Although there are multiple publications on this topic, there is a lack of consistent guidance for the healthcare practitioner caring for the bariatric patient. This article will encompass literature reviewing the pharmacotherapy approach to prevention and management of nutritional deficiencies since the American Society of Metabolic and Bariatric Surgery guidelines were published in 2008.
Collapse
|
10
|
Stroh C, Meyer F, Manger T. Beriberi, a severe complication after metabolic surgery - review of the literature. Obes Facts 2014; 7:246-52. [PMID: 25095897 PMCID: PMC5644786 DOI: 10.1159/000366012] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/09/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The epidemic growth of morbid obesity has led to an increase in the number of bariatric interventions. During the distribution process of bariatric surgical interventions, the risk for severe nutritious complications such as bariatric beriberi can rise. METHODS By means of systematic literature review, epidemiological data, clinical characteristics and diagnostic as well as therapeutic recommendations for bariatric beriberi were elicited. Databases and registries such as PubMed, Cochrane and Ovid were searched for a defined time period with the key words 'lack of thiamine' / 'Wernicke-Korsakoff syndrome' / 'encephalopathy' after bariatric surgical interventions. RESULTS Up to December 2013, overall 255 patients had been found as published cases, indicating that the risk for the postoperative occurrence of thiamine deficiency and Wernicke-Korsakoff syndrome is increased in women. In addition, the risk correlates with patient's age. The majority of patients developed symptoms of a dry beriberi with peripheral neuritis, ataxia and paraplegia, indicating an advanced stage of disease approximately 4-12 weeks postoperatively. Laboratory analysis in case of a suspicious clinical finding is the appropriate diagnostics. As treatment, prompt initiation of parenteral thiamine substitution under clinical monitoring is required. CONCLUSION Bariatric beriberi can occur within the first 1-3 postoperative months. To minimize the risk of severe consequences, immediate substitution of thiamine in clinical suspicion or prolonged parenteral nutrition is necessary. A delayed diagnosis or missing the correct diagnosis can lead to irreversible damages of the CNS with coma and fatal outcome. Knowledge on the subject, including development of thiamine deficiency, symptomatology and emergency treatment, are considered essential for bariatric surgeons but also for further medical disciplines involved in treatment.
Collapse
Affiliation(s)
- Christine Stroh
- SRH Municipal Hospital, Department of General, Abdominal and Pediatric Surgery, Gera, Germany, Magdeburg, Germany
- *Christine Stroh MD, Department of General, Abdominal and Pediatric Surgery, Municipal Hospital Gera, Straße des Friedens 122, 07548 Gera (Germany),
| | - Frank Meyer
- University Hospital, Department of General, Abdominal and Vascular Surgery, Magdeburg, Germany
| | - Thomas Manger
- SRH Municipal Hospital, Department of General, Abdominal and Pediatric Surgery, Gera, Germany, Magdeburg, Germany
| |
Collapse
|
11
|
Chisolm-Straker M, Cherkas D. Altered and unstable: wet beriberi, a clinical review. J Emerg Med 2013; 45:341-4. [PMID: 23849362 DOI: 10.1016/j.jemermed.2013.04.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 09/18/2012] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Undifferentiated altered mental status and hemodynamic instability are common presenting complaints in the Emergency Department (ED). Emergency practitioners do not have the luxury of time to perform sequential examination, history, testing, diagnosis, and treatment. Rather, we do all of these things at once to save lives and decrease morbidity. An important diagnosis to consider and upon which we can easily intervene is that of thiamine deficiency. OBJECTIVES We present a case of an altered and unstable woman who presented to our busy ED and had rapid improvement after the administration of vitamin B1. We discuss the presentation, pathophysiology, consequences of missed diagnosis, and management of this disease process. CASE REPORT A middle-aged woman presented to our ED with unstable vital signs and an alteration in her mental status. She was unable to provide a history. Empiric treatment with thiamine resulted in the resolution of her hemodynamic instability and improvement in her mental status. CONCLUSION Our patient benefited from the swift administration of thiamine and illustrates the importance of thiamine administration in the altered or hemodynamically unstable emergency patient with an elevated lactate.
Collapse
Affiliation(s)
- Makini Chisolm-Straker
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA
| | | |
Collapse
|