Wernicke's encephalopathy: new clinical settings and recent advances in diagnosis and management

Brain MRI: A safe and a specific tool in the diagnosis of Gayet Wernicke's encephalopathy in pregnant women: Case report

Gayet-Wernicke encephalopathy (GWE) is a neuropsychiatric syndrome due to Vitamin B1 (thiamine) deficiency, fatal in 30% of cases and preventable if treatment is initiated early, characterized by the classic triad of encephalopathy, ocular involvement: ophthalmoplegia and/or nystagmus and ataxia. GWE is mainly observed in alcoholics, but can also appear in any state of malnutrition. In obstetrics, hyperemesis gravidarum can be complicated by GWE due to low thiamine stores and increased thiamine requirements. We report a case of Gayet-Wernicke encephalopathy complicating incoercible vomiting in a pregnant woman.

Bilateral hearing loss as the initial presentation of reversible Wernicke's encephalopathy with splenial lesion

BACKGROUND

Wernicke's encephalopathy (WE) is an acute neurological syndrome resulting from thiamine (vitamin B1) deficiency. It has been recognized increasingly in non-alcoholic patients, such as in the condition of malnutrition. Recent literature has shed light on uncommon symptoms and neuroimaging findings.

CASE REPORT

We reported a case of a 44-year-old male who initially presented with bilateral hearing loss, and exhibited abnormality in the splenium of the corpus callosum on magnetic resonance imaging (MRI) diffusion-weighted imaging sequence. On the following day the patient developed new symptoms, including unstable walking, double vision and hallucination. The subsequent brain MRI demonstrated lesions involving periaqueductal grey matter and bilateral medial thalamus, indicating the diagnosis of WE. Empirical treatment with intravenous thiamine resulted in complete clinical and radiological resolution.

CONCLUSION

To the best of our knowledge, the current case is the first report of WE in literature with uncommon but reversible manifestations. This case warns us to maintain a heightened level of suspicion for WE in malnourished patients with neurological deficits, despite the possibility of atypical presentations encompassing bilateral hearing disturbances and unusual neuroradiological results. Early diagnosis and timely administration of thiamine in WE are likely to lead to a favorable outcome and full recovery.

Treatment of nasopharyngeal carcinoma and prevention of non-alcoholic Wernicke’s disease: A case report and review of literature

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.

Beyond the bowel: Wernicke's encephalopathy as a neurological complication of Crohn's disease: A case report

Wernicke encephalopathy (WE) is a rare but severe neurological syndrome characterized, in its classic form, by the acute onset of ocular disturbances, ataxia, and cognitive impairment. It is caused by a deficiency of thiamine (vitamin B1) and mainly affects chronic alcoholics, although it can also affect patients with pathologies that lead to malnutrition. We present a case of a 58-year-old woman, who presented with significant weight loss over the past 6 months and who came to the emergency department for episodes of repetitive vomiting and a sleepy state. The patient underwent blood chemistry tests and a brain CT scan, which revealed symmetrical and bilateral hypodensity of the medial portion of the thalamus, tectal plate, and periaqueductal gray matte, suggestive of WE. She was subsequently referred to the Department of Neurology and underwent a brain MRI, which confirmed the clinical suspicion. She also had an abdominal CT scan and ileo-colonoscopy and was diagnosed with Crohn's disease. Immediately after the clinical diagnosis of WE, a replacement therapy based on intravenous thiamine at high doses was promptly set up, and the patient improved from a clinical point of view. Wernicke encephalopathy can be difficult to diagnose when it occurs in non-alcoholic patients; WE associated with IBD is a rare condition, and it can present with atypical and more subtle symptoms. Radiologists and physicians must be aware of this condition and imaging findings for rapid diagnosis and treatment.

Cognitive impairment among alcohol treatment service users in South Wales: an exploratory examination of typologies of behaviour, impairment, and service attendance

Introduction

Alcohol dependence is a global issue with many negative consequences, including alcohol-related brain damage (ARBD). Assessment of the sociodemographic and cognitive characteristics of individuals with confirmed or suspected ARBD presenting to alcohol services warrants further investigation.

Methods

This study retrospectively examined rates of cognitive impairment using Montreal Cognitive Assessment (MoCA) data from 300 adults who visited three alcohol support services. We demonstrate that 55.3% of the sample had significant levels of cognitive impairment. Females' cognitive performance was disproportionately negatively affected by historical alcohol use relative to males.

Results

The analysis identified four categories of participants, and the majority had a long history (+10 years) of alcohol use and were still actively drinking. Those taking part in active treatment for ARBD or practising abstinence demonstrated lower levels of cognitive impairment. Additionally, prior access to specialised ARBD care was associated with higher MoCA scores.

Discussion

This research has identified a range of key service engagement, sociodemographic and cognitive characteristics that could be used to optimise support for those with alcohol dependence, whilst also highlighting some critical questions to be addressed in future research.

Predicting Recurrent Deficiency and Suboptimal Monitoring of Thiamin Deficiency in Patients with Metabolic and Bariatric Surgery

INTRODUCTION

Vitamin B1 (thiamine) deficiency (TD) after metabolic and bariatric surgery (MBS) is often insidious and, if unrecognized, can lead to irreversible damage or death. As TD symptoms are vague and overlap with other disorders, we aim to identify predictors of recurrent TD and failure to collect B1 labs.

METHODS

We analyzed a large sample of data from patients with MBS (n = 878) to identify potential predictors of TD risk. We modeled recurrent TD and failure to collect B1 labs using classical statistical and machine learning (ML) techniques.

RESULTS

We identified clusters of labs associated with increased risk of recurrent TD: micronutrient deficiencies, abnormal blood indices, malnutrition, and fluctuating electrolyte levels (aIRR range: 1.62-4.68). Additionally, demographic variables associated with lower socioeconomic status were predictive of recurrent TD. ML models predicting characteristics associated with failure to collect B1 labs achieved 75-81% accuracy, indicating that clinicians may fail to match symptoms with the underlying condition.

CONCLUSIONS

Our analysis suggests that both clinical and social factors can increase the risk of life-threatening TD episodes in some MBS patients. Identifying these indicators can help with diagnosis and treatment.

Thiamine use is associated with better outcomes for traumatic brain injury patients

Background

Traumatic brain injury (TBI) is a global health concern that often leads to poor prognosis. We designed this study to explore whether thiamine use is associated with a better prognosis of TBI.

Methods

TBI patients selected from the Medical Information Mart for Intensive Care-III database were included in the study. Univariate and multivariate Cox regression analyses were performed to examine the relationship between thiamine use and mortality in TBI patients. Propensity score matching (PSM) was utilized to generate balanced cohorts of the non-thiamine use group and the thiamine use group. Subgroup analysis was performed in the cohort after PSM to verify the association between thiamine use and mortality in TBI patients across different stratifications.

Results

The incidence of thiamine use in TBI was 18.3%. The thiamine use group had a lower 30-day mortality rate (p < 0.001), a longer length of ICU stay (p < 0.001), and a longer length of hospital stay (p < 0.001) than the non-thiamine use group, both in the primary cohort before PSM and the cohort after PSM. A multivariate Cox regression analysis confirmed that thiamine use was independently associated with mortality (OR = 0.454, p < 0.001) after adjusting for confounding effects. In the cohort after PSM, the subgroup analysis showed that thiamine use is associated with lower mortality in TBI patients with a Glasgow Coma Scale (GCS) score of < 13, but it is not associated with mortality in TBI patients whose GCS score is ≥13.

Conclusion

Thiamine supplementation is effective in improving the outcome of TBI, except in cases of mild TBI. The optimal thiamine supplementation strategy for TBI is worthwhile to be explored in future studies.

Wernicke's encephalopathy treated with high dose intravenous thiamine: a case report

Wernicke's encephalopathy (WE) is a dangerous and potentially fatal neurological condition associated with thiamin deficiency. The standard treatment for WE is intravenous (IV) thiamin, but limited research describes optimal dosing. We present a case of a 40-year-old male with severe alcohol use disorder (AUD) and chronic malnourishment who developed WE. Upon administration of 100 mg IV thiamin, symptoms of WE persisted, but when the dose was increased to 500 mg, altered mental status and ophthalmoplegia resolved rapidly. IV thiamin is a reliable and low-risk treatment for WE, even when administered at high doses. High-dose IV thiamin (i.e., >/100 mg) can treat neurological symptoms and cognitive dysfunction in WE and should be considered for first-line treatment. Further study of WE diagnostic and treatment guidelines is warranted to maximize recovery potential.

Reversible Bilateral Vision Loss: An Unusual Presentation of Wernicke-Korsakoff Syndrome

Neuro-ophthalmic manifestations of Wernicke encephalopathy (WE) are uncommon and vary from nystagmus, oculomotor palsies, anisocoria, and optic disc edema to vision loss. We describe a case of a 53-year-old woman presenting with subacute bilateral painless vision decline, lower-extremities weakness with impaired ambulation, headache, and abdominal pain. Neurological examination was pertinent for confabulation, bilateral decreased visual acuity with an absent blink to threat, absent afferent pupillary defect and fundus abnormalities, and significant allodynia in bilateral lower extremities. Besides elevated inflammatory marker with an erythrocyte sedimentation rate (ESR) of 130 mm/hr, her infectious, autoimmune, paraneoplastic, and neuromyelitis optica work-up was overall unremarkable. Brain MRI showed abnormal fluid-attenuated inversion recovery (FLAIR) signaling in bilateral mammillary bodies and around periaqueductal gray matter concerning WE. Due to concerns of Wernicke-Korsakoff syndrome (WKS), parenteral high-dose thiamine was initiated with significant clinical improvement. The patient was also later found to have a positive anti-myelin oligodendrocyte glycoprotein (MOG) antibody, which was deemed false positive given the atypical phenotype and symptomatic improvement with thiamine supplementation. This case encourages the consideration of vision loss as a manifestation of WKS, especially in patients who have risk factors. Testing serum levels of thiamine is strongly encouraged; however, initiating empiric treatment is advocated for high clinical suspicion due to its reversible nature and minimal risk for side effects.

A Patient With Slow Communication and Difficulty Walking

A 70-year-old woman with hypertension and dyslipidemia presented with slow communication and difficulty walking 90 days after 6 courses of postoperative chemotherapy following right breast cancer surgery. What is your diagnosis?

Typical and atypical MRI abnormalities in Wernicke's encephalopathy: Correlation with blood vitamin B1 levels

PURPOSE

Clinical features of Wernicke's encephalopathy (WE) confirmed strictly through the low blood vitamin B1 (VB1) levels are limited. This study aimed to analyse magnetic resonance imaging (MRI) findings, and clinical characteristics, in patients with WE who have confirmed low blood VB1 levels.

METHODS

Clinical and laboratory records of 12 consecutive patients with WE admitted to our hospital during the past 11 years were reviewed. The WE diagnosis was confirmed based on low blood VB1 levels and the presence of at least one of the classical triad.

RESULTS

Ophthalmoplegia and nystagmus were recorded in 75% and 50% of the patients, respectively. Eleven of 12 patients presented with consciousness disturbance/memory loss. All patients experienced gait disturbances. Eight of the 12 patients exhibited MRI abnormalities at typical sites (the dorsal midbrain [n = 7], medial thalamus [n = 6], mammillary bodies [n = 5], and dorsal pons [n = 5]). Of the 12 patients, six showed abnormalities at atypical sites (the splenium of the corpus callosum [n = 4], fornix [n = 3], cerebral cortex [n = 2], cerebellar vermis [n = 2], and dorsal medulla [n = 1]). Patients with positive MRI abnormalities had significantly lower blood VB1 levels than those without abnormalities (9.5 vs. 16.0 ng/mL).

CONCLUSIONS

In cases of confirmed WE with low blood VB1 levels, the corpus callosum, fornix, and cerebral cortex were more frequently involved than in previous studies. MRI abnormalities at both typical and atypical sites were correlated with low blood VB1 levels in WE, suggesting that lower blood VB1 levels are associated with more severe brain damage in patients with WE.

The Weight of Bariatric Surgery: Wernicke-Korsakoff Syndrome after Vertical Sleeve Gastrectomy-A Case Series

In this case series, the simultaneous occurrence of Wernicke's encephalopathy (WE) and dry beriberi was reported in three patients who underwent vertical sleeve gastrectomy (VSG) between May 2021 and May 2023. All patients were obese women who underwent vertical sleeve gastrectomy (VSG) without immediate postoperative complications, but two weeks later, hyperemesis and subsequent encephalopathy with ocular movement abnormalities and weakness were observed over the following thirty days. Patients were referred to neurology, where due to the high suspicion of WE, thiamine replacement therapy was initiated; meanwhile, diagnostic neuroimaging and blood tests were conducted. Neurological and psychiatric evaluations and neuroconduction studies were performed to assess the clinical evolution and present sequelae. One year after diagnosis, all patients exhibited affective and behavioral sequelae, anterograde memory impairment, and executive functioning deficits. Two patients met the criteria for Korsakoff syndrome. Additionally, peripheral nervous system sequelae were observed, with all patients presenting with sensorimotor polyneuropathy. In conclusion, Wernicke's encephalopathy requires a high diagnostic suspicion for timely intervention and prevention of irreversible sequelae, which can be devastating. Therefore, raising awareness among medical professionals regarding the significance of this disease is essential.

Wernicke Encephalopathy After Roux-en-Y Gastric Bypass Presenting with Altered Mental Status-A Video Case Report

Wernicke encephalopathy (WE) is a seldom encountered yet significant neuropsychiatric ailment resulting from a deficiency in thiamine (vitamin B1). While commonly linked with chronic alcoholism or insufficient dietary intake, instances of WE following bariatric and metabolic surgeries, notably laparoscopic Roux-en-Y gastric bypass (RYGB), have been sporadically documented. This case study elucidates the condition of a male patient who, 3 months after undergoing RYGB to address severe obesity, displayed abrupt alterations in mental status, swiftly ameliorated by immediate administration of intravenous high-dose thiamine.

Diagnosis, management and outcomes of primary hypokalemic periodic paralysis during pregnancy

Primary hypokalaemic periodic paralysis during pregnancy has been rarely reported. Four pregnant women with the acute onset of flaccid paralysis presented between January 2018 and December 2021. Focussed history and physical examination helped an appropriate radiological and laboratory investigation plan to be made. All women recovered within 4-7 days of potassium supplementation. Supplemental potassium continued until delivery. A pain management plan with continuous epidural infusion helped in avoiding stress-induced hypokalaemia. None of the women developed an episode of muscle weakness during the intervening period. In conclusion, a focussed history and targeted laboratory investigation are needed to diagnose primary hypokalaemic periodic paralysis. Early administration of oral or intravenous potassium is crucial in improving fetomaternal outcomes.

[Substance use disorder: Epidemiology, medical consequences and treatment]

Substance use is a common health problem, and substance use disorder, which is its most severe presentation, is associated with multiple medical consequences and a negative impact on individual and on population health. Substance use disorder needs to be addressed as any chronic medical condition; therefore, it has to be detected at the early stages and has to be properly treated to prevent drug-related harm. Internists should be able to recognize and treat intoxication and abstinence. Internists should also be able to refer the patient to state of the art long term treatment, aimed to detoxification and treatment induction to promote abstinence and prevent relapse. In this narrative review we will discuss substance use epidemiology, its main medical consequences and its treatment, with a focus on alcohol, opiates, cocaine and other stimulants, cannabis and benzodiazepines.

Seizures in the third trimester of pregnancy- A rare case of Wernicke's encephalopathy mimicking Eclampsia

Unless otherwise demonstrated, seizures during pregnancy that happen after 20 weeks of gestation are typically caused by eclampsia. In our clinical case we report the diagnostic challenge of Wernicke's encephalopathy occurring at 34 weeks and mimicking an eclamptic attack. This is about a 30-year-old female patient who suffers from hyperemesis gravidarum during her pregnancy. she has no known history of epilepsy .The patient was brought to the emergency room by medical transport at 34 weeks of gestation due to a seizure at home. The initial diagnosis was eclampsia. Emergency high-level extraction under general anesthesia was decided for maternal rescue. However, after extubation, the patient's condition deteriorated, with the onset of a confusion syndrome characterized by agitation, temporal-spatial disorientation, attention and vigilance disorders, and challenging communication. Angio MRI was performed, revealing signs consistent with Wernicke's encephalitis.

Water-soluble vitamins and trace elements in children with chronic kidney disease stage 5d

Children receiving maintenance dialysis (chronic kidney disease (CKD) stage 5d) have unique risk factors for micronutrient deficiency or toxicity. Children receiving chronic dialysis often require specialized diet plans that may provide more than the recommended daily allowance (RDA) of water-soluble vitamins and micronutrients, with or without the addition of a kidney-friendly vitamin. The following is a comprehensive review of current literature on disorders of micronutrients in this population including those of water-soluble vitamins (vitamin C and vitamin B complexes) and trace elements (copper, selenium, and zinc) and has three areas of focus: (1) the risk factors and clinical presentations of disorders of micronutrients, both deficiency and toxicity, (2) the tools to evaluate micronutrient status, and (3) the central role of renal dietitians in optimizing nutritional status from a micronutrient perspective.

Hospital Outcomes in Medical Patients With Alcohol-Related and Non-Alcohol-Related Wernicke Encephalopathy

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.

Vitamin deficiencies in children: Lessons from clinical and neuroimaging findings

BACKGROUND AND AIMS

Water-soluble vitamins play an essential coenzyme role in the nervous system. Acquired vitamin deficiencies are easily treatable, however, without treatment, they can lead to irreversible complications. This study aimed to provide clinical, laboratory parameters and neuroimaging data on vitamin deficiencies in an attempt to facilitate early diagnosis and prompt supplementation.

METHODS

From July 1998 to July 2023, patients at Necker-Enfants-Malades Hospital presenting with acute neurological symptoms attributed to acquired vitamin deficiency were included. Clinical data were extracted from Dr Warehouse database. Neuroimaging, biochemical and electrophysiological data were reviewed.

RESULTS

Patients with vitamin B1 deficiency exhibited abnormal eye movements (n = 4/4), fluctuations in consciousness (n = 3/4), and ataxia (n = 3/4). Brain MRI showed alterations of fourth ventricle region (n = 4/4), periaqueductal region (n = 4/4), tectum (n = 3/4), and median thalami (n = 3/4). Patients with vitamin B2 deficiency presented with early onset hypotonia (n = 3/4), hyperlactatemia (n = 4/4), and hyperammonemia (n = 4/4). Plasma acylcarnitines revealed a multiple acyl-coA dehydrogenase deficiency-like profile (n = 4/4). In vitamin B12 deficiency, young children presented with developmental delay (n = 7/7) and older children with proprioceptive ataxia (n = 3/3). Brain MRI revealed atrophy (n = 7/7) and spinal MRI hyperintensity in posterior cervical columns (n = 3/3). Metabolic findings showed elevated methylmalonic acid (n = 6/7) and hyperhomocysteinemia (n = 6/7). Patients with vitamin C deficiency exhibited gait disturbances and muscle weakness (n = 2/2).

CONCLUSIONS

Acquired vitamin deficiencies may display reversible clinical symptoms mimicking inherited metabolic disorders. Some situations raise suspicion for diagnosis: concordant clinical presentation, suggestive neuroimaging findings, and/or biochemical evidence. Any acute neurological condition should be treated without waiting for definitive biochemical confirmation.

Wernicke encephalopathy induced by glucose infusion: A case report and literature review

Introduction

Wernicke encephalopathy (WE) is a potentially fatal condition caused by thiamine (vitamin B1) deficiency. Chronic alcoholism is the most common cause of WE; however, other conditions responsible for thiamine deficiency should also be considered.

Case Report

We report the case of a 64-year-old woman with a history of diabetes who presented with confusion and apathy. Magnetic resonance imaging of the brain showed T2 hyperintensities involving dorsolateral medulla oblongata, tegmentum of the pons, vermis of the cerebellum, periaqueductal region, and the bilateral mammillary bodies. She had a history of intravenous glucose administration before her mental symptoms developed. On suspicion of WE, she was treated with a high dose of thiamine empirically. Her clinical condition improved rapidly in 2 weeks.

Conclusion

Endogenous thiamine stores can be rapidly depleted in the case of enhanced glucose oxidation. Patients who receive glucose should also be prescribed thiamine to avoid inducing or exacerbating WE.

Neuromyelitis Optica Spectrum Disorder Resembling Wernicke's Encephalopathy: A Case Report and Review of the Literature

We describe a case of Neuromyelitis Optica Spectrum Disorder (NMOSD) mimicking Wernicke's Encephalopathy (WE) to highlight an atypical presentation of NMOSD. A 39-year-old female presented with subacute encephalopathy and progressive ophthalmoplegia. Her MRI revealed T2 hyperintensities involving the mammillary bodies, periaqueductal grey matter, medial thalami, third ventricle, and area postrema. Whole blood thiamine levels were elevated and she did not improve with IV thiamine. CSF was notable for lymphocytic pleocytosis and elevated protein. She tested positive for serum Aquaporin-4 (AQP4) antibody. Subsequent imaging revealed multilevel lesions in the cervical and thoracic spinal cord. Her CSF GFAP antibody also came back positive. She steadily and significantly improved after high-dose IV steroids and plasmapheresis. She later started on chronic rituximab therapy. This represents a unique case of NMOSD presenting with the classical clinical and imaging features of WE, as opposed to the typical presenting symptoms of NMOSD. As such, demyelinating disorders should be considered when there is concern for diencephalic and midline pathologies, particularly without classic WE risk factors. Conversely, clinicians should be aware of secondary nutritional complications arising from severe area postrema syndrome.

Acute encephalopathy in the ICU: a practical approach

PURPOSE OF REVIEW

Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury.

RECENT FINDINGS

Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes.

SUMMARY

Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.

Thiamine deficiency as a cause of anorexia in terminally ill cancer patients: A case of possible gastrointestinal beriberi

OBJECTIVES

Anorexia in cancer patients has a variety of causes and impairs patients' quality of life. However, there have been few reports of thiamine deficiency (TD) playing a role in anorexia during palliative care. The objective of this report was to describe such a case.

METHODS

An 82-year-old woman with advanced cervical cancer was admitted for palliative care because of progressive disease. One month after admission, she developed myoclonus on the left side, difficulty speaking, slurred speech, and drooping of the left corner of the mouth, with no consciousness disturbance. She also developed nausea and complained of decreased dietary intake for more than 2 weeks.

RESULTS

The patient's thiamine level, which had been measured 2 weeks earlier, was 27 ng/ml, which was below the normal range, and 100 mg of thiamine was administered intravenously. After 2 hours, the patient's neurological findings resolved, and her dietary intake improved from 30% to 40% of meals to 90% to 100%. Subsequently, the patient did not experience similar symptoms, and her clinical course was stable. Based on the patient's clinical course, gastrointestinal beriberi was diagnosed.

SIGNIFICANCE OF RESULTS

This case shows that TD may cause anorexia. Many patients who receive palliative care have decreased dietary intake. Consequently, such patients may present with gastrointestinal beriberi, as in the present case. Appropriate diagnosis and treatment may contribute to increasing such patients' quality of life. It may be necessary to differentiate TD from other conditions as a cause of anorexia in patients receiving palliative care.

Thiamine deficiency-related neuropathy: A reversible entity from an endemic area

BACKGROUND AND PURPOSE

Despite thiamine deficiency being a lesser-known entity in modern times, beriberi in various forms, including thiamine deficiency-related neuropathy, remains endemic in Kashmir due to the consumption of polished rice as a staple food. This observational study investigates cases of peripheral neuropathy of unknown etiology and their potential responsiveness to thiamine administration.

METHODS

This prospective study enrolled adult patients presenting to the emergency department with weakness consistent with thiamine deficiency-related neuropathy and conducted a therapeutic challenge with thiamine on 41 patients. Response to thiamine therapy was monitored based on subjective and objective improvements in weakness and power. Patients were divided into thiamine responders (n = 25) and nonresponders (n = 16) based on their response to thiamine therapy and nerve conduction studies.

RESULTS

Most of the baseline characteristics were similar between responders and nonresponders, except the responders exhibited lower thiamine levels and higher partial pressure of oxygen and lactate levels compared to nonresponders. All patients had a history of consuming polished rice and traditional salt tea. Although weakness in the lower limbs was present in both groups, nonresponders were more likely to exhibit weakness in all four limbs. Clinical improvement was observed within 24 h, but proximal muscle weakness persisted for an extended period of time.

CONCLUSIONS

Thiamine deficiency-related neuropathy presents with predominant lower limb weakness, exacerbated by vomiting, poor food intake, psychiatric illness, and pregnancy. Thiamine challenge should be followed by observation of clinical and biochemical response.

Unusual encephalopathy with Wernicke-Korsakoff syndrome-like features due to adjuvant nivolumab for malignant melanoma

INTRODUCTION

Autoimmune encephalitis is a rare immune-related adverse event of PD-1 inhibitors, nivolumab and pembrolizumab. Autoimmune hypophysitis can also be seen with the use of these agents. The relationship between these two phenomena is currently unknown.

CASE REPORT

We describe a 79-year-old man with anterior scalp melanoma who received adjuvant nivolumab therapy. Sixteen weeks after the completion of nivolumab therapy, the patient presented to the hospital with altered mental status, anterograde amnesia, and symptoms of nausea and vomiting. The patient's encephalopathy was associated with confabulations. Workup identified increased CSF protein without increased cellularity, along with decreased serum cortisol and ACTH levels. This was consistent with encephalitis and central adrenal insufficiency.

MANAGEMENT AND OUTCOME

The patient had a robust clinical response to steroids, with resolution of mental status changes and normalization of blood pressure. He continues to receive maintenance steroid therapy without any further symptoms six months later.

CONCLUSIONS

We report herein a unique case of encephalopathy in the setting of nivolumab use for the treatment of melanoma. The condition resembled Korsakoff psychosis seen in the setting of alcoholism and was associated with central adrenal insufficiency. A prompt response to steroids was both diagnostic and therapeutic in our case, suggesting the resolution of autoimmune phenomena related to nivolumab.

Wernicke's Encephalopathy in Acute and Chronic Kidney Disease: A Systematic Review

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.

Nutrition, Exercise, and Cognitive Rehabilitation for Dementia Prevention

Dementia is one of the most significant global challenges in medical and social care in the 21st century. It affects not only the patients themselves, but also their families, caregivers, and society in general, causing physical, psychological, and socioeconomic effects. As of 2020, there are approximately 6 million people in Japan aged 65 or older with dementia, and this number is expected to increase to around 7 million by 2025, meaning that one out of every five elderly people will have dementia. To prevent the onset and progression of dementia, it is crucial to have a proper understanding of its risks and adopt a healthy lifestyle. Leading an active life from an early stage can also aid in delaying or preventing the onset of dementia. Livingston has identified 12 risks that can lead to dementia, including physical inactivity, smoking, excessive alcohol consumption, air pollution, head injury, social isolation, poor educational history, obesity, hypertension, diabetes, depression, and hearing loss. Modifying one's lifestyle and leading an active life can be crucial in reducing these risks. The Mediterranean diet is gaining attention as a good practice for dementia prevention due to its diversity, richness in omega-3 fatty acids and vitamins. Exercise has been shown to prevent dementia on biological, behavioral, and socio-psychological levels. Repetitive transcranial magnetic stimulation is a non-invasive brain stimulation method that can alter brain plasticity and is being studied for clinical applications as a non-drug therapy for preventing dementia progression.

Long-Term Impacts of a Targeted Intervention in the Emergency Department on Inpatient Prescribing Practices

Background: In 2009, researchers successfully implemented an intervention to decrease the inappropriate prescribing of multivitamin infusions (MVIs) in the emergency department (ED) for patients presenting with alcohol-related illnesses. Objective: The purposes of our study were to determine the impact of the 2009 intervention on hospital-wide prescribing practices of vitamin therapies for alcohol-related illnesses, and to evaluate its long-term sustainability. Methods: A retrospective observational cohort study was conducted at a 60,000-visit ED, 811-bed academically-affiliated tertiary referral hospital with an average census of 515 and 714 patients in 2009 and 2019, respectively. Patients were included if they presented to the ED from 2009 to 2019 with an alcohol-related illness as defined by ICD-9 and ICD-10 codes. The primary outcome was the change in the monthly average of MVIs ordered inpatient within the first four months compared to the last four months of the study period. Secondary outcomes included changes in the mean distribution (MD) per month of thiamine administrations in the ED and inpatient setting, and MVIs ordered in the ED. Results: The MD of MVIs ordered per month decreased by 3.5% (95% CI -5.3, -1.7) in the inpatient setting and decreased by 1.4% (95% CI -2.5, -.3) in the ED from the beginning to the end of our study period. Conclusions: This study suggests the effects of an intervention made in the ED sustained impact over a 10-year timeframe, and decreased the use of MVIs in both the ED and hospital-wide.

What can cause cancer patients to attempt suicide? Thiamine deficiency mimicking the symptoms of major depressive disorder

OBJECTIVES

Thiamine deficiency (TD) presents with various physical and psychiatric symptoms, but no cases with depression-like symptoms have been reported.

METHODS

We report a patient with cancer who appeared to attempt suicide as a consequence of depressive mood likely related to TD.

RESULTS

The patient was a 58-year-old woman diagnosed with recurrent endometrial cancer, with lung metastasis and pelvic dissemination. The patient apparently attempted suicide was referred to the psycho-oncology department. At the time of the examination, major depressive disorder was suspected based on her mental symptoms, but when thiamine was administered intravenously in response to her poor dietary intake, her palpitations, dyspnea, anorexia, and insomnia improved, and her suicidal ideation disappeared at her reexamination 1 hour later after thiamine administration.

SIGNIFICANCE OF RESULTS

It is likely that the observed palpitations, dyspnea, anorexia, and insomnia, as well as the severe depression and the attempted suicide, which were thought to be physical symptoms associated with depression, were actually related to TD. Suicidal ideation and attempted suicide are conspicuous as psychiatric symptoms. However, in such cases, rather than simply starting treatment for depression, it is necessary to consider reversible TD as a cause of these symptoms and perform differential diagnosis to confirm the physical illness.

Rehabilitation Strategies for Wernicke-Korsakoff Syndrome: Physiotherapy Interventions and Management Approaches

Korsakoff syndrome and Wernicke's encephalopathy (WE) show neurological and cognitive deficits. Wernicke-Korsakoff syndrome (WKS) is a compound neurological condition. The cause of this neurological condition could be the consumption of alcohol regularly for a chronic duration. A tailored rehabilitation protocol that focuses on cognitive and physical deficiencies was implemented along with thiamine supplementation for managing a case of a 49-year-old male patient who had a history of high alcohol consumption and was exhibiting typical signs of WKS. After planning a proper physiotherapy plan, it is necessary to look after the patient's progress along with re-evaluation, which reveals notable gains in cognitive function, memory, and functional independence. There is a dearth of research on the impact of physical therapy in managing WKS. The above case report reflects the benefits of combining physiotherapy, cognitive rehabilitation, and balance training to improve patient functionality and independence. Tailored rehabilitation interventions like the Benson relaxation method (BRM), brain gym exercises, Frenkel's exercise, electrical stimulation, sensorimotor training, basic body awareness therapy (BBAT), and gait training can be used to enhance a patient's quality of life. Addressing individual needs is essential in managing WKS, focusing on the importance of comprehensive care beyond cognitive rehabilitation alone.

Atypical Wernicke's encephalopathy without mental status changes following bariatric surgery in an adolescent patient

Morbid obesity is a systemic disease which can result in chronic complications, including hypertension, diabetes mellitus, depression, osteoarthritis and low self-esteem in the adolescent population.Bariatric surgery can be indicated to treat more severe forms of obesity, but these procedures are not without long-term risks. Therefore, adequate preoperative and postoperative care, which includes preoperative psychosocial evaluation for compliance, ongoing nutrition counselling and vitamin and micronutrient supplementation, is required for all patients, especially adolescent patients, who generally may not comply with medical therapies and/or be able to developmentally fully appreciate or comprehend the health consequences of their behaviours, prior to as well as after bariatric surgery to prevent complications.Thiamine pyrophosphate, an active form of thiamine (also known as vitamin B1, a water-soluble vitamin), which functions as a coenzyme in glucose and energy metabolism, is one such vitamin that requires supplementation postoperatively. It is mandatory for glucose to be administered concomitantly with thiamine, as glucose alone can precipitate Wernicke's encephalopathy (WE) in thiamine-deficient individuals. WE is a medical emergency, with a mortality rate of up to 20%. WE is best understood as a classic triad of mental confusion, gait ataxia and eye movement abnormalities, and atypical WE or Wernicke's syndrome (WS) is seen when the classic triad is not present. Cases that meet some, but do not necessarily meet all three criteria, are referred to as atypical WE or WS which can lead to delayed diagnosis. Atypical WE has an incidence of 19% which can lead to misdiagnosis of a preventable medical emergency with fatal complications.The following case reviews the consequences of post-bariatric thiamine supplementation therapy non-adherence and resulting in a deficiency in an adolescent patient.

Wernicke Syndrome: Case Report and Literature Review of Contributing Factors-Can Malpractice Dynamics Be Identified?

Wernicke Encephalopathy (WE) is a neurological acute syndrome related to vitamin B1 deficiency and is relatively common in patients with chronic alcoholism. In the case of Hyperemesis Gravidarum, thiamine body stores become unable to meet the increased demand, resulting in acute deficiency. WE is associated with typical clinical and radiological findings. Treatment pathways rely on thiamine replacement. The case herein reported is centered around a 33-year-old diabetic patient at 12 weeks of gestation, with WE due to hyperemesis gravidarum. The disease manifested itself with weakness, mental confusion, headache, and impaired vision. The diagnosis was established after the detection of typical findings by MRI. Thirty days after therapy was started, most of the patient's neurological disorders were resolved. The patient was discharged 40 days later with instructions to continue daily thiamine supplementation. The pregnancy outcome was good. Unfortunately, mild ataxia persisted in 2-year follow-up as a long-term consequence. When diagnosed and treated, WE has a favorable prognosis. However, roughly 80% of patients experience memory loss, which may continue for a long time, while gait disorders reportedly affect about 35% of patients. Mild ataxia and dysmetria may persist, too. We reviewed the scientific literature on WE in women with HG until February 2023. Hardly any authors report data on long-term sequelae. Our report emphasizes how important it is to take into consideration this complication in clinical practice, referring to published guidelines and recommendations. Neurological maternal sequelae can demonstrably persist despite early diagnosis and appropriate management. For this reason, a long-term follow-up is recommended. Wernicke syndrome management cannot yet rely on well-established conclusive guidelines; hence, a cautionary approach ought to be prioritized in order to ensure medicolegal soundness.

Pyruvate Dehydrogenase Complex in Neonatal Hypoxic-Ischemic Brain Injury

The disruption of cerebral energy metabolism in relation to brain damage has been the subject of extensive research. However, the pyruvate dehydrogenase complex (PDHC), which is primarily characterized by poor cerebral energy metabolism following brain trauma, has received relatively little study in comparison to newborn hypoxic-ischemic brain injury. Mitochondrial PDHC, a multienzyme complex that functions as a crucial hub in energy metabolism and acts as a central metabolic node to mediate pyruvate oxidation after glycolysis and fuel the Krebs cycle to meet energy demands, has been reported to be one cause of energy metabolism dysfunction according to recent studies. Here we assess the potential mechanisms of neonatal hypoxic-ischemic brain injury-related brain dysfunction mediated by PDHC and further discuss the neuroprotective effects of therapeutic medicines that target PDHC activation. We also provide a summary of recent research on medicines that target PDHC in neonates with hypoxic-ischemic brain damage. Through an understanding of the mechanisms by which it is modulated and an investigation of the neuroprotective techniques available to activate brain PDHC and improve neonatal hypoxic-ischemic impairment, our review emphasizes the significance of PDHC impairment in neonatal hypoxic-ischemic brain injury.

Descriptive spectrum of thiamine deficiency in pregnancy: A potentially preventable condition

OBJECTIVE

Pregnancy, a nutritionally demanding situation in terms of macro- and micronutrient supply owing to heightened maternal, placental, and fetal needs, significantly affects thiamine reserves. Thiamine deficiency during pregnancy and the postpartum period, presenting with varied manifestations and outcomes, is a relatively common condition in our population. The study aimed to understand the various manifestations and outcomes of acute thiamine deficiency in pregnant and postpartum women, emphasizing the significance of early recognition and thiamine therapy to prevent serious complications during pregnancy and after childbirth.

METHODS

This prospective study conducted in a tertiary care center in North India enrolled consecutive pregnant and postpartum women presenting with clinical features consistent with thiamine deficiency disorders, such as thiamine deficiency-related neuropathy, high-output heart failure, heart failure with reduced ejection fraction, Wernicke's encephalopathy, gastric beriberi, and thiamine-responsive acute pulmonary hypertension. In addition to capturing medical history including drug intake, dietary consumption, and comorbidities, women underwent brief relevant clinical examinations and laboratory assessments, including whole-blood thiamine levels. Response to intravenous thiamine supplementation was also monitored.

RESULTS

Data of 31 women (12 pregnant, 19 postpartum) with a diagnosis of acute thiamine deficiency and a mean age of 28.88 ± 2.69 years were analyzed. The mean thiamine level was 1.28 ± 0.44 μg/dL with mean blood lactate of 3.46 ± 3.33. The most common presentation was gastric beriberi (n = 10), followed by paraparesis (n = 6), high-output heart failure (n = 6), acute pulmonary hypertension, heart failure with reduced ejection fraction (n = 3 each), and an acute confusional state (n = 2). All patients responded to thiamine challenge.

CONCLUSION

In the context of borderline thiamine status, particularly in our population with endemic thiamine deficiency and heightened demand for thiamine during pregnancy and the peripartum period, the deficiency can have varied and serious manifestations of dry and wet beriberi. Early recognition of the clinical features and thiamine therapy can be life-saving. There is a need for validated clinical criteria owing to the non-availability of thiamine testing in resource-limited settings.

Silent Echoes: A Case Report of Wernicke Encephalopathy's Unheard Voice

Wernicke encephalopathy (WE) is an acute neuropsychiatric emergency that is caused by a deficiency in vitamin B1 (thiamine). This condition is most commonly seen in patients with alcohol use disorder; however, patients with other disorders of severe malnourishment are also at increased risk. In severe cases, this disease may be followed by Korsakoff's psychosis and even death.  We present a case of a 64-year-old African American female with a history of alcohol use disorder who presented to the emergency department on account of an acute confusional state. Neurological examination revealed right beating nystagmus on the left gaze and a wide-based gait. Initial laboratory work-up was unrevealing; however, magnetic resonance imaging (MRI) of the brain demonstrated an abnormal T2 fluid-attenuated inversion recovery (FLAIR) signal involving the bilateral mammillary bodies and surrounding lateral ventricles that extended into the periaqueductal parenchyma. The patient was admitted to the neurology unit, and high-dose intravenous thiamine was commenced. During hospitalization, the patient's confusion improved and they were subsequently discharged with oral thiamine. The spectrum of severity of WE is wide, ranging from fatal disease and can lead to permanent brain damage or even Korsakoff syndrome, characterized by severe memory loss and confabulation. The diagnosis is mainly clinical and based on the presence of symptoms in the classic triad of mental status change, oculomotor abnormality, and ataxia. This triad is only present in about 10% of cases, making the diagnosis very challenging. Laboratory testing can assist in making the diagnosis, but it is not always reliable or available. In situations of clinical uncertainty, imaging may also be used to support diagnosis or rule out other differentials. The mainstay of treatment is with high-dose parenteral thiamine.

Wernicke encephalopathy: limitations in a laboratory and radiological diagnosis

Wernicke encephalopathy is an emergent neurological disorder caused by vitamin B1 (thiamine) deficiency. Here, we present a case of Wernicke encephalopathy in a male patient in his 70s with normal serum thiamine levels and MRI findings on admission. He had a history of heavy alcohol consumption and a gradual decrease in food intake. On arrival at the hospital, his consciousness was impaired which persisted even after glucose replacement. Moreover, horizontal nystagmus and cerebellar ataxia were observed. Head CT scan and MRI revealed no abnormal findings. Further, his serum thiamine level was within the normal range. The patient was clinically diagnosed with Wernicke encephalopathy, and high-dose thiamine therapy was started. Then, his symptoms improved immediately. Thus, in case of clinical suspicion, treatment for Wernicke encephalopathy must be initiated promptly even in patients with normal serum thiamine levels.

Alcohol-related dementia

Dementia is one of the leading causes of death both in the UK and worldwide. Approximately 1 million people have been diagnosed with this condition in the UK. Although there are many types of dementia, this article will focus on alcohol-related dementia. Alcohol has become a leading cause of death in the 50-69-year age group in England, and with consumption rising rapidly, there is an increased risk that young and middle-aged people will develop alcohol-related dementia in the future. The aim of this article is to review the evidence base and discuss whether alcohol-related dementia is a sub-class of dementia or a separate entity.

Alcoholic ketoacidosis evaluated with a point-of-care capillary beta-hydroxybutyrate measurement device

BACKGROUND

The diagnosis of alcoholic ketoacidosis (AKA) has traditionally been made based only on clinical history and the presence of severe metabolic acidosis with a high anion gap (AG); however, the concentration of beta-hydroxybutyrate (BOHB), a pivotal ketone body in AKA, is not evaluated in most cases. The aim of this study was to clarify the clinical spectrum of AKA in terms of the severity of ketoacidosis by using a point-of-care capillary BOHB measurement device.

METHODS

This retrospective case series was conducted at a Japanese private teaching hospital. Patients with suspected AKA, based on their clinical history, who underwent BOHB measurement using a point-of-care capillary measurement device in the emergency department, were included. Data on their clinical presentations, blood tests, and treatments were collected, described, and compared between patients with a BOHB concentration higher than 3.0 mmol/L (H-BOHB) and those with a concentration less than 3.0 mmol/L (L-BOHB).

RESULTS

A total of 83 patients were included in this study. Sixty-eight patients were categorized as having H-BOHB and 15 as having L-BOHB. Nausea (71%), vomiting (71%), tachycardia (76%), and tachypnea (46%) were commonly observed at presentation. Hyponatremia (46%), hypokalemia (34%), hypomagnesemia (42%), and hyperphosphatemia (41%) were frequent electrolyte abnormalities upon presentation. Rehydration with balanced crystalloids and glucose-containing intravenous fluids, electrolyte supplementation, and thiamine replacement were the major treatments. The mean length of stay in the ICU and hospital were 4.4 and 7.0 days, respectively, with low overall mortality (1%). The H-BOHB and L-BOHB groups did not differ in terms of clinical data. Seventy percent of patients with L-BOHB had severe metabolic acidosis with a high AG due to hyperlactatemia (mean lactate concentration: 8.5 mmol/L).

CONCLUSIONS

We described the clinical features of AKA measured by using a point-of-care capillary BOHB measurement device. Although certain patients diagnosed with AKA based only on their clinical history had predominant lactic acidosis with minor elevations in BOHB concentration, the BOHB concentration had no effect on the clinical spectrum of AKA in this study.

The role of MRI in the prognosis of Wernicke's encephalopathy

BACKGROUND AND PURPOSE

Wernicke's encephalopathy (WE) is a severe acute disorder related to thiamine deficiency. This study was aimed at revealing the relationship between clinical and imaging findings and WE recovery.

METHODS

We retrospectively reviewed 34 cases of WE diagnosed between 2003 and 2020 (median age: 57 years, 14 females) at two academic institutions. WE cases were divided into two groups with symptomatic recovery within 4 weeks (group 1) or later (group 2). The lesion sites were divided into typical and atypical sites (total sites defined as when either typical or atypical sites were involved). Clinical and MRI features were compared between them as appropriate.

RESULTS

WE patients were divided into group 1 (19 cases, median age: 57 years, 10 females) and group 2 (15 cases, median age: 57 years, four females). Regarding clinical features, only cerebellar ataxia was more often observed in group 1 than in group 2. Regarding MRI features, signal abnormality on T2-weighted image (WI)/fluid-attenuated inversion recovery (FLAIR) was more often observed in atypical sites between groups 1 and 2 (1/19 vs. 7/15; p = .01). There were significant differences between groups 1 and 2 regarding the presence of both vasogenic edema and cytotoxic edema in total sites (4/11 vs. 11/15, p = .005; 1/19 vs. 6/15, p = .03), with a significant difference in the presence of vasogenic edema in typical sites (4/19 vs. 10/15, p = .01).

CONCLUSION

The early recovered group showed a lower incidence of T2WI/FLAIR abnormality in atypical sites and diffusion signal abnormality in total or typical sites with a lower incidence of cerebellar ataxia.

Treatment variability and its relationships to outcomes among patients with Wernicke's encephalopathy: A multicenter retrospective study

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.

Wernicke Encephalopathy After Bariatric Surgery: a Literature Review

Wernicke encephalopathy (WE) is an acute neurological disorder classically characterized by ataxia, ophthalmoplegia, and altered mental status. This is caused by thiamine deficiency and is usually seen in malnourished populations. However, with the advent and rise of bariatric surgery in the last 50 years, WE has become an increasingly recognized and potentially deadly complication. Here, we review the populations at risk, clinical presentation, and the incidence of WE in the bariatric surgery population from 1985 to 2023. While the predominant procedure shifts throughout the years, the overall incidence of WE per 100,000 cases for the following procedures are sleeve gastrectomy (1.06), gastric band (1.16), RYGB (4.29), and biliopancreatic diversion with duodenal switch (8.92). Thus, early intervention and post-operative supplementation is recommended to prevent WE.

Thiamine deficiency disorders in women and children

Thiamine (vitamin B1) is available in common foods such as the outer husk of rice and is necessary for normal cardiovascular, neurological and metabolic processes. Thiamine deficiency is common in many parts of Asia and Africa, affecting up to a third or more of children and women of child-bearing age. The diagnosis is based on clinical suspicion, especially when noting heart failure in infants, encephalopathy in patients of any age, and peripheral neuropathy in older children and adults. Blood tests for whole-blood thiamine diphosphate (the quantity of biologically active thiamine present) and erythrocyte transketolase activity (the functional impact of thiamine) are not always readily available in areas where thiamine deficiency is common. Treatment is safe and effective, although dosing guidelines vary widely; 50 mg daily for 5 days is probably effective for treating acute thiamine deficiency disorders, and ongoing adequate thiamine intake is also needed. Prevention efforts depend on local and regional circumstances, including dietary diversification, food fortification, and/or supplementation of children and women at risk.Abbreviations: HIC: high-income countries; LMIC: low- and middle-income countries; MRI: magnetic resonance imaging; TDD: thiamine deficiency disorders.

Alcohol-Related Metabolic Emergencies

Patients with alcohol use disorders are commonly identified and managed in the emergency department. Although the alcohol-intoxicated patient has a high risk for significant injury and diseases, the majority will be allowed to sober in the emergency department and can be discharged without incident. However, there are metabolic derangements in these patients, such as alcoholic ketoacidosis, Wernicke-Korsakoff, and potomania that very commonly present similar to intoxication and can be misdiagnosed by emergency clinicians.