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Ma YY, He XC, Gao Y, Ma TT, Cheng G, Yue CW. Treatment of nasopharyngeal carcinoma and prevention of non-alcoholic Wernicke's disease: A case report and review of literature. World J Clin Cases 2024; 12:5628-5635. [PMID: 39188614 PMCID: PMC11269984 DOI: 10.12998/wjcc.v12.i24.5628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/20/2024] [Accepted: 07/02/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Wernicke encephalopathy is a neurological disorder caused by thiamine deficiency, commonly seen in alcoholic populations but also involving other circumstances that may lead to thiamine deficiency. The recognition of Wernicke encephalopathy often depends on clinicians' keen ability to detect its typical triad of features; however, most cases do not present with the full constellation of signs, which complicates the timely identification of Wernicke encephalopathy. CASE SUMMARY This case report describes a patient with nasopharyngeal carcinoma who developed abnormal ocular function and ataxia following concurrent chemoradiotherapy, without a history of alcohol abuse. With the aid of radiological examinations, he received a timely diagnosis and treatment; however, his symptoms did not fully resolve during follow-up. CONCLUSION For patients with malignant tumors exhibiting neurological symptoms, clinicians should consider the possibility of Wernicke encephalopathy and provide prophylactic thiamine therapy.
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Affiliation(s)
- Yu-Yang Ma
- Yan’an Key Laboratory of Microbial Drug Innovation and Transformation, School of Basic Medicine, Yan’an University, Yan’an 716000, Shaanxi Province, China
- Department of Cardiology, Second Division, Shaanxi Provincial People’s Hospital, Xi’an 710000, Shaanxi Province, China
| | - Xiao-Chan He
- Xi’an Honghui Hospital, Xi’an Jiaotong University, Xi’an 710000, Shaanxi Province, China
| | - Yu Gao
- Yan’an Key Laboratory of Microbial Drug Innovation and Transformation, School of Basic Medicine, Yan’an University, Yan’an 716000, Shaanxi Province, China
| | - Tian-Tian Ma
- Department of Cardiology, Second Division, Shaanxi Provincial People’s Hospital, Xi’an 710000, Shaanxi Province, China
| | - Gong Cheng
- Department of Cardiology, Second Division, Shaanxi Provincial People’s Hospital, Xi’an 710000, Shaanxi Province, China
| | - Chang-Wu Yue
- Yan’an Key Laboratory of Microbial Drug Innovation and Transformation, School of Basic Medicine, Yan’an University, Yan’an 716000, Shaanxi Province, China
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Kroopnick AJ, Miller EC. Approach to Altered Mental Status in Pregnancy and Postpartum. Semin Neurol 2024. [PMID: 39151911 DOI: 10.1055/s-0044-1788977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2024]
Abstract
The evaluation and diagnosis of altered mental status in the pregnant or postpartum patient largely parallels the approach used for any other patient; however, there are several critical differences including that some neuroobstetric diagnoses require emergent delivery of the fetus. Being familiar with the physiological changes and medical complications of pregnancy and delivery is therefore essential. This review first addresses pregnancy-specific disorders that may result in altered mental status, such as the hypertensive disorders of pregnancy and pregnancy-related metabolic and endocrinopathies. The focus then shifts to the complex physiologic changes in pregnancy and how these changes contribute to the distinct epidemiology of pregnancy-related cerebrovascular complications like intracranial hemorrhage, ischemic stroke, and reversible cerebral vasoconstriction syndrome. Medical disorders that are not unique to pregnancy, such as infections and autoimmune conditions, may present de novo or worsen during pregnancy and the peripartum period and require a thoughtful approach to diagnosis and management. Finally, the unique nervous system complications of obstetric anesthesia are explored. In each section, there is a focus not only on diagnosis and syndrome recognition but also on the emergent treatment needed to reverse these complications, bearing in mind the unique physiology of the pregnant patient.
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Affiliation(s)
- Adam J Kroopnick
- Department of Neurology, Columbia University, New York, New York
| | - Eliza C Miller
- Department of Neurology, Columbia University, New York, New York
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Rhee JY, Nakhate V, Soares C, Tentor Z, Dietrich J. Altered Mental Status in Cancer. Semin Neurol 2024. [PMID: 39102863 DOI: 10.1055/s-0044-1788806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
Patients with cancer experience high rates of alterations in mental status. The mechanisms for altered mental status (AMS) in this population are manifold. The cancer itself may cause AMS through direct invasion of the central nervous system or as metastatic leptomeningeal spread. However, cancer patients are also vulnerable to tumor-associated complications such as seizures, cerebral edema, strokes, or cancer treatment-related complications such as infections, direct neural injury from radiation or chemotherapy, edema, or dysregulated autoimmune response from immunotherapies. Both during treatment and as sequelae, patients may suffer neurocognitive complications from chemotherapy and radiation, medications or opportunistic infections, as well as toxic-metabolic, nutritional, and endocrine complications. In this review, we describe a clinical approach to the cancer patient presenting with AMS and discuss the differential drivers of AMS in this patient population. While common etiologies of AMS in noncancer patients (toxic-metabolic or infectious encephalopathy, delirium) are also applicable to cancer patients, we additionally provide a cancer-specific differential diagnosis that warrants special consideration in the cancer patient with AMS.
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Affiliation(s)
- John Y Rhee
- Division of Neuro-Oncology, Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Vihang Nakhate
- Division of Neuro-Oncology, Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Christy Soares
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Zachary Tentor
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Jorg Dietrich
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
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Arendt CT, Uckermark C, Kovacheva L, Lieschke F, Golbach R, Edwin Thanarajah S, Hattingen E, Weidauer S. Wernicke Encephalopathy: Typical and Atypical Findings in Alcoholics and Non-Alcoholics and Correlation with Clinical Symptoms. Clin Neuroradiol 2024:10.1007/s00062-024-01434-y. [PMID: 39014226 DOI: 10.1007/s00062-024-01434-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/14/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE Clinical diagnosis of Wernicke encephalopathy (WE) can be challenging due to incomplete presentation of the classical triad. The aim was to provide an update on the relevance of standard MRI and to put typical and atypical imaging findings into context with clinical features. METHODS In this two-center retrospective observational study, the local radiology information system was searched for consecutive patients with clinical or imaging suspicion of WE. Two independent raters evaluated T2-weighted imaging (WI), fluid-attenuation inversion recovery (FLAIR), diffusion WI (DWI), T2*WI and/or susceptibility WI (SWI), and contrast-enhanced (CE)-T1WI, and noted the involvement of typical (i.e., mammillary bodies (MB), periaqueductal grey (PAG), thalamus, hypothalamus, tectal plate) and atypical (all others) lesion sites. Unusual signal patterns like hemorrhages were also documented. Reported clinical features together with the diagnostic criteria of the latest guidelines of the European Federation of Neurological Societies (EFNS) were used to test for relationships with MRI biomarkers. RESULTS 47 patients with clinically confirmed WE were included (Jan '99-Apr '23; mean age, 53 yrs; 70% males). Interrater reliability for imaging findings was substantial (κ = 0.71), with lowest agreements for T2WI (κ = 0.85) compared to all other sequences and for PAG (κ = 0.65) compared to all other typical regions. In consensus, 77% (n = 36/47) of WE cases were rated MRI positive, with FLAIR (n = 36/47, 77%) showing the strongest relation (χ2 = 47.0; P < 0.001) compared to all other sequences. Microbleeds in the MB were detected in four out of ten patients who received SWI, not visible on corresponding T2*WI. Atypical findings were observed in 23% (n = 11/47) of cases, always alongside typical findings, in both alcoholics (n = 9/44, 21%) and non-alcoholics (n = 2/3, 67%). Isolated involvement of structures, explicitly PAG (n = 4/36; 11%) or MB (n = 1/36; 3%), was present but observed less frequently than combined lesions (n = 31/36; 86%). A cut-off width of 2.5 mm for the PAG on 2D axial FLAIR was established between cases and age- and sex-matched controls. An independent association was demonstrated only between short-term memory loss and changes in the MB (OR = 2.2 [95% CI: 1.1-4.5]; P = 0.024). In retrospect, EFNS criteria were positive (≥ 2 out of 4) in every case, but its count (range, 2-4) showed no significant (P = 0.427) relationship with signal changes on standard MRI. CONCLUSION The proposed sequence protocol (FLAIR, DWI, SWI and T1WI + CE) yielded good detection rates for neuroradiological findings in WE, with SWI showing microbleeds in the MB with superior detectability. However, false negative results in about a quarter of cases underline the importance of neurological alertness for the diagnosis. Awareness of atypical MRI findings should be raised, not only in non-alcoholics. There is limited correlation between clinical signs and standard MRI biomarkers.
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Affiliation(s)
- C T Arendt
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.
| | - C Uckermark
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - L Kovacheva
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - F Lieschke
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - R Golbach
- Institute of Biostatistics and Mathematical Modeling, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - S Edwin Thanarajah
- Department for Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - E Hattingen
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - S Weidauer
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
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Turrini I, Guidetti C, Contaldo I, Pulitanò S, Rigante D, Veredice C. Wernicke Encephalopathy Caused by Avoidance-Restrictive Food Intake Disorder in a Child: A Case-Based Review. Diseases 2024; 12:112. [PMID: 38920544 PMCID: PMC11202895 DOI: 10.3390/diseases12060112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/10/2024] [Accepted: 05/22/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Wernicke encephalopathy (WE) is an acute and potentially fatal neuropsychiatric disorder resulting from thiamine deficiency: its etiology and clinical presentation can be heterogeneous and arduously recognized, especially in children and adolescents. CASE PRESENTATION An 8-year-old girl arrived to the emergency room with ataxic gait, nystagmus, and mental confusion after a 10-day history of repeated severe vomiting; her recent clinical history was characterized by restricted nutrition due to a choking phobia, which caused substantial weight loss. Brain magnetic resonance imaging revealed a bilaterally increased T2 signal in the medial areas of the thalami and cerebral periaqueductal region. Diagnosis of WE based on clinical and neuroradiological findings was established and confirmed after labwork showing low serum thiamine. Following psychiatric evaluation, the patient was also diagnosed with avoidance-restrictive food intake disorder (ARFID), which required starting cognitive behavioral therapy and introducing aripiprazole. The patient displayed improvement of the radiological findings after one month and complete resolution of her neurological symptoms and signs. CONCLUSIONS Eating disorders like ARFID might forerun acute signs of WE; this possibility should be considered even in pediatric patients, especially when atypical neurological pictures or feeding issues come out.
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Affiliation(s)
- Ida Turrini
- Pediatric Neurology Unit, Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (I.T.); (C.V.)
| | - Clotilde Guidetti
- Pediatric Neurology Unit, Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (I.T.); (C.V.)
| | - Ilaria Contaldo
- Pediatric Neurology Unit, Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (I.T.); (C.V.)
| | - Silvia Pulitanò
- Pediatric Intensive Care Unit, Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Università Cattolica Sacro Cuore, 00168 Rome, Italy
| | - Donato Rigante
- Università Cattolica Sacro Cuore, 00168 Rome, Italy
- Department of Life Sciences and Public Health, Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara Veredice
- Pediatric Neurology Unit, Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (I.T.); (C.V.)
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Zahr NM. Alcohol Use Disorder and Dementia: A Review. Alcohol Res 2024; 44:03. [PMID: 38812709 PMCID: PMC11135165 DOI: 10.35946/arcr.v44.1.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
PURPOSE By 2040, 21.6% of Americans will be over age 65, and the population of those older than age 85 is estimated to reach 14.4 million. Although not causative, older age is a risk factor for dementia: every 5 years beyond age 65, the risk doubles; approximately one-third of those older than age 85 are diagnosed with dementia. As current alcohol consumption among older adults is significantly higher compared to previous generations, a pressing question is whether drinking alcohol increases the risk for Alzheimer's disease or other forms of dementia. SEARCH METHODS Databases explored included PubMed, Web of Science, and ScienceDirect. To accomplish this narrative review on the effects of alcohol consumption on dementia risk, the literature covered included clinical diagnoses, epidemiology, neuropsychology, postmortem pathology, neuroimaging and other biomarkers, and translational studies. Searches conducted between January 12 and August 1, 2023, included the following terms and combinations: "aging," "alcoholism," "alcohol use disorder (AUD)," "brain," "CNS," "dementia," "Wernicke," "Korsakoff," "Alzheimer," "vascular," "frontotemporal," "Lewy body," "clinical," "diagnosis," "epidemiology," "pathology," "autopsy," "postmortem," "histology," "cognitive," "motor," "neuropsychological," "magnetic resonance," "imaging," "PET," "ligand," "degeneration," "atrophy," "translational," "rodent," "rat," "mouse," "model," "amyloid," "neurofibrillary tangles," "α-synuclein," or "presenilin." When relevant, "species" (i.e., "humans" or "other animals") was selected as an additional filter. Review articles were avoided when possible. SEARCH RESULTS The two terms "alcoholism" and "aging" retrieved about 1,350 papers; adding phrases-for example, "postmortem" or "magnetic resonance"-limited the number to fewer than 100 papers. Using the traditional term, "alcoholism" with "dementia" resulted in 876 citations, but using the currently accepted term "alcohol use disorder (AUD)" with "dementia" produced only 87 papers. Similarly, whereas the terms "Alzheimer's" and "alcoholism" yielded 318 results, "Alzheimer's" and "alcohol use disorder (AUD)" returned only 40 citations. As pertinent postmortem pathology papers were published in the 1950s and recent animal models of Alzheimer's disease were created in the early 2000s, articles referenced span the years 1957 to 2024. In total, more than 5,000 articles were considered; about 400 are herein referenced. DISCUSSION AND CONCLUSIONS Chronic alcohol misuse accelerates brain aging and contributes to cognitive impairments, including those in the mnemonic domain. The consensus among studies from multiple disciplines, however, is that alcohol misuse can increase the risk for dementia, but not necessarily Alzheimer's disease. Key issues to consider include the reversibility of brain damage following abstinence from chronic alcohol misuse compared to the degenerative and progressive course of Alzheimer's disease, and the characteristic presence of protein inclusions in the brains of people with Alzheimer's disease, which are absent in the brains of those with AUD.
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Affiliation(s)
- Natalie M Zahr
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California. Center for Health Sciences, SRI International, Menlo Park, California
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7
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Jung DM, Narayanan M, Deshpande N, Lu EP, Cuneo A. No lack of movement. J Hosp Med 2024. [PMID: 38783633 DOI: 10.1002/jhm.13412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 03/18/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Danielle Minji Jung
- Internal Medicine Residency Program, University of Southern California School of Medicine, Los Angeles, California, USA
| | - Maya Narayanan
- Department of Medicine, Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Neha Deshpande
- Department of Medicine, Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Elise P Lu
- Department of Paediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Ami Cuneo
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington, USA
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Chaudhary AJ, Joyce KM, Haq K, Qureshi MH, Donthireddy V. Non-alcoholic Wernicke's Encephalopathy Masquerading As CNS Relapse of Acute Myeloid Leukemia. Cureus 2024; 16:e61184. [PMID: 38933646 PMCID: PMC11207165 DOI: 10.7759/cureus.61184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 06/28/2024] Open
Abstract
While Wernicke's encephalopathy (WE) is mostly caused by thiamine deficiency secondary to chronic alcohol use, other conditions that may affect one's nutritional status, such as bariatric surgery, hyperemesis gravidarum, chronic gastrointestinal disease, HIV/AIDS, and certain malignancies, may also lead to this outcome. We are discussing one such case, WE, in a young man with acute myeloid leukemia (AML) who underwent chemotherapy. The patient presented with blurred vision, paresthesia, weakness, and vomiting. Although he denied alcohol abuse, his symptoms, physical exam findings, and MRI results were consistent with WE. Treatment with thiamine resulted in a significant improvement in his visual disturbances and mental status. The authors highlight the importance of recognizing WE in non-alcoholic patients, particularly those undergoing prolonged hospitalization and chemotherapy, as nutritional deficiencies can develop. They recommend thiamine supplementation for patients receiving chemotherapy and those with poor oral intake. The case underscores the need for high clinical suspicion and early intervention in atypical cases of WE.
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Affiliation(s)
| | - Katherine M Joyce
- Emergency Medicine/Internal Medicine/Critical Care, Henry Ford Health System, Detroit, USA
| | - Kamran Haq
- Internal Medicine, Henry Ford Health System, Detroit, USA
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Rasiah R, Gregoriano C, Mueller B, Kutz A, Schuetz P. Hospital Outcomes in Medical Patients With Alcohol-Related and Non-Alcohol-Related Wernicke Encephalopathy. Mayo Clin Proc 2024; 99:740-753. [PMID: 38069922 DOI: 10.1016/j.mayocp.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 05/05/2024]
Abstract
OBJECTIVE To conduct a nationwide retrospective cohort study to assess trends and hospitalization-associated outcomes in patients with Wernicke encephalopathy. PATIENTS AND METHODS In this nationwide retrospective cohort study, we used in-hospital claims data of patients hospitalized with Wernicke encephalopathy in Switzerland from January 1, 2012, to December 31, 2020. We estimated incidence rates per 100,000 person-years among the overall Swiss population stratified by alcohol and non-alcohol-induced Wernicke encephalopathy. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included progression to Korsakoff syndrome and 1-year hospital readmission. We estimated odds ratios (ORs) for binary outcomes. RESULTS It was found that 4098 of 4393 hospitalizations (93.3%) for Wernicke encephalopathy during the 8-year study were alcohol-related. Incidence rates for hospitalizations were 14-fold higher in alcohol-related compared with non-alcohol-related Wernicke encephalopathy (5.43 vs 0.39 per 100,000 person-years). The risk for in-hospital mortality was significantly lower in patients with alcohol-related vs non-alcohol-related Wernicke encephalopathy (3.2% vs 8.5%; adjusted OR, 0.38; 95% CI, 0.23 to 0.62). Patients with alcohol-related Wernicke encephalopathy had higher risk for development of Korsakoff syndrome (16.9% vs 1.7%; adjusted OR, 10.64; 95% CI, 4.37 to 25.92) and 1-year hospital readmission (31.6% vs 18.7%; adjusted OR, 1.4; 95% CI, 1.04 to 1.88). CONCLUSION In this Swiss nationwide cohort study, Wernicke encephalopathy was a rare but serious cause for hospitalization and mainly alcohol-related. Patients with alcohol-related Wernicke encephalopathy had lower risks of in-hospital mortality but were more likely to develop Korsakoff syndrome and be readmitted to the hospital.
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Affiliation(s)
- Roshaani Rasiah
- Medical University Department, Division of General Internal and Emergency Medicine, Cantonal Hospital Aarau, Aarau, Switzerland.
| | - Claudia Gregoriano
- Medical University Department, Division of General Internal and Emergency Medicine, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Cantonal Hospital Aarau, Aarau, Switzerland; Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexander Kutz
- Medical University Department, Division of General Internal and Emergency Medicine, Cantonal Hospital Aarau, Aarau, Switzerland; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Cantonal Hospital Aarau, Aarau, Switzerland; Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
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Oudman E, Wijnia JW, Severs D, Oey MJ, van Dam M, van Dorp M, Postma A. Wernicke's Encephalopathy in Acute and Chronic Kidney Disease: A Systematic Review. J Ren Nutr 2024; 34:105-114. [PMID: 37838073 DOI: 10.1053/j.jrn.2023.10.003] [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: 05/10/2023] [Revised: 08/02/2023] [Accepted: 10/08/2023] [Indexed: 10/16/2023] Open
Abstract
Thiamine (vitamin B1) deficiency is relatively common in patients with kidney disease. Wernicke's encephalopathy (WE) is caused by vitamin B1 deficiency. Our aim was to systematically review the signs and symptoms of WE in patients with kidney disease. We conducted a systematic literature review on WE in kidney disease and recorded clinical and radiographic characteristics, treatment and outcome. In total 323 manuscripts were reviewed, which yielded 46 cases diagnosed with acute and chronic kidney disease and WE published in 37 reports. Prodromal characteristics of WE were loss of appetite, vomiting, weight loss, abdominal pain, and diarrhea. Parenteral thiamine 500 mg 3 times per day often led to full recovery, while Korsakoff's syndrome was found in those receiving low doses. To prevent WE in kidney failure, we suggest administering high doses of parenteral thiamine in patients with kidney disease who present with severe malnutrition and (prodromal) signs of thiamine deficiency.
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Affiliation(s)
- Erik Oudman
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands.
| | - Jan W Wijnia
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands
| | - David Severs
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Misha J Oey
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands
| | - Mirjam van Dam
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands
| | - Maaike van Dorp
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands
| | - Albert Postma
- Experimental Psychology, Helmholtz Institute, Utrecht University, The Netherlands; Slingedael Center of Expertise for Korsakoff Syndrome, Lelie Care Group, Rotterdam, The Netherlands
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Koca O, Turna ZH. Letter to the Editor: Total parenteral nutrition-induced Wernicke's encephalopathy after oncologic gastrointestinal surgery. Open Med (Wars) 2024; 19:20240920. [PMID: 38463520 PMCID: PMC10921446 DOI: 10.1515/med-2024-0920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 03/12/2024] Open
Affiliation(s)
- Oguzhan Koca
- Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53 Fatih, 34098Istanbul, Turkey
| | - Zeynep Hande Turna
- Division of Medical Oncology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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12
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Vasantha Shekar Reddy H, S Nagabushana D, Kattamanchi D, Dakappa A. Nystagmus in a child with nephrotic syndrome. BMJ Case Rep 2024; 17:e259734. [PMID: 38417935 PMCID: PMC10900356 DOI: 10.1136/bcr-2024-259734] [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: 03/01/2024] Open
Abstract
We report a child with steroid-dependent nephrotic syndrome presenting with excessive irritability, double vision and inability to walk for 5 days. On examination, the child was irritable with Glasgow coma sccale (GCS of 12/15, had bilateral convergent squint (R>L), vertical nystagmus, ataxia without any focal neurological deficits and normal fundus. MRI brain with venogram showed bilateral symmetric FLAIR hyperintensity in the medial thalamus and periaqueductal grey matter showing diffuse restriction with normal venogram. A possibility of Wernicke encephalopathy (WE) was considered and the child was started on thiamine supplementation, following which he had significant improvement in his symptoms. His irritability reduced with significant improvement in the range of eye movements and vertical nystagmus. At 3-month follow-up, the child is asymptomatic with normal gait. Although WE is uncommon in children with nephrotic syndrome, the possibility has to be kept in mind when a child presents with atypical neurological symptoms.
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Affiliation(s)
| | | | | | - Ahish Dakappa
- Pediatrics, MS Ramaiah Medical College Hospital, Bangalore, India
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Palmirotta C, Turi G, Tagliente S, Pansini M, De Trane S, Lagravinese G. The Effects of Intensive Rehabilitation Combined with Thiamine Treatment on Cognitive Recovery in a Case of Non-Alcoholic Wernicke-Korsakoff Syndrome. Neurol Int 2024; 16:263-273. [PMID: 38392959 PMCID: PMC10891903 DOI: 10.3390/neurolint16010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
Wernicke-Korsakoff Syndrome (WKS) is a severe neurological disorder resulting from thiamine deficiency, commonly associated with alcohol consumption but also stemming from dietary imbalances or other clinical conditions. Cognitive deficits, affecting memory and executive functions, pose a serious concern, with partial recovery often not complete. A 28-year-old woman underwent surgery for acute necrotizing hemorrhagic pancreatitis, leading to admission for post-acute intensive treatment due to prolonged bed rest syndrome. Clinical examinations revealed sensory-motor neuropathy, denervation in the active phase, mammillary body hyperintensity, and cognitive impairment. The patient exhibited poor orientation, lacked awareness of her clinical condition, and experienced impaired nonverbal memory, practical constructive issues, and planning difficulties-consistent with WKS. The patient received high-dose thiamine (300 mg TDS), coupled with daily physiokinesitherapy and occupational therapy. A final neuropsychological evaluation three months later showed substantial remission of executive and memory difficulties, improved spatial-temporal orientation, and enhanced awareness. The complex case required timely multidisciplinary intervention for accurate diagnosis and effective rehabilitation. The patient experienced rapid clinical improvement and cognitive recovery with high-dose thiamine and physiotherapy.
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Affiliation(s)
- Cinzia Palmirotta
- Istituti Clinici Scientifici Maugeri IRCCS, Laboratory of Neuropsychology, Bari Institute, 70124 Bari, Italy; (C.P.); (G.T.); (S.T.)
| | - Gilda Turi
- Istituti Clinici Scientifici Maugeri IRCCS, Laboratory of Neuropsychology, Bari Institute, 70124 Bari, Italy; (C.P.); (G.T.); (S.T.)
| | - Serena Tagliente
- Istituti Clinici Scientifici Maugeri IRCCS, Laboratory of Neuropsychology, Bari Institute, 70124 Bari, Italy; (C.P.); (G.T.); (S.T.)
| | - Michele Pansini
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 0AG, UK;
- Clinica Di Radiologia EOC, Istituto Di Imaging Della Svizzera Italiana (IIMSI), 6900 Lugano, Switzerland
| | - Stefania De Trane
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Unit of Bari Institute, 70124 Bari, Italy;
| | - Gianvito Lagravinese
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Unit of Bari Institute, 70124 Bari, Italy;
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14
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Bento MA, Vieira JB, Silva ML, Camolas J. Case report: Wernicke-Korsakoff syndrome after bariatric surgery. Front Nutr 2024; 10:1321275. [PMID: 38249599 PMCID: PMC10796817 DOI: 10.3389/fnut.2023.1321275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/01/2023] [Indexed: 01/23/2024] Open
Abstract
Vitamin and mineral deficiencies are prevalent nutritional disorders following bariatric surgery. Although they are more prevalent after malabsorptive procedures such as bypass, they also occur in restrictive procedures such as gastric sleeve. The mechanisms that lead to the occurrence of these deficits are related to the presence of poor nutritional intake or poor adherence to multivitamins and multimineral supplementation. Wernicke-Korsakoff syndrome (WKS) is an acute neurological disorder resulting from thiamine deficiency. This syndrome is composed of two distinct phases: first, Wernicke Encephalopathy (WE), the acute phase of this syndrome, which is characterized by a triad of mental confusion, ocular signs, and ataxia, followed by the chronic phase of WKS, called Korsakoff's syndrome (KS), which is known for the presence of anterograde amnesia and confabulation. We aimed to report a case of a patient with WKS after bariatric surgery. The patient's retrospective chart review was performed in order to retrieve the relevant clinical data. The patient was a 24-year-old female student with a BMI of 48 kg/m2 who underwent sleeve gastrectomy surgery for morbid obesity. Over the following 2 months, recovery from surgery was complicated by non-specific symptoms such as nausea, recurrent vomiting, and a significant reduction in food intake, which led the patient to visit the emergency department six times with hospitalization on the last occasion for a definitive diagnosis. During the 15 days of hospitalization, the patient developed ocular diplopia, nystagmus, complaints of rotatory vertigo, and gait abnormalities. A magnetic resonance imaging of the head was performed but revealed no significant changes. After a formal neurological assessment, treatment with parenteral thiamine (100 mg, three times a day) was started without prior dosing. The observed clinical improvement confirmed the diagnosis of WKS. Bariatric surgery may contribute to thiamine deficiency and, consequently, to WKS. Education about the adverse consequences of malnourishment is mandatory before and after the surgery. Investigation of nutritional deficiencies both pre- and post-operatively is crucial in order to prevent complications such as WKS.
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Affiliation(s)
| | | | - Maria Leonor Silva
- Egas Moniz Center for Interdisciplinary Research, Egas Moniz School of Health and Science, Almada, Portugal
- GENA (Applied Nutrition Research Group), Egas Moniz School of Health and Science, Almada, Portugal
| | - José Camolas
- Serviço de Endocrinologia, Hospital Santa Maria, Lisbon, Portugal
- Egas Moniz Center for Interdisciplinary Research, Egas Moniz School of Health and Science, Almada, Portugal
- Laboratório de Nutrição, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- EnviHeB Lab, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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15
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Taha M, Alharbi AM, Al-Zahrani SS, Alzamzami HH, Alotaibi BA, Alhariry AA, Bahakeem RF. Awareness of Bariatric Sleeve Gastrectomy Complications Among the General Population of Saudi Arabian Regions. Cureus 2024; 16:e52187. [PMID: 38347967 PMCID: PMC10859316 DOI: 10.7759/cureus.52187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 02/15/2024] Open
Abstract
Sleeve gastrectomy (SG) is a type of procedure called bariatric surgery that provides large weight loss and has a positive impact on diseases associated with obesity. However, it has brought several complications that have an impact on those undergoing surgery, which are classified into intraoperative and postoperative issues. The study's goal is to assess the Saudi Arabian population's awareness of SG consequences. This study assessed the general population's knowledge in Saudi Arabia in 2023 using a cross-sectional approach. The total number of participants was 1,013, the majority of whom were individuals between the ages of 18 and 25 (471, 46%), and females (692, 68%). A total of 692 (68%) participants showed awareness of BMI; in addition, 987 (97%) were aware of gastric sleeve surgery, and 538 (53%) understood its indications correctly. Regarding SG complications, approximately 821 (81%) of participants showed awareness. There were significant associations between knowledge of gastric sleeve surgery and residence in the northern region of Saudi Arabia. In conclusion, our study indicated that the general population is aware of the complications of gastric sleeve surgery, but it found a deficiency in their knowledge about BMI.
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Affiliation(s)
- Medhat Taha
- Department of Anatomy, College of Medicine, Umm Al-Qura University, Al-Qunfudhah, SAU
| | - Abdulaziz M Alharbi
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Sara S Al-Zahrani
- Department of Medicine, College of Medicine, Umm Al-Qura University, Al-Qunfudhah, SAU
| | - Hatun H Alzamzami
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Bader A Alotaibi
- Department of Medicine, Al-Dawadmi Medical College, Shaqra University, Riyadh, SAU
| | - Anmar A Alhariry
- Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Raghad F Bahakeem
- Department of Medicine, College of Medicine, Umm Al-Qura University, Makkah, SAU
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16
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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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17
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Manigrasso M, Velotti N, De Palma GD, Musella M. Comment on Wijnia, J.W. A Clinician's View of Wernicke-Korsakoff Syndrome. J. Clin. Med. 2022, 11, 6755. J Clin Med 2023; 12:6393. [PMID: 37835037 PMCID: PMC10573923 DOI: 10.3390/jcm12196393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/01/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
We have read with great interest the article by Wijnia [...].
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Affiliation(s)
- Michele Manigrasso
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy;
| | - Nunzio Velotti
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy; (N.V.); (M.M.)
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy;
| | - Mario Musella
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy; (N.V.); (M.M.)
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18
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Kumar N. Nutritional Neuropathies. Continuum (Minneap Minn) 2023; 29:1469-1491. [PMID: 37851039 DOI: 10.1212/con.0000000000001292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This article reviews the etiologies, presentations, and management of neuropathies related to nutritional deficiencies. LATEST DEVELOPMENTS Peripheral neuropathy can be the predominant or only manifestation of certain nutrient deficiencies. Cognitive difficulties or involvement of other parts of the central nervous system, such as the optic nerve and spinal cord, may accompany nutritional peripheral neuropathies. In most patients, the nutritional deficiency may have a single predominant cause, but in some cases, multiple causes may coexist. Obesity, for unclear reasons, can be associated with nutrient deficiencies. The rising rates of bariatric surgery and the incidence of nutrient deficiencies following bariatric surgery make this a particularly relevant topic for neurologists. ESSENTIAL POINTS Neuropathies caused by nutrient deficiencies are preventable with appropriate supplementation in high-risk situations. Early recognition and prompt treatment are essential to ensure an optimal outcome and minimize neurologic morbidity.
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19
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Kopelman MD. Observations on the Clinical Features of the Wernicke-Korsakoff Syndrome. J Clin Med 2023; 12:6310. [PMID: 37834954 PMCID: PMC10573380 DOI: 10.3390/jcm12196310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/30/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
This paper begins with a short case report of florid, spontaneous confabulation in a 61-year-old man with an alcohol-induced Wernicke-Korsakoff syndrome. His confabulation extended across episodic and personal semantic memory, as well as orientation in time and place, as measured on Dalla Barba's Confabulation Battery. Five other brief case summaries will then be presented, followed by a summary of the clinical, neurological, and background neuropsychological findings in three earlier series of Korsakoff patients. These observations will be considered in light of Wijnia's recent and my own, earlier reviews of the Korsakoff syndrome. Taken together, they indicate the need for a multi-faceted approach (clinical, neurological, neuropsychological, and neuroimaging) to the assessment and diagnosis of the disorder.
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Affiliation(s)
- Michael D Kopelman
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, UK
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20
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Zhang YK, Liu JR, Yin KL, Zong Y, Wang YZ, Cao YM. Creutzfeldt-Jakob disease presenting as Korsakoff syndrome caused by E196A mutation in PRNP gene: A case report. World J Clin Cases 2023; 11:5982-5987. [PMID: 37727484 PMCID: PMC10506038 DOI: 10.12998/wjcc.v11.i25.5982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/25/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Prion diseases are a group of degenerative nerve diseases that are caused by infectious prion proteins or gene mutations. In humans, prion diseases result from mutations in the prion protein gene (PRNP). Only a limited number of cases involving a specific PRNP mutation at codon 196 (E196A) have been reported. The coexistence of Korsakoff syndrome in patients with Creutzfeldt-Jakob disease (CJD) caused by E196A mutation has not been documented in the existing literature. CASE SUMMARY A 61-year-old Chinese man initially presented with Korsakoff syndrome, followed by rapid-onset dementia, visual hallucinations, akinetic mutism, myoclonus, and hyperthermia. The patient had no significant personal or familial medical history. Magnetic resonance imaging of the brain revealed extensive hyperintense signals in the cortex, while positron emission tomography/computed tomography showed a diffuse reduction in cerebral cortex metabolism. Routine biochemical and microorganism testing of the cerebrospinal fluid (CSF) yielded normal results. Tests for thyroid function, human immunodeficiency virus, syphilis, vitamin B1 and B12 levels, and autoimmune rheumatic disorders were normal. Blood and CSF tests for autoimmune encephalitis and autoantibody-associated paraneoplastic syndrome yielded negative results. A test for 14-3-3 protein in the CSF yielded negative results. Whole-genome sequencing revealed a disease-causing mutation in PRNP. The patient succumbed to the illness 11 months after the initial symptom onset. CONCLUSION Korsakoff syndrome, typically associated with alcohol intoxication, also manifests in CJD patients. Individuals with CJD along with PRNP E196A mutation may present with Korsakoff syndrome.
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Affiliation(s)
- Yong-Kang Zhang
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Jia-Rui Liu
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Kang-Li Yin
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Yuan Zong
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Yu-Zhen Wang
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Ye-Min Cao
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
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21
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Borgemenke R, Borgemenke S, Mall S, Pagur P. Wernicke Encephalopathy Secondary to Hyperemesis Gravidarum in a 22-Year-Old Female Patient: A Case Report. Cureus 2023; 15:e45172. [PMID: 37842375 PMCID: PMC10575565 DOI: 10.7759/cureus.45172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Wernicke encephalopathy is an acute, reversible neurological disorder, which, if untreated, can develop into Korsakoff syndrome. Commonly associated with alcohol use disorder, Wernicke encephalopathy is a metabolic disorder caused by a deficiency of thiamine, vitamin B1. This case report presents a clinical manifestation of Wernicke encephalopathy, in which a 22-year-old pregnant female with hyperemesis gravidarum and significant weight loss developed acute metabolic encephalopathy. Diagnostic imaging played an important role both in diagnosing the patient acutely in the hospital and during a follow-up visit one year after treatment.
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Affiliation(s)
- Ryan Borgemenke
- Diagnostic Radiology, Kettering Health Network, Kettering, USA
| | - Samuel Borgemenke
- Diagnostic Radiology, Ohio University Heritage College of Osteopathic Medicine, Athens, USA
| | - Sharal Mall
- Diagnostic Radiology, Kettering Health Network, Kettering, USA
| | - Patrick Pagur
- Diagnostic Radiology, Kettering Health Network, Kettering, USA
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22
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Safran JT, Bodaghi M, Sherwin NK, Wallace JR. Wernicke's encephalopathy in adolescents with anorexia nervosa. PSYCHIATRY RESEARCH CASE REPORTS 2023; 2:100091. [PMID: 36567898 PMCID: PMC9758782 DOI: 10.1016/j.psycr.2022.100091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022]
Abstract
Anorexia Nervosa (AN) has always been prevalent in adolescents. During the COVID-19 pandemic, the eating disorder community across the world has noted a sharp increase in adolescent patients with AN and the severity of medical compromise. Rarely seen sequelae have become increasingly more common. This case report describes two previously healthy female adolescents with severe malnutrition due to AN admitted for nutritional stabilization who exhibited paranoid delusions responsive to thiamine and olanzapine. Though neither exhibit the full triad or all the Caine criteria for Wernicke's Encephalopathy (WE), the triad will not present completely in most patients with WE, especially in the pediatric population. Having one symptom of the triad is indicative of WE. Due to the decreased number of clinical criteria for Wernicke's encephalopathy coupled with the lack of typical brain MRI findings found in these patients, we recommend a high index of suspicion for WE and investigation with thiamine. Thiamine supplementation should be standard care in AN with oral supplementation in stable conditions. In the case of refeeding syndromes, preventative parenteral thiamine 100 mg IV qd, and in the case of thiamine deficiency, thiamine 500 mg IV TID.
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Affiliation(s)
- Jeremy T. Safran
- Child and Adolescent Psychiatry Chief Fellow (PGY5), Children's National Hospital, 6833 4th St. NW, Washington, DC 20012, United States,Corresponding author
| | - Mahdieh Bodaghi
- Medical Director of Psychiatry Consult Liaison Services, Children's National Hospital, United States
| | - Nomi K. Sherwin
- Department of Adolescent Medicine, Indiana University School of Medicine, United States
| | - Jessica R. Wallace
- General Pediatrics Clinical Pharmacy Specialist, Children's National Hospital, United States
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23
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Ulasoglu-Yildiz C, Yildirim Z, Myers CE, Gluck MA, Gurvit H. Altered learning and transfer abilities in Korsakoff's syndrome depending on task complexity. APPLIED NEUROPSYCHOLOGY. ADULT 2023:1-13. [PMID: 37243624 DOI: 10.1080/23279095.2023.2217975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Korsakoff's syndrome (KS) is characterized by episodic memory impairment due to damage to the medial diencephalic structures. Although commonly associated with chronic alcoholism, starvation due to the hunger strike is one of its nonalcoholic causes. Learning the stimulus-response associations and transferring the just-learned associations to novel combinations were previously tested by specific tasks in memory-impaired patients with hippocampal, basal forebrain, and basal ganglia damage. To add to this previous research, we aimed to use the same tasks in a group of patients with hunger strike-related KS presenting a stable isolated amnestic profile. Twelve patients with hunger strike-related KS and matched healthy controls were tested in two tasks varying in task complexity. Each task included two phases: the initial phase is feedback-based learning of (simple vs. complex) stimulus-response associations, and the following phase is transfer generalization (in the presence vs. absence of feedback). On a task involving simple associations, five patients with KS failed to learn the associations, while the other seven patients showed intact learning and transfer. On the other task involving more complex associations, seven patients showed slower learning and failed at transfer generalization, whereas the other five patients failed even at the acquisition phase. These findings of a task-complexity-related impairment on associative learning and transfer represent a distinct pattern from the spared learning but impaired transfer previously observed on these tasks in patients with medial temporal lobe amnesia.
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Affiliation(s)
- Cigdem Ulasoglu-Yildiz
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
- Hulusi Behcet Life Sciences Research Laboratory, Neuroscience Unit, Istanbul University, Istanbul, Turkey
| | - Zerrin Yildirim
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Catherine E Myers
- Department of Pharmacology, Physiology and Neuroscience, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Mark A Gluck
- Center for Molecular and Behavioral Neuroscience, Rutgers University, Newark, NJ, USA
| | - Hakan Gurvit
- Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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24
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Böing S, Ten Brink AF, Hoogerbrugge AJ, Oudman E, Postma A, Nijboer TCW, Van der Stigchel S. Eye Movements as Proxy for Visual Working Memory Usage: Increased Reliance on the External World in Korsakoff Syndrome. J Clin Med 2023; 12:jcm12113630. [PMID: 37297825 DOI: 10.3390/jcm12113630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/12/2023] [Accepted: 05/14/2023] [Indexed: 06/12/2023] Open
Abstract
In the assessment of visual working memory, estimating the maximum capacity is currently the gold standard. However, traditional tasks disregard that information generally remains available in the external world. Only when to-be-used information is not readily accessible, memory is taxed. Otherwise, people sample information from the environment as a form of cognitive offloading. To investigate how memory deficits impact the trade-off between sampling externally or storing internally, we compared gaze behaviour of individuals with Korsakoff amnesia (n = 24, age range 47-74 years) and healthy controls (n = 27, age range 40-81 years) on a copy task that provoked different strategies by having information freely accessible (facilitating sampling) or introducing a gaze-contingent waiting time (provoking storing). Indeed, patients sampled more often and longer, compared to controls. When sampling became time-consuming, controls reduced sampling and memorised more. Patients also showed reduced and longer sampling in this condition, suggesting an attempt at memorisation. Importantly, however, patients sampled disproportionately more often than controls, whilst accuracy dropped. This finding suggests that amnesia patients sample frequently and do not fully compensate for increased sampling costs by memorising more at once. In other words, Korsakoff amnesia resulted in a heavy reliance on the world as 'external memory'.
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Affiliation(s)
- Sanne Böing
- Experimental Psychology, Helmholtz Institute, Utrecht University, 3584 CS Utrecht, The Netherlands
| | - Antonia F Ten Brink
- Experimental Psychology, Helmholtz Institute, Utrecht University, 3584 CS Utrecht, The Netherlands
| | - Alex J Hoogerbrugge
- Experimental Psychology, Helmholtz Institute, Utrecht University, 3584 CS Utrecht, The Netherlands
| | - Erik Oudman
- Korsakoff Center of Expertise Slingedael, 3086 EZ Rotterdam, The Netherlands
| | - Albert Postma
- Experimental Psychology, Helmholtz Institute, Utrecht University, 3584 CS Utrecht, The Netherlands
- Korsakoff Center of Expertise Slingedael, 3086 EZ Rotterdam, The Netherlands
| | - Tanja C W Nijboer
- Experimental Psychology, Helmholtz Institute, Utrecht University, 3584 CS Utrecht, The Netherlands
- Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and De Hoogstraat Rehabilitation, 3583 TM Utrecht, The Netherlands
| | - Stefan Van der Stigchel
- Experimental Psychology, Helmholtz Institute, Utrecht University, 3584 CS Utrecht, The Netherlands
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Silva AR, Almeida-Xavier S, Lopes M, Soares-Fernandes JP, Sousa F, Varanda S. Is there a time window for MRI in Wernicke encephalopathy - a decade of experience from a tertiary hospital. Neurol Sci 2023; 44:703-708. [PMID: 36335281 DOI: 10.1007/s10072-022-06477-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Wernicke encephalopathy (WE) is a neuropsychiatric syndrome caused by thiamine deficiency. Despite its low sensitivity, brain magnetic resonance imaging (MRI) is the most useful diagnostic technique. Our aim was to investigate whether the timing of the imaging study, and thiamine replacement can influence brain MRI findings in these patients. METHODS Retrospective observational study of hospitalized patients between January/2008 and December/2020 with a clinical diagnosis of WE. Data from clinical presentation, diagnostic features, therapeutic approach, and outcomes were collected. RESULTS We identified 41 patients (55 ± 13.3 years) with WE. Brain MRI was performed in 36 patients, and one third had T2/FLAIR hyperintensities suggestive of WE. We found an association between a history of poor diet and periventricular hyperintensities (p = 0.023), especially on the ventral surface of the thalamus and the periaqueductal region. It was found that the odds of having a typical imaging of WE decreased by 5.3% for each additional unit (100 mg) of thiamine administered (p = 0.046) (95% CI [0.89, 0.99]). On the other hand, the number of days from clinical presentation was not found to be a viable predictor (p = 0.254) (95% CI [0.88, 1.03]) Recovery was positively correlated with the total dose of thiamine received until discharge (p = 0.020). CONCLUSIONS MRI hyperintensities seem to be dependent on the timing of thiamine correction and, particularly, on the thiamine dosage prescribed at admission. Nevertheless, thiamine replacement should not be delayed, as its timely prescription is associated with a better prognosis at discharge.
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Affiliation(s)
- Ana Rita Silva
- Department of Neurology, Hospital de Braga, Braga, Portugal.
| | | | | | | | - Filipa Sousa
- Department of Neurology, Hospital de Braga, Braga, Portugal
| | - Sara Varanda
- Department of Neurology, Hospital de Braga, Braga, Portugal
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Krzysztoforska K, Piechal A, Wojnar E, Blecharz-Klin K, Pyrzanowska J, Joniec-Maciejak I, Krzysztoforski J, Widy-Tyszkiewicz E. Protocatechuic Acid Prevents Some of the Memory-Related Behavioural and Neurotransmitter Changes in a Pyrithiamine-Induced Thiamine Deficiency Model of Wernicke-Korsakoff Syndrome in Rats. Nutrients 2023; 15:nu15030625. [PMID: 36771332 PMCID: PMC9921060 DOI: 10.3390/nu15030625] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023] Open
Abstract
The purpose of this research was to investigate the effects of protocatechuic acid (PCA) at doses of 50 and 100 mg/kg on the development of unfavourable changes in cognitive processes in a pyrithiamine-induced thiamine deficiency (PTD) model of the Wernicke-Korsakoff syndrome (WKS) in rats. The effects of PCA were assessed at the behavioural and biochemical levels. Behavioural analysis was conducted using the Foot Fault test (FF), Bar test, Open Field test, Novel Object Recognition test (NOR), Hole-Board test and Morris Water Maze test (MWM). Biochemical analysis consisting of determination of concentration and turnover of neurotransmitters in selected structures of the rat CNS was carried out using high-performance liquid chromatography. PTD caused catalepsy (Bar test) and significantly impaired motor functions, leading to increased ladder crossing time and multiplied errors due to foot misplacement (FF). Rats with experimentally induced WKS showed impaired consolidation and recall of spatial reference memory in the MWM test, while episodic memory related to object recognition in the NOR was unimpaired. Compared to the control group, rats with WKS showed reduced serotonin levels in the prefrontal cortex and changes in dopamine and/or norepinephrine metabolites in the prefrontal cortex, medulla oblongata and spinal cord. PTD was also found to affect alanine, serine, glutamate, and threonine levels in certain areas of the rat brain. PCA alleviated PTD-induced cataleptic symptoms in rats, also improving their performance in the Foot Fault test. In the MWM, PCA at 50 and 100 mg/kg b.w. improved memory consolidation and the ability to retrieve acquired information in rats, thereby preventing unfavourable changes caused by PTD. PCA at both tested doses was also shown to have a beneficial effect on normalising PTD-disrupted alanine and glutamate concentrations in the medulla oblongata. These findings demonstrate that certain cognitive deficits in spatial memory and abnormalities in neurotransmitter levels persist in rats that have experienced an acute episode of PTD, despite restoration of thiamine supply and long-term recovery. PCA supplementation largely had a preventive effect on the development of these deficits, to some extent also normalising neurotransmitter concentrations in the brain.
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Affiliation(s)
- Kinga Krzysztoforska
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology CePT, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland
- Correspondence:
| | - Agnieszka Piechal
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology CePT, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland
| | - Ewa Wojnar
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology CePT, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland
| | - Kamilla Blecharz-Klin
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology CePT, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland
| | - Justyna Pyrzanowska
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology CePT, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland
| | - Ilona Joniec-Maciejak
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology CePT, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland
| | - Jan Krzysztoforski
- Faculty of Chemical and Process Engineering, Warsaw University of Technology, Waryńskiego 1, 00-645 Warsaw, Poland
| | - Ewa Widy-Tyszkiewicz
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology CePT, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland
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Muacevic A, Adler JR, Lara-Reyna J, Park K, Harvey EJ. Duodenal Adenocarcinoma in the Setting of Bariatric Surgery: A Perfect Storm for Wernicke's Encephalopathy. Cureus 2023; 15:e33765. [PMID: 36793835 PMCID: PMC9924300 DOI: 10.7759/cureus.33765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2023] [Indexed: 01/15/2023] Open
Abstract
Wernicke's encephalopathy (WE) is a condition resulting from thiamine deficiency that typically presents with acute neurologic symptoms including ataxia, eye movement disorders, and altered mental status. Though classically seen in patients with alcohol use disorder, it can also occur as a complication of bariatric surgery and gastrointestinal cancers. Here, we present a patient with a history of gastric band surgery and an intact alimentary tract. She presented with acute, intractable vomiting and epigastric abdominal pain, incompletely relieved by deflating her gastric band, and was found to have duodenal adenocarcinoma causing partial duodenal obstruction. She was then found to have binocular diplopia, horizontal nystagmus, dizziness, reduced proprioception, and pins-and-needles numbness in her bilateral lower extremities, and there was concern for gait instability; thus, WE was suspected. The patient was treated with high-dose thiamine repletion, and her symptoms resolved shortly thereafter. WE is rare in patients who have undergone gastric band surgery, and to our knowledge, this is the first case of WE in a patient with concurrent duodenal adenocarcinoma. This case illustrates that patients with a history of bariatric surgery may be more susceptible to developing WE in the face of a new gastrointestinal insult, such as duodenal cancer.
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Kareem O, Nisar S, Tanvir M, Muzaffer U, Bader GN. Thiamine deficiency in pregnancy and lactation: implications and present perspectives. Front Nutr 2023; 10:1080611. [PMID: 37153911 PMCID: PMC10158844 DOI: 10.3389/fnut.2023.1080611] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/03/2023] [Indexed: 05/10/2023] Open
Abstract
During pregnancy, many physiologic changes occur in order to accommodate fetal growth. These changes require an increase in many of the nutritional needs to prevent long-term consequences for both mother and the offspring. One of the main vitamins that are needed throughout the pregnancy is thiamine (vitamin B1) which is a water-soluble vitamin that plays an important role in many metabolic and physiologic processes in the human body. Thiamine deficiency during pregnancy can cause can have many cardiac, neurologic, and psychological effects on the mother. It can also dispose the fetus to gastrointestinal, pulmonological, cardiac, and neurologic conditions. This paper reviews the recently published literature about thiamine and its physiologic roles, thiamine deficiency in pregnancy, its prevalence, its impact on infants and subsequent consequences in them. This review also highlights the knowledge gaps within these topics.
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Affiliation(s)
- Ozaifa Kareem
- Department of Pharmaceutical Sciences, University of Kashmir, Srinagar, India
- *Correspondence: Ozaifa Kareem, ,
| | - Sobia Nisar
- Department of Medicine, Government Medical College, Srinagar, India
| | - Masood Tanvir
- Department of Medicine, Government Medical College, Srinagar, India
| | - Umar Muzaffer
- Department of Medicine, Government Medical College, Srinagar, India
| | - G. N. Bader
- Department of Pharmaceutical Sciences, University of Kashmir, Srinagar, India
- G. N. Bader,
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Cornea A, Lata I, Simu M, Rosca EC. Wernicke Encephalopathy Presenting with Dysphagia: A Case Report and Systematic Literature Review. Nutrients 2022; 14:nu14245294. [PMID: 36558453 PMCID: PMC9788281 DOI: 10.3390/nu14245294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Wernicke encephalopathy (WE) is a well-known neurological condition caused by thiamine (vitamin B1) deficiency that occurs in both alcoholic and non-alcoholic populations. We aimed to report a case of a patient with WE who presented with dysphagia and dysphonia and later developed typical symptoms of thiamine deficiency and to conduct a systematic review of the literature on this rare presentation of WE. We searched two databases (PubMed and Scopus) and included publications up to November 2022. We found 12 cases of WE and dysphagia, aged between 12 and 81 years; swallowing problems presented at the onset in nine patients (including the current case report). Our findings suggest that thiamine deficiency should be suspected in patients with dysphagia of unknown cause, even in the absence of alcohol abuse. In contrast to most WE patients, the majority of patients included in this review presented with dysphagia at the onset of their disease, even in the absence of the classic triad of cognitive impairment, ataxia, and oculomotor abnormalities, indicating that there could be varying susceptibilities to clinical manifestations of thiamine deficiency in different brain regions.
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Affiliation(s)
- Amalia Cornea
- Department of Neurology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania
- Department of Neurology, Clinical Emergency County Hospital Timisoara, Bd. Losif Bulbuca No. 10, 300736 Timisoara, Romania
| | - Irina Lata
- Department of Neurology, Clinical Emergency County Hospital Timisoara, Bd. Losif Bulbuca No. 10, 300736 Timisoara, Romania
| | - Mihaela Simu
- Department of Neurology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania
- Department of Neurology, Clinical Emergency County Hospital Timisoara, Bd. Losif Bulbuca No. 10, 300736 Timisoara, Romania
| | - Elena Cecilia Rosca
- Department of Neurology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania
- Department of Neurology, Clinical Emergency County Hospital Timisoara, Bd. Losif Bulbuca No. 10, 300736 Timisoara, Romania
- Correspondence: or ; Tel.: +40-746-173794
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Koca O, Demir B, Derin S, Turna ZH. A case report of Wernicke Korsakoff syndrome in a patient with cholangiocellular carcinoma: An underestimated cause of encephalopathy in cancer patients. Medicine (Baltimore) 2022; 101:e31904. [PMID: 36482648 PMCID: PMC9726370 DOI: 10.1097/md.0000000000031904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Wernicke's encephalopathy, a disorder caused by thiamin deficiency, is characterized by a classical triad of encephalopathy, ataxia, and ophthalmoplegia. Although alcoholism is the most common predisposing factor, it can also be associated with nonalcoholic states (hyperemesis gravidarum, intestinal obstruction, bariatric surgery, and others). This work presents a case of nonalcoholic Wernicke-Korsakoff syndrome diagnosed in a cholangiocellular carcinoma patient and literature review. CASE REPORT A 65-year-old male patient with a history of cholangiocellular carcinoma (Klatskin tumor) was treated with radiotherapy at the operation site after Roux-en-Y hepaticojejunostomy. During follow-up, the patient developed gastric outlet obstruction and was diagnosed with peritoneal carcinomatosis after a palliative gastrojejunostomy. As the patient could not tolerate oral nutrition during hospitalization, total parenteral nutrition was administered. After 10 days of admission, the patient showed decreased response to verbal stimuli as well as bilateral horizontal nystagmus, lethargy, and disorientation. Furthermore, the patient displayed confabulation. Clinical and imaging findings were consistent with Wernicke's encephalopathy. Therefore, treatment with intravenous thiamin replacement was initiated. The patient's encephalopathy regressed on the second day after treatment, and he recovered the place-person-time orientation. In the following month, the abnormal imaging findings were almost entirely resolved. CONCLUSION In order to prevent irreversible brain damage induced by chronic thiamin deficiency, thiamin replacement therapy with parenteral nutrition solutions should be included as a treatment for hospitalized cancer patients unable to receive enteral nutrition for a long time.
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Affiliation(s)
- Oguzhan Koca
- Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Bilal Demir
- Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sumeyra Derin
- Division of Medical Oncology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Zeynep Hande Turna
- Division of Medical Oncology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Muacevic A, Adler JR, Chang JS, Lui F. Wernicke's Encephalopathy Presenting With Confusion in a Patient With Schizophrenia. Cureus 2022; 14:e32320. [PMID: 36628041 PMCID: PMC9825115 DOI: 10.7759/cureus.32320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 12/13/2022] Open
Abstract
Wernicke's encephalopathy (WE) is a neuropsychiatric condition caused by thiamine deficiency often associated with alcoholism. Other less common causes include prolonged gastroenterology problems or dietary insufficiencies associated with hyperemesis gravidarum, bariatric surgery, and eating disorders. Prolonged WE without proper treatment can lead to the chronic and irreversible condition, Wernicke-Korsakoff syndrome. Despite being known for its classic triad of clinical symptoms (nystagmus/ophthalmoplegia, gait ataxia, and confusion), WE patients more commonly present with non-specific symptoms of altered mental status. Obscure clinical presentations often led to delays in the appropriate of patients with WE. We are presenting a case of WE that is unusual because the underlying cause is schizophrenia and the lack of alcohol use. For a punctual diagnosis, a high index of suspicion is essential to prevent further exacerbation of neuronal death seen in WE. IV thiamine should be administered to any patient with acute encephalopathy or altered mental status, given its low cost and lack of side effects.
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32
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Wijdicks EFM. Identifying encephalopathies from acute metabolic derangements. J Intern Med 2022; 292:846-857. [PMID: 35809045 DOI: 10.1111/joim.13538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Metabolic derangements, when acute and severe, affect brain function. This presents mostly with a marked decline in the level of consciousness, resulting in impaired responsiveness, abnormal receptivity, impaired content, and loss of memory retention. The term metabolic encephalopathy has been used but is conjecture that can be challenged in the age of modern neuroimaging. We now recognize that many metabolic encephalopathies may involve structural lesions and at an early stage. Common clinical conundrums are the evaluation of the degree of brain injury and its recoverability. This review discusses the appropriate terminology for these conditions, the diagnostic approach, therapy recommendations, and prediction of recovery potential. In evaluating a presumed metabolic cause for encephalopathy, we must (1) search for and rule out structural injury to the brain despite an obvious explanatory metabolic derangement, (2) recognize that several confounding conditions often co-exist, and (3) acknowledge that resolution of brain dysfunction may be protracted despite normalization of laboratory values.
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Affiliation(s)
- Eelco F M Wijdicks
- Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, Rochester, Minnesota, USA
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33
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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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Alcohol Withdrawal Is an Oxidative Stress Challenge for the Brain: Does It Pave the Way toward Severe Alcohol-Related Cognitive Impairment? Antioxidants (Basel) 2022; 11:antiox11102078. [PMID: 36290801 PMCID: PMC9598168 DOI: 10.3390/antiox11102078] [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: 09/01/2022] [Revised: 09/22/2022] [Accepted: 10/19/2022] [Indexed: 11/21/2022] Open
Abstract
Alcohol use is a leading cause of mortality, brain morbidity, neurological complications and minor to major neurocognitive disorders. Alcohol-related neurocognitive disorders are consecutive to the direct effect of chronic and excessive alcohol use, but not only. Indeed, patients with severe alcohol use disorders (AUD) associated with pharmacological dependence suffer from repetitive events of alcohol withdrawal (AW). If those AW are not managed by adequate medical and pharmacological treatment, they may evolve into severe AW, or be complicated by epileptic seizure or delirium tremens (DT). In addition, we suggest that AW favors the occurrence of Wernicke’s encephalopathy (WE) in patients with known or unknown thiamine depletion. We reviewed the literature on oxidative stress as a core mechanism in brain suffering linked with those conditions: AW, epileptic seizure, DT and WE. Thus, we propose perspectives to further develop research projects aiming at better identifying oxidative stress brain damage related to AW, assessing the effect of repetitive episodes of AW, and their long-term cognitive consequences. This research field should develop neuroprotective strategies during AW itself or during the periwithdrawal period. This could contribute to the prevention of severe alcohol-related brain damage and cognitive impairments.
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Erick M. Gestational malnutrition, hyperemesis gravidarum, and Wernicke's encephalopathy: What is missing? Nutr Clin Pract 2022; 37:1273-1290. [PMID: 36250744 DOI: 10.1002/ncp.10913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/28/2022] [Accepted: 08/28/2022] [Indexed: 11/11/2022] Open
Abstract
Hyperemesis gravidarum (HG), or the severe nausea and vomiting of pregnancy, is one of the most dreaded complications of gestation, affecting between 1.5% and 3.0% of pregnant women. From the late 1800s to the mid-1980s, the etiology was frequently cited to have psychological and/or-later-perhaps hormonal origins, which have numbered at least 10. Current research has unearthed a genetic basis for HG that implicates growth differentiation factor 15, insulin-like growth factor binding protein 7, and hormone receptors (namely, glial cell line-derived neurogenic factor family receptor alpha-like and the progesterone receptor). Whatever the origins of this disease, it has caused immeasurable physiological and psychological damage to women, their fetuses, and their families. The psychological trauma includes a high rate of suicidal ideation as well as posttraumatic stress disorder. Whereas the healthcare costs are substantial for the mother with HG, the lifetime costs to the neonate include that which accompanies reduced employment earnings related to cognitive compromise. Another devastating outcome of severe HG can be Wernicke's encephalopathy (WE), which has a high fetal and maternal mortality rate. Our study explored 18 current reports of HG and WE. We highlighted additional presenting features we believe also accompany, and sometimes replace, the classically taught triad components of WE: ataxia, confabulation, and nystagmus. We agree with the conclusion made by Sheehan and Ironside in 1939 that thiamin alone may not reverse WE, and we offer possible explanations. Lastly, we offer suggestions for remediation.
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Affiliation(s)
- Miriam Erick
- Department of Nutrition, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Rybak K, Warchoł A, Drobczyński Ł, Banaszkiewicz A. Metronidazole-Induced Encephalopathy in a 16-Year-Old Girl with Crohn’s Disease: Case Report and Review of the Pediatric Literature. CHILDREN 2022; 9:children9091408. [PMID: 36138717 PMCID: PMC9497710 DOI: 10.3390/children9091408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022]
Abstract
Metronidazole-induced encephalopathy (MIE) is a rare and unpredictable complication that is most commonly reported in adults. Here, we present the case of MIE in a patient treated with rectal, oral, and intravenous metronidazole. This is the first case of MIE reported after suppositories. A 16-year-old girl with Crohn’s disease treated with mesalazine and exclusive enteral nutrition was operated on due to perianal fistulas and abscesses. She received oral metronidazole for 25 days and rectal metronidazole for 15 days as an adjuvant before surgery. Moreover, 2.5 g of intravenous metronidazole was administrated during the perioperative period. The second day after the surgery, symptoms of cerebellar syndrome appeared. She presented with an inability to coordinate balance and gait. Although she showed accurate verbal responses, her speech was slow, slurred, and scanning. The finger–nose test was positive. The T2-weighted magnetic resonance imaging revealed an increased symmetrical signal within the dentate nuclei of the cerebellum and in the corpus callosum. The changes were characterized by restricted diffusion. Based on the clinical picture and magnetic resonance imaging findings, MIE was diagnosed. Treatment with metronidazole was discontinued. The cumulative dose of metronidazole that she received for 29 days was 54 g: 38 g p.o., 13.5 g p.r., and 2.5 g i,v. The first symptoms appeared on the 28th day of antibiotic therapy after receiving 52 g of metronidazole. The neurological symptoms resolved after six days; however, three days after the resolution, paresthesia appeared in the distal phalanges of both feet and lasted for approximately two months. Our report highlights that neurologic symptoms related to metronidazole treatment should raise the suspicion of MIE.
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Affiliation(s)
- Karolina Rybak
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, 02-091 Warsaw, Poland
- Correspondence:
| | - Aleksandra Warchoł
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Łukasz Drobczyński
- Department of Pediatric Radiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Aleksandra Banaszkiewicz
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, 02-091 Warsaw, Poland
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Kumar S, Bolar AR, Shetty R, Govindappa SKG, Pramod MNB, Agadi JB, Vishwanathan LG, Adiga CP. Wernicke's encephalopathy: Is visual loss a red herring? Clin Case Rep 2022; 10:e6372. [PMID: 36188048 PMCID: PMC9510764 DOI: 10.1002/ccr3.6372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022] Open
Abstract
Predominantly visual loss, is very rare in Wernicke's encephalopathy. A 22 year old lady, in her 28th week of gestation, presented with a confused mental state, bilateral papilloedema with retinal hemorrhages, ophthalmoparesis, and cerebellar signs. Her MRI brain was suggestive of Wernicke's encephalopathy and she recovered with intravenous thiamine
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Wagner P, Bui T. Wernicke-Korsakoff Syndrome in a Hunger Striker Despite Oral Thiamine Supplementation. Int Med Case Rep J 2022; 15:399-403. [PMID: 35959495 PMCID: PMC9359357 DOI: 10.2147/imcrj.s377779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/30/2022] [Indexed: 11/23/2022] Open
Abstract
Case We present the case of a 49-year-old woman who underwent a 237-day hunger strike on the streets of Pittsburgh, Pennsylvania. Despite medical supervision and appropriate micronutrient supplementation, including higher-than-recommended dosing of oral thiamine, the patient developed Wernicke’s Encephalopathy and subsequent Korsakoff Syndrome. She is now permanently impaired. Introduction Hunger strikers are subject to numerous sequelae of micronutrient deficiency. Among these are the paired conditions of Wernicke’s Encephalopathy and Korsakoff Syndrome, conditions secondary to prolonged thiamine deficiency. Unfortunately, few published guidelines exist regarding the medical management of hunger strikers. Preventative dosing guidance is borrowed from what is recommended for prolonged malnourishment from eating disorders or chronic alcohol use. Available guidelines are rarely academic. Rather, they were created by governmental agencies for the management of hunger strikers in prison or similar states of detention or incarceration. There is an indirect body of evidence that oral thiamine supplementation is rarely protective against the sequelae of thiamine deficiency in hunger strikers. We discuss supplementation recommendations and the evidence for their failure in practice. We briefly explore the historical evidence for the anatomic and physiologic changes of prolonged starvation that potentially explain this treatment failure, and offer alternatives to standard supplementation. Conclusion The current recommendations of the management of hunger strikers regarding the prevention of thiamine deficiency are inadequate, and rarely prevent the clinical sequelae. Alternate management strategies need to be both researched and empirically used, while that research is being carried out. Novel lipid-soluble thiamine derivatives have promise, but prophylactic intravenous/intramuscular thiamine should be explored as the current standard of care.
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Affiliation(s)
- Phillip Wagner
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
- Correspondence: Phillip Wagner, Email
| | - Thuy Bui
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Micronutrient Deficiencies Presenting with Optic Disc Swelling Associated with or without Intracranial Hypertension: A Systematic Review. Nutrients 2022; 14:nu14153068. [PMID: 35893919 PMCID: PMC9331791 DOI: 10.3390/nu14153068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a neurological disorder characterised by optic disc swelling secondary to raised intracranial pressure (ICP) of unknown cause. Obesity is the most established and prevalent risk factor in developed countries. As obesogenic diets are high in calories and nutrient-poor, there may be associated nutritional deficiencies that contribute to the clinical presentation of IIH. Yet none, aside from iron deficiency, are currently included in the inclusion or exclusion criteria for the diagnosis of IIH. Our primary aim was to determine which micronutrient deficiencies, aside from iron deficiency, could present with optic disc swelling associated with or without intracranial hypertension that could potentially meet current IIH diagnostic criteria. To this end, we conducted a systematic search of articles published between 1 January 1980 and 18 December 2020 reporting cases of optic disc swelling associated with micronutrient deficiencies. In total, 65 cases met the eligibility criteria from initial searches: all were case reports and case series with a high risk of bias. Our findings suggest that patients with IIH or unexplained optic disc swelling ought to be screened, investigated, and treated for associated micronutrient deficiencies in vitamin A, B1 and B12; and weight loss interventions in IIH patients ought to promote better nutrition in addition to overall calorie restriction.
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Brown S, Hutt-Williams S. Wernicke's encephalopathy in advanced cancer. BMJ Support Palliat Care 2022; 12:460-462. [PMID: 35831181 DOI: 10.1136/spcare-2022-003787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
Abstract
This 54-year-old woman with metastatic breast cancer presented with severe confusion, incontinence and self-neglect. MRI suggested Wernicke's encephalopathy (WE) without any history of alcohol misuse. The patient's symptoms seemed to not respond to acute treatment. Cancer progression was assumed to be causing her condition and she was discharged to a nursing home with community palliative care team follow-up. This case demonstrates the natural course of cancer-associated WE and eventual improvement with thiamine therapy. It also illustrates a role for specialist palliative care follow up for patients discharged to a nursing home for expected end-of-life care.
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Affiliation(s)
- Samantha Brown
- Palliative Medicine, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Suzanne Hutt-Williams
- Palliative Medicine, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
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Koury M, Tantum J, Savard C, Donohue J. A Case of Wernicke’s Encephalopathy Due to Idiopathic Gastroparesis: A Rare Cause of Encephalopathy in a Young Woman. Cureus 2022; 14:e25653. [PMID: 35784977 PMCID: PMC9249061 DOI: 10.7759/cureus.25653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2022] [Indexed: 11/05/2022] Open
Abstract
Wernicke’s encephalopathy (WE) is a rare, life-threatening neurological disease due to thiamine deficiency. It is most commonly associated with chronic alcoholism but is also associated with disorders of malabsorption and malnutrition. We present a case of a young female with idiopathic gastroparesis who developed Wernicke’s encephalopathy due to poor oral intake and malnutrition as a result of gastroparesis. This case exemplifies that Wernicke’s encephalopathy should be on the differential in patients who present with encephalopathy with a history of gastroparesis.
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Hari T, Elsherbiny S. Bariatric surgery-what the ophthalmologist needs to know. Eye (Lond) 2022; 36:1147-1153. [PMID: 34675393 PMCID: PMC8529860 DOI: 10.1038/s41433-021-01811-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/06/2021] [Accepted: 10/05/2021] [Indexed: 11/09/2022] Open
Abstract
The incidence of bariatric surgery is increasing due to obesity being one of our top public health challenges. As such, bariatric-related ophthalmic changes are a potentially new clinical area of knowledge, with increasing published evidence on post-bariatric complications experienced by patients and identified by clinicians. We reviewed the available literature and summarised the different complications and potential recommendations. A search strategy was conducted with PubMed, Cochrane, Medline, Embase, Allied and Complementary Medicine and DH-DATA databases to look for papers answering our research question: "What are the ophthalmological complications for patients after bariatric surgery?". Our search gave a total of 59 relevant papers. Bariatric surgery, particularly subtypes that cause direct bypass of nutrients from the stomach, lead to nutritional deficiencies. Vitamin A, crucial for proper functioning of body systems and specialised cells, manifests ophthalmologically as corneal ulceration, nyctalopia, conjunctival xerosis and more. Thiamine levels are also depleted, leading to Wernicke's Encephalopathy. Pre-existing diabetic retinopathy is also noted to worsen sub acutely, although evidence is conflicting. Patients undergoing surgery to treat idiopathic intracranial hypertension would have reduced IOP and resolving papilloedema. Other comorbidities of obesity like HBA1C levels, obstructive sleep apnoea, and metabolic syndrome also resolve post-surgery. History taking remains the cornerstone of medical practice. From the evidence, we suggest consideration of pre-surgery screening for ophthalmic pathology and post-operative monitoring of disease progression. Real-world data needs to continuously be analysed to create definitive management pathways that can help clinicians recognise ophthalmic complications early, improving patient outcomes.
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Affiliation(s)
| | - Samer Elsherbiny
- Machen Eye Unit, South Warwickshire NHS Foundation Trust, Warwick, UK
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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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Seto N, Ishida M, Hamano T, Onishi H, Uchida N. A case of Wernicke encephalopathy arising in the early stage after the start of hemodialysis. CEN Case Rep 2022; 11:314-320. [PMID: 34988882 DOI: 10.1007/s13730-021-00669-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/27/2021] [Indexed: 11/29/2022] Open
Abstract
Wernicke encephalopathy (WE) resulting from vitamin B1 (VB1) deficiency is commonly regarded as being associated with a high alcohol intake; however, recently many non-alcohol-related cases have been reported. Herein, we report a case of WE due to VB1 deficiency in the early stage after the start of hemodialysis. The patient was a 79-year-old male recommended for hemodialysis due to chronic renal failure. He was admitted to our hospital due to a hemorrhagic duodenal ulcer, but hemodialysis was started as the result of exacerbation of renal function. After the start of 3-times-weekly hemodialysis, the patient's general condition was settled and he was able to consume about half his usual dietary intake. Seventeen days after the start of hemodialysis, impaired consciousness and involuntary movements appeared, and subsequent head magnetic resonance imaging showed increased signal intensity around the cerebral aqueduct. VB1 administration based on a suspicion of WE resulted in a significant improvement in neurological symptoms and no sequelae were observed. Hemodialysis may be a risk factor for VB1 deficiency. When a dialysis patient presents with psychiatric symptoms or impaired consciousness, in particular, it is important to always keep the possibility of VB1 deficiency in mind.
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Affiliation(s)
- Nayuta Seto
- Department of Internal Medicine, Chichibu Municipal Hospital, 8-15 Kumaki Twon, Chichibu City, Saitama, 368-8686, Japan
| | - Mayumi Ishida
- Department of Psycho-Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Saitama, 350-1298, Japan
| | - Tatsuya Hamano
- Department of Urology, Chichibu Municipal Hospital, 8-15 Kumaki Twon, Chichibu City, Saitama, 368-8686, Japan
| | - Hideki Onishi
- Department of Psycho-Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Saitama, 350-1298, Japan.
| | - Nozomu Uchida
- Department of Internal Medicine, Ogano Town Central Hospital, 300 Ogano, Ogano Town, Saitama, 368-0105, Japan.,Department of General Medicine, Saitama Medical University International Medical Center, 1397-1 Yamane, Saitama, 350-1298, Japan
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Clinical diagnosis, outcomes and treatment of thiamine deficiency in a tertiary hospital. Clin Nutr 2021; 41:33-39. [PMID: 34864453 DOI: 10.1016/j.clnu.2021.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 10/09/2021] [Accepted: 10/29/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute thiamine deficiency can occur in patients with or without history of alcohol abuse and can lead to life-threatening complications. Clinical diagnosis is challenging, often resulting in delayed recognition and treatment. Patients may present with heterogenous symptoms, more diverse than the historical neurological description. Cerebral MRI can contribute to the diagnosis in patients with neurological signs but it is not always feasible in emergency settings. Prompt parenteral supplementation is required to obtain the improvement of symptoms and avoid chronic complications. AIMS To describe the clinical presentation of reported cases of thiamine deficiency, assess prescription and results of cerebral imaging, review treatments that had been prescribed in accordance or not with available guidelines, and study the short-term outcome of these patients. METHODS This is a monocentric retrospective analysis of all reported cases of thiamine deficiency in a French tertiary hospital between January 1st 2008 and December 31st 2018. RESULTS Fifty-six cases were identified during the study period. Forty-five (80%) patients had a history of alcohol abuse. Most patients were diagnosed based on neurological symptoms but non-specific and digestive symptoms were frequent. Thirty-four percent of patients fulfilled clinical criteria for malnutrition. A brain MRI was performed in 54% of patients and was abnormal in 63% of these cases. Eighty-five percent of patients were treated by parenteral thiamine administration and the supplementation was continued orally in 55% of them. The majority of patients initially received 1000 mg daily of IV thiamine but the dose and duration of thiamine supplementation were variable. At the time of discharge, partial or complete improvement of symptoms was noted in 59% of patients. CONCLUSION This study highlights the clinical and radiological heterogeneity of thiamine deficiency. These observations should encourage starting thiamine supplementation early in patients with risk factors or suggestive symptoms even in non-alcoholic patients, and underline the importance of early nutritional support.
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Velotti N, Vitiello A, Berardi G, Milone M, Musella M. Comment on "Wernicke-Korsakoff syndrome despite no alcohol abuse: A summary of systematic reports" - A matter of bariatric patients' management. J Neurol Sci 2021; 427:117569. [PMID: 34253350 DOI: 10.1016/j.jns.2021.117569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/02/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Nunzio Velotti
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Italy.
| | - Antonio Vitiello
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Italy
| | - Giovanna Berardi
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Italy
| | - Mario Musella
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Italy
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