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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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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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Mohammed EA, Hajji SA, Aljenaee K, Ghanbar MI. Wernicke's encephalopathy-induced hearing loss complicating sleeve gastrectomy. BMJ Case Rep 2020; 13:13/9/e233144. [PMID: 32933905 DOI: 10.1136/bcr-2019-233144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 25-year-old woman brought to the hospital with symptoms of acute confusion, disorientation, diplopia, hearing loss and unsteady gait which started 4 days prior to her presentation with rapid worsening in its course until the day of admission. She had a surgical history of laparoscopic sleeve gastrectomy 2 months earlier which was complicated by persistent vomiting around one to three times per day. She lost 30 kg of her weight over 2 months and was not compliant to vitamin supplementation. CT of the brain was unremarkable. Brain MRI was done which showed high signal intensity lesions involving the bilateral thalamic regions symmetrically with restricted diffusion on fluid-attenuated inversion recovery imaging. Other radiological investigations, such as magnetic resonance venography and magnetic resonance angiography of the brain were unremarkable. An official audiogram confirmed the sensorineural hearing loss. A diagnosis of Wernicke's encephalopathy due to thiamin deficiency post-sleeve gastrectomy was made based on the constellation of her medical background, clinical presentation and further supported by the distinct MRI findings. Consequently, serum thiamin level was requested and intravenous thiamin 500 mg three times per day for six doses was started empirically, then thiamin 250 mg intravenously once daily given for 5 more days. Marked improvement in cognition, eye movements, strength and ambulation were noticed soon after therapy. She was maintained on a high caloric diet with calcium, magnesium oxide, vitamin D supplements and oral thiamin with successful recovery of the majority of her neurological function with normal cognition, strength, reflexes, ocular movements, but had minimal resolution of her hearing deficit. Serum thiamin level later was 36 nmol/L (67-200).
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Affiliation(s)
| | | | - Khaled Aljenaee
- Endocrine and Diabetes, Al Adan Hospital, Kuwait, Al Asimah, Kuwait
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Oudman E, Wijnia JW, Oey M, van Dam M, Painter RC, Postma A. Wernicke’s encephalopathy in hyperemesis gravidarum: A systematic review. Eur J Obstet Gynecol Reprod Biol 2019; 236:84-93. [DOI: 10.1016/j.ejogrb.2019.03.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/04/2019] [Accepted: 03/04/2019] [Indexed: 12/13/2022]
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Mun-Wei L, Gayathri G, Kwang Hwee G, Ruban K, Suresh Kumar V, Shatriah I. Optic Discs Swelling Procrastinates Wernicke's Encephalopathy Associated with Hyperemesis Gravidarum: A Case Report and Review of Literature. Cureus 2018; 10:e2793. [PMID: 30112269 PMCID: PMC6089490 DOI: 10.7759/cureus.2793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Wernicke’s encephalopathy following severe hyperemesis gravidarum is an uncommon clinical entity. We describe a rare manifestation of optic discs swelling in a pregnant woman that has caused a diagnostic dilemma. With high index of suspicion of clinical manifestations and radiological evidences, a clinical diagnosis of Wernicke’s encephalopathy was made. Intravenous thiamine therapy was instituted, and prompt improvement of clinical signs was observed. The association of optic discs swelling and Wernicke’s encephalopathy after hyperemesis gravidarum is discussed.
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Affiliation(s)
- Lam Mun-Wei
- Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, MYS
| | | | | | | | | | - Ismail Shatriah
- Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, MYS
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Walker MA, Zepeda R, Afari HA, Cohen AB. Hearing loss in Wernicke encephalopathy. Neurol Clin Pract 2014; 4:511-515. [PMID: 29443160 DOI: 10.1212/cpj.0000000000000072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Melissa A Walker
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Rodrigo Zepeda
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Henrietta A Afari
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Adam B Cohen
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston
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Isenberg-Grzeda E, Kutner HE, Nicolson SE. Wernicke-Korsakoff-syndrome: under-recognized and under-treated. PSYCHOSOMATICS 2013; 53:507-16. [PMID: 23157990 DOI: 10.1016/j.psym.2012.04.008] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 04/11/2012] [Accepted: 04/12/2012] [Indexed: 01/12/2023]
Abstract
BACKGROUND Wernicke-Korsakoff syndrome (WKS) is a well described syndrome of neurological and cognitive problems that comprises both Wernicke's encephalopathy (WE) and Korsakoff syndrome (KS). WE is an acute neuropsychiatric disorder caused by thiamine deficiency. KS is a chronic consequence of thiamine deficiency with prominent impairment in memory formation. METHOD The authors review the literature on the pathophysiology, presentation, and treatment of WKS, focusing on the acute identification and treatment of WE. RESULTS Most cases of WE are missed by clinicians, likely because patients do not present with the classic signs associated with the condition. Attaining high serum levels of thiamine during treatment may be important to restore cognitive function as quickly as possible, though the exact dosing and route needed for effective treatment is unknown. Data indicates that the administration of intravenous (IV) thiamine has little risk. CONCLUSION In order to prevent this potentially devastating disease, physicians should have a high index of suspicion for WKS and dose thiamine accordingly.
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Affiliation(s)
- Elie Isenberg-Grzeda
- Dept. of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
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Quattrocchi CC, Longo D, Delfino LN, Errante Y, Aiello C, Fariello G, Bernardi B. MR differential diagnosis of acute deep grey matter pathology in paediatric patients. Pediatr Radiol 2013. [PMID: 23196927 DOI: 10.1007/s00247-012-2491-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A high metabolic demand, rich vascularization and high concentrations of ionic elements leading to the generation of oxygen free radicals, give to the deep grey matter (DGM) nuclei specific susceptibility to both acute and chronic insults, especially in paediatric patients. Reaching a diagnosis in the early stages of acute diseases in many patients is crucial for instigating prompt specific therapy leading to a favourable outcome. On the basis of a review of a 10-year in-house database and a review of the literature on CNS pathology involving the DGM nuclei in paediatric patients, we summarize the MR findings and clinical clues that may help the radiologist in the difficult differential diagnosis process. The terms "acute" and "chronic" refer to the clinical onset of the disease. MR imaging allows the detection of an injury, determination of its precise anatomical location and characterization of the signal changes. This, combined with a knowledge of specific MRI patterns, may be a roadmap to a definite diagnosis. Clinical history, physical and laboratory findings, timing of the MR examination and advanced MR imaging techniques (diffusion-weighted imaging and (1)H-MR spectroscopy), are crucial in some patients.
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Sutamnartpong P, Muengtaweepongsa S, Kulkantrakorn K. Wernicke's encephalopathy and central pontine myelinolysis in hyperemesis gravidarum. J Neurosci Rural Pract 2013; 4:39-41. [PMID: 23546346 PMCID: PMC3579041 DOI: 10.4103/0976-3147.105608] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A pregnant woman, who had been suffering from hyperemesis gravidarum, presented with alteration of consciousness, ocular nystagmus and ataxia. Magnetic Resonance Imaging of the brain showed typical findings of Wernicke's encephalopathy and central pontine myelinolysis. The clinical features responded dramatically to thiamine supplementation.
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Affiliation(s)
- Panee Sutamnartpong
- Department of Neurology, Faculty of Medicine, Thammasart University, Thailand
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Palacios-Marqués A, Delgado-García S, Martín-Bayón T, Martínez-Escoriza JC. Wernicke's encephalopathy induced by hyperemesis gravidarum. BMJ Case Rep 2012; 2012:bcr-2012-006216. [PMID: 22684836 DOI: 10.1136/bcr-2012-006216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Wernicke's encephalopathy (WE) is a reversible neurological emergency caused by thiamine deficiency. Prolonged vomiting in pregnancy results in thiamine depletion. The early recognition of its clinical signs and symptoms is essential to establish the suspected diagnosis and can be confirmed by MRI. Prompt administration of thiamine is important for preventing the occurrence of sequelae in the mother and for improving the fetal prognostic. We report a case of WE induced by hyperemesis gravidarum with a good maternal and fetal outcome.
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Affiliation(s)
- Ana Palacios-Marqués
- Obstetrics and Gynaecology Department, University General Hospital of Alicante, Alicante, Spain.
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Dysautonomie sévère révélatrice d’une encéphalopathie de Gayet-Wernicke. Rev Neurol (Paris) 2011; 167:250-3. [DOI: 10.1016/j.neurol.2010.07.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Revised: 04/13/2010] [Accepted: 07/07/2010] [Indexed: 11/24/2022]
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Rufa A, Rosini F, Cerase A, Giannini F, Pretegiani E, Buccoliero R, Dotti MT, Federico A. Wernicke Encephalopathy After Gastrointestinal Surgery for Cancer: Causes of Diagnostic Failure or Delay. Int J Neurosci 2011; 121:201-8. [DOI: 10.3109/00207454.2010.544430] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fontoura P. The 'Ajuda Paralyses': history of a neuropsychiatric debate in mid-19th-century Portugal. Brain 2010; 133:3141-52. [DOI: 10.1093/brain/awq211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Irreversible Optic Neuropathy in Wernicke Encephalopathy and Leber Hereditary Optic Neuropathy. J Neuroophthalmol 2010; 30:49-53. [DOI: 10.1097/wno.0b013e3181ce80c6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Borlot F, Freitas MRD, Araujo LMD, Delgado AF, Koda YKL, Paz JAD, Marques-Dias MJ. Encefalopatia de Wernicke em criança com doença de Crohn. REVISTA PAULISTA DE PEDIATRIA 2009. [DOI: 10.1590/s0103-05822009000400016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Descrever um caso de encefalopatia de Wernicke associada à doença de Crohn na infância. DESCRIÇÃO DO CASO: Menino de cinco anos, com diagnóstico de doença de Crohn por colonoscopia com biópsia há um ano; desde então, fez uso de diversos medicamentos sem resultados terapêuticos. Evoluiu com pancreatite há três meses, quando foi iniciada nutrição parenteral. Apresentou subitamente sonolência, episódios de frases desconexas e alteração da movimentação ocular. O exame neurológico evidenciou nistagmo vertical para cima em todas as posições e nistagmo horizontal no desvio conjugado do olhar. A ressonância magnética do encéfalo mostrou alterações compatíveis com a encefalopatia de Wernicke, sendo instituído o tratamento com tiamina parenteral imediatamente, com reversão completa dos sintomas por volta do 30º dia de tratamento. COMENTÁRIOS: Embora seja uma entidade rara, deve-se suspeitar de encefalopatia de Wernicke frente à presença de fatores de risco, uma vez que o tratamento imediato evita as sequelas neurológicas.
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Netravathi M, Sinha S, Taly AB, Bindu PS, Bharath RD. Hyperemesis-gravidarum-induced Wernicke's encephalopathy: serial clinical, electrophysiological and MR imaging observations. J Neurol Sci 2009; 284:214-6. [PMID: 19477464 DOI: 10.1016/j.jns.2009.05.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2009] [Revised: 04/21/2009] [Accepted: 05/01/2009] [Indexed: 10/20/2022]
Abstract
Wernicke's encephalopathy (W.E.), a potentially reversible condition caused by thiamine deficiency, is usually suspected in the setting of chronic alcoholism and might not be recognized when associated with other conditions. We describe a young pregnant woman who presented with rapidly evolving ataxia, diplopia and irrelevant speech following repeated vomiting. Characteristic brain MRI and rapid response to thiamine suggested that she had W.E. possibly due to hyperemesis gravidarum. A high index of suspicion is required, since delayed or lack of treatment may lead to high morbidity and mortality.
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Affiliation(s)
- M Netravathi
- Department of Neurology, NIMHANS, Bangalore, India
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Affiliation(s)
- Suehana Rahman
- Bariatric Unit, Division of Surgery, University College London Hospitals, London, UK
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