Preventing Wernicke's encephalopathy in anorexia nervosa: A systematic review

Prevalence of thiamine deficiency in anorexia nervosa: a systematic review and narrative synthesis

Thiamine is an essential vitamin that plays a crucial role in many biochemical processes in the body. Anorexia nervosa (AN) is one potential cause of a state of deficiency which can result in grave medical sequelae. There is limited available evidence of the prevalence of thiamine deficiency in patients who suffer from AN. The current study aimed to systematically review all available evidence on the prevalence of thiamine deficiency in cohorts with AN. Studies were included where thiamine status in a group of participants with AN was measured, either through self-reporting or objective measurement. Eight databases (Scopus, CINAHL complete, Medline complete, EMBASE, WEB OF SCIENCE, PROSPERO, COCHRANE DATABASE OF SYSTEMATIC REVIEWS and Cochrane Central Register of Controlled Trials (CENTRAL) were searched. PRISMA guidelines were followed. The study was registered on PROSPERO. A minimum of two researchers conducted each part of the review. The search identified 42 articles whose full texts were screened for eligibility, with 17 retained for qualitative synthesis. The prevalence rates of thiamine deficiency in AN varied from 5.9% to 100% when based on self-report dietary intake. When objective measurements were taken, rates ranged from 0% to 56.7%. The review suggested that age, body mass index (BMI), duration of illness and subtype of AN were not associated with thiamine status. The limited available evidence suggested that the use of supplements, prior treatment and higher energy intakes were associated with a reduced risk of developing a thiamine deficiency among individuals with AN. Poor study methodology including small sample size, inconsistent deficiency definition and study heterogeneity limits the conclusions that can be drawn. Ultimately, there is insufficient strength of evidence to draw definitive clinical recommendations. This review highlights the need for further studies with more robust methodology to help further inform clinical practice.

Wernicke encephalopathy in a patient with medullary infarctions: a case report

Wernicke encephalopathy (WE) is an acute life-threatening neurological condition caused by thiamine (vitamin B1) deficiency. Patients with WE often present with a triad of symptoms consisting of ophthalmoplegia, gait ataxia, and mental confusion. If WE is not treated in a timely manner, it can lead to serious complications such as confusion, coma, or death. Although alcohol abuse is the most commonly reported cause of WE, nonalcoholic causes-although rare-do exist. Herein, we present the case of a nonalcoholic woman with medullary infarctions who presented with intractable vomiting. Her clinical state subsequently progressed to include ophthalmoplegia and gait ataxia. A diagnosis of WE was suspected based on her clinical presentation; this was confirmed by brain magnetic resonance imaging (MRI) and the finding of decreased serum thiamine levels. Brain magnetic resonance imaging demonstrated the complete resolution of abnormal hyperintensities during a follow-up visit, 6 months after treatment.

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.

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.

Comparison of metabolic parameters between oral and total parenteral nutrition in children with severe eating disorders

BACKGROUND

This study investigated changes of lipid parameters in children with severe eating disorders during refeeding in order to explore the optimal timing for lipid preparation administration.

METHODS

We prospectively assessed the physical conditions of patients with eating disorders after the start of nutrition therapy. The assessments were performed at admission and at 2 and 4 weeks. Lipid metabolism was assessed based on triglyceride (TG), total cholesterol (TC), and free carnitine (FC) levels, as well as acylcarnitine/free carnitine (AC/FC) ratio.

RESULTS

A total of 18 patients were included. Of these, 12 and 6 received an oral diet (OD group) and total parenteral nutrition (TPN group), respectively. The mean body mass indexes at hospital admission were 12.8 kg/m2 in the OD group and 12.7 kg/m2 in the TPN group. At 2 weeks after the start of refeeding, TC, TG, and AC/FC levels were significantly lower in the TPN group than in the OD group. Other blood test results did not show any significant differences between the two groups.

CONCLUSIONS

Fat-free glucose-based nutrition promoted lipid metabolism over a 2-week period after the start of refeeding, suggesting that balanced energy and lipid intake are essential, even in TPN.

Comparison of metabolic parameters between oral and total parenteral nutrition in children with severe eating disorders

BACKGROUND

This study investigated changes of lipid parameters in children with severe eating disorders during refeeding in order to explore the optimal timing for lipid preparation administration.

METHODS

We prospectively assessed the physical conditions of patients with eating disorders after the start of nutrition therapy. The assessments were performed at admission and at 2 and 4 weeks. Lipid metabolism was assessed based on triglyceride (TG), total cholesterol (TC), and free carnitine (FC) levels, as well as acylcarnitine/free carnitine (AC/FC) ratio.

RESULTS

A total of 18 patients were included. Of these, 12 and 6 received an oral diet (OD group) and total parenteral nutrition (TPN group), respectively. The mean body mass indexes at hospital admission were 12.8 kg/m2 in the OD group and 12.7 kg/m2 in the TPN group. At 2 weeks after the start of refeeding, TC, TG, and AC/FC levels were significantly lower in the TPN group than in the OD group. Other blood test results did not show any significant differences between the two groups.

CONCLUSIONS

Fat-free glucose-based nutrition promoted lipid metabolism over a 2-week period after the start of refeeding, suggesting that balanced energy and lipid intake are essential, even in TPN.

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.

Wernicke Encephalopathy: An Updated Narrative Review

Wernicke's encephalopathy (WE) and Korsakoff Syndrome (KS) are distinct neurological disorders that may have overlapping clinical features. Due to the overlap, they are collectively known as Wernicke-Korsakoff syndrome. WE is related to diencephalic and mesencephalic dysfunction due to thiamine. WE typically manifests as confusion, ophthalmoplegia, nystagmus, and gait ataxia (Wernicke's triad), although they may not consistently occur together. Although WE mostly occurs in alcoholics, other etiologies, such as post-bariatric surgery, must be considered. Early diagnosis and therapy by intravenous thiamine are essential to prevent WE complications and to reduce morbidity and mortality. Therefore, physicians' and patients' awareness of WE is essential for early diagnosis and therapy. Accordingly, this narrative review aimed to provide an update on WE by reviewing articles published between April 2015 to April 2022 about the etiology, pathophysiology, diagnosis, and WE management updates. EMBASE, PubMed, Google Scholar, Google, and Scopus search engines were used to conduct the literature search.

Coordination and Cognition in Pure Nutritional Wernicke’s Encephalopathy with Cerebellar Degeneration after COVID-19 Infection: A Unique Case Report

Background: Alcoholic cerebellar degeneration is a restricted form of cerebellar degeneration, clinically leading to an ataxia of stance and gait and occurring in the context of alcohol misuse in combination with malnutrition and thiamine depletion. However, a similar degeneration may also develop after non-alcoholic malnutrition, but evidence for a lasting ataxia of stance and gait and lasting abnormalities in the cerebellum is lacking in the few patients described with purely nutritional cerebellar degeneration (NCD). Methods: We present a case of a 46-year-old woman who developed NCD and Wernicke’s encephalopathy (WE) due to COVID-19 and protracted vomiting, resulting in thiamine depletion. We present her clinical course over the first 6 months after the diagnosis of NCD and WE, with thorough neuropsychological and neurological examinations, standardized clinical observations, laboratory investigations, and repeated MRIs. Results: We found a persistent ataxia of stance and gait and evidence for an irreversible restricted cerebellar degeneration. However, the initial cognitive impairments resolved. Conclusions: Our study shows that NCD without involvement of alcohol neurotoxicity and with a characteristic ataxia of stance and gait exists and may be irreversible. We did not find any evidence for lasting cognitive abnormalities or a cerebellar cognitive-affective syndrome (CCAS) in this patient.

Assessing severity in anorexia nervosa: Do the DSM-5 and an alternative severity rating based on overvaluation of weight and shape severity differ in psychological and biological correlates?

OBJECTIVE

This study evaluated the severity ratings for anorexia nervosa (AN) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and an alternative severity rating based on overvaluation of weight/shape, on a range of psychological and biological variables.

METHOD

A sample of 312 treatment-seeking patients with AN (mean age = 25.3, SD = 7.6; mean BMI = 16.8 kg/m² , SD = 2.4) were categorised using both DSM-5 severity levels (mild/moderate/severe/extreme) and weight/shape (low/high) overvaluation. The severity categories were compared on a range of psychological (e.g., eating psychopathology) and biological (e.g., sodium) variables.

RESULTS

Results showed that the overvaluation of weight/shape appeared better at indexing the level of severity in psychological variables among patients with AN compared to the DSM-5 severity rating with moderate to large effect sizes. Moreover, the DSM-5 mild and moderate severity groups experienced significantly higher eating and general psychopathology than the severe and extreme groups. Finally, neither the DSM-5 nor the weight/shape severity groups differed on any of the biological variables.

CONCLUSIONS

This study provided no support for the DSM-5 severity rating for AN, while initial support was found for the weight/shape overvaluation approach in indexing psychological but not biological correlates.

Duodenal Adenocarcinoma in the Setting of Bariatric Surgery: A Perfect Storm for Wernicke's Encephalopathy

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.

Wernicke Encephalopathy Presenting with Dysphagia: A Case Report and Systematic Literature Review

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.

Risk of somatic diseases in patients with eating disorders: the role of comorbid substance use disorders

AIMS

Eating disorders (EDs) and substance use disorders (SUDs) often co-occur, and both involve somatic diseases. So far, no study has considered whether comorbid SUDs may impact somatic disease risk in patients with EDs. Therefore, this study aimed to examine the impact of comorbid SUDs on the risk of 11 somatic disease categories in patients with anorexia nervosa (AN), bulimia nervosa (BN) and unspecified eating disorder (USED) compared to matched controls.

METHODS

A retrospective cohort study was conducted using Danish nationwide registries. The study population included 20 759 patients with EDs and 83 036 controls matched on month and year of birth, sex and ethnicity. Hazard ratios (HRs) were calculated to compare the risk of being diagnosed with a somatic disease (within 11 categories defined by the ICD-10) following first ED diagnosis (index date) between ED patients and controls both with and without SUDs (alcohol, cannabis or hard drugs).

RESULTS

The ED cohort and matched controls were followed for 227 538 and 939 628 person-years, respectively. For ED patients with SUDs, the risk pattern for being diagnosed with different somatic diseases (relative to controls without SUDs) varied according to type of ED and SUD [adjusted HRs ranged from 0.95 (99% CI = 0.57; 1.59) to 4.17 (2.68, 6.47)]. The risk estimates observed among ED patients with SUDs were generally higher than those observed among ED patients without SUDs [adjusted HRs ranged from 1.08 (99% CI = 0.95, 1.22) to 2.56 (2.31, 2.84)]. Abuse of alcohol only had a non-synergistic effect on six disease categories in AN patients and five in BN and USED patients. Abuse of cannabis (with/without alcohol) had a non-synergistic effect on five disease categories in AN and BN patients and two in USED patients. Abuse of hard drugs (with/without alcohol or cannabis) had a non-synergistic effect on nine disease categories in AN patients, eight in BN patients and seven in USED patients.

CONCLUSIONS

The present study documents non-synergistic but not synergistic harmful somatic consequences of SUDs among patients with different EDs, with AN and hard drugs being the most predominant factors. Hence, EDs and SUDs did not interact and result in greater somatic disease risk than that caused by the independent effects. Since EDs and SUDs have independent effects on many somatic diseases, it is important to monitor and treat ED patients for SUD comorbidity to prevent exacerbated physical damage in this vulnerable population.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

A Guide to the Postmortem Investigation of Starvation in Adults

ABSTRACT

Starvation is a rare cause of death in developed countries and is a complex multifaceted pathological process. To complicate the forensic investigation of starvation further, many medical conditions independent of starvation may cause wasting. This article provides one of the first comprehensive guides to the postmortem investigation of starvation in adults, with reference tables on organ-specific macroscopic and microscopic features, as well as features for excluding alternative causes of wasting. The eclectic literature on this complex topic is summarized in an accessible and easily referenced format, including mechanisms of death and ancillary postmortem investigations.

Clinical analysis of Wernicke encephalopathy after liver transplantation

BACKGROUND

Wernicke encephalopathy (WE) is an acute neurological disease resulting from vitamin B1 deficiency, and there are only very few case reports of WE after liver transplantation. The present study aimed to investigate the clinical characteristics, etiology, magnetic resonance imaging (MRI) features, treatment and prognosis of patients with WE after liver transplantation.

METHODS

Twenty-three patients with WE after liver transplantation from the First Affiliated Hospital, Zhejiang University School of Medicine and Jiangxi Provincial People's Hospital between January 2011 and December 2021 were retrospectively analyzed.

RESULTS

Among the 23 patients diagnosed with WE after liver transplantation, 6 (26%) had a classic triad of impaired consciousness, oculomotor palsy and ataxia, 17 (74%) had two features. The misdiagnosis rate was 65%. After treatment with high-dose vitamin B1, 19 (83%) patients showed improvement, whereas 4 showed no improvement, including 3 with residual short-term memory impairments and 1 with residual spatial and temporal disorientation and ataxia.

CONCLUSIONS

The misdiagnosis rate is high in the early stage of WE, and the prognosis is closely associated with whether WE is diagnosed early and treated timely. High-dose glucose or glucocorticoids can trigger WE and cannot be administered before vitamin B1 treatment. Vitamin B1 is suggested to be used as a prophylactic treatment for patients with WE after liver transplantation.

Neuropathological investigation of patients with prolonged anorexia nervosa

OBJECTIVES

Recent neuroimaging studies have indicated that the mesolimbic pathway, known to work as reward neuronal circuitry, regulates cognitive-behavioral flexibility in prolonged anorexia nervosa (AN). Although AN is associated with the highest mortality rate among psychiatric disorders, there have been few neuropathological studies on this topic. This study aims to identify alterations of the reward circuitry regions, especially in the nucleus accumbens (NAcc), using AN brain tissues.

METHODS

The neuronal networks in AN cases and controls were examined by immunohistochemistry directed at tyrosine hydroxylase (TH; dopaminergic neuron marker) and glial fibrillary acidic protein (GFAP; astrocyte marker). We also immunochemically analyzed frozen samples presenting astrogliosis, especially in the NAcc and striatum.

RESULTS

Histologically, neuronal deformation with cytoplasmic shrinkage was seen in reward-related brain regions, such as the orbitofrontal cortex/anterior cingulate cortex. The NAcc showed massive GFAP-positive astrocytes and dot-like protrusions of astrocytes in the shell compartment. In the shell, TH and GFAP immunoreactivities revealed prominent astrogliosis within striosomes, which receive projection from the ventral tegmental area (VTA). The numbers of GFAP-positive astrocytes in the NAcc (P = 0.0079) and VTA (P = 0.0025) of AN cases were significantly higher than those of controls. Strongly immunoreactive 18 to 25 kDa bands, which might represent degradation products, were detected only in the NAcc of AN cases. Clinically, all cases presented cognitive rigidity, which might reflect a deficit of the reward pathway.

CONCLUSION

Our findings suggest impaired dopaminergic innervation between the NAcc and VTA in AN. Functional dysconnectivity in the reward-related network might induce neuropsychiatric symptoms associated with AN.

Anorexia nervosa: Outpatient treatment and medical management

Anorexia nervosa (AN) is a disabling, costly and potentially deadly illness. Treatment failure and relapse are common after completing treatment, and a substantial proportion of patients develop severe and enduring AN. The time from AN debut to the treatment initiation is normally unreasonably long. Over the past 20 years there has been empirical support for the efficacy of several treatments for AN. Moreover, outpatient treatment with family-based therapy or individual psychotherapy is associated with good outcomes for a substantial proportion of patients. Early intervention improves outcomes and should be a priority for all patients. Outpatient treatment is usually the best format for early intervention, and it has been demonstrated that even patients with severe or extreme AN can be treated as outpatients if they are medically stable. Inpatient care is more disruptive, more costly, and usually has a longer waiting list than does outpatient care. The decision as to whether to proceed with outpatient treatment or to transfer the patient for inpatient therapy may be difficult. The core aim of this opinion review is to provide the knowledge base needed for performing safe outpatient treatment of AN. The scientific essentials for outpatient treatment are described, including how to assess and manage the medical risks of AN and how to decide when transition to inpatient care is indicated. The following aspects are discussed: early intervention, outpatient treatment of AN, including outpatient psychotherapy for severe and extreme AN, how to determine when outpatient treatment is safe, and when transfer to inpatient healthcare is indicated. Emerging treatments, ethical issues and outstanding research questions are also addressed.

Can the Ketogenic diet lead to Wernicke's encephalopathy?

BACKGROUND

Wernicke's encephalopathy (WE), a neurological disorder due to the deficiency of thiamine, is often underdiagnosed in the pediatric population. The classic triad of mental status changes, oculomotor abnormality, and ataxia is observed in only 16-21% of all pediatric presentations. Wernicke's is most often associated with alcohol dependence, but also malignancy, parenteral nutrition, and gastrointestinal (GI) malformations. The correlation between following a Ketogenic diet and acquiring Wernicke's, however, has not previously been reported.

CASE REPORT

A 16-year-old previously healthy male presented with an eleven-day history of neurological deficits and GI upset. The patient had recently lost one hundred pounds while following a "ketogenic" diet. He was subsequently diagnosed with Wernicke's, received intravenous thiamine, and was transferred to the inpatient rehabilitation, where he received extensive diet education. After making significant functional improvement, he was discharged home.

RELEVANCE

This case illustrates the importance of including Wernicke's in the differential diagnosis when a pediatric patient presents with neurological deficits after rapid weight loss. Wernicke's encephalopathy may be fatal in the pediatric population, therefore, it must be treated immediately if clinically suspected. Children presenting with Wernicke's would benefit from early intervention, intensive inpatient rehabilitation, and comprehensive education regarding the role of food and exercise on weight loss and health.

Anorexia Nervosa-What Has Changed in the State of Knowledge about Nutritional Rehabilitation for Patients over the Past 10 Years? A Review of Literature

Anorexia nervosa (AN) is a psycho-metabolic disorder with a high risk of somatic complications such as refeeding syndrome (RFS) and carries the highest mortality rate of all psychiatric illnesses. To date, the consensus on the care for patients with AN has been based on recommendations for a combination of alimentation and psychotherapy. It is important to establish an initial caloric intake that will provide weight gain and minimize the risk of complications in the treatment of undernourished patients. Research over the past few years suggests that current treatment recommendations may be too stringent and should be updated. The aim of this paper is to systematize the current reports on nutritional rehabilitation in AN, to present the results of studies on the safe supplementation of patients and its potential impact on improving prognosis and the healing process. This review of literature, from 2011-2021, describes the changing trend in the nutritional protocols used and the research on their efficacy, safety, and long-term effects. In addition, it presents previous reports on the potential benefits of introducing vitamin, pro-and prebiotic and fatty acid supplementation.

Wernicke-Korsakoff syndrome despite no alcohol abuse: A summary of systematic reports

BACKGROUND

Wernicke-Korsakoff syndrome (WKS) is a neurological disorder typically found in alcohol use disorder. The fact that it also occurs in nonalcoholic patients is less well known and often ignored. For the first time, this review offers a systematic investigation of the frequency and associated features of nonalcoholic WKS in the published literature.

METHOD

We included 11 recent systematic reports, with a total of 586 nonalcoholic WKS cases following hyperemesis gravidarum (n = 177), cancer (n = 129), bariatric surgery (n = 118), hunger strike (n = 41), soft drink diet in children (n = 33), depression (n = 21), Crohn's disease (n = 21), schizophrenia (n = 15), anorexia nervosa (n = 12), ulcerative colitis (n = 10), and incidental thiamine-deficient infant formula (n = 9).

FINDINGS

Vomiting and extreme weight loss were strong predictors of nonalcoholic WKS in adults. Blurred vision was a common presenting sign in about one-fourth of the patients. The classic triad of WKS is characterized by confusion, ataxia, and eye-movement disorders. All reviewed studies reported high percentages of patients presenting with an altered mental status, while both motor symptoms were variably present.

INTERPRETATION

The foregoing observations led to several important conclusions. First, we can see that nutritional impoverishment leads to profound brain damage in the form of WKS. Second, it seems that physicians are either unaware of or underestimate the risks for nonalcoholic WKS. Physicians must be specifically vigilant in detecting and treating WKS in patients with sudden and severe weight loss and vomiting. Third, lower doses of thiamine frequently lead to chronic Wernicke-Korsakoff syndrome. We noticed that when thiamine treatment for WKS was administered, in many cases doses were too low. In line with proven interventions we therefore recommend a parenteral thiamine treatment of 500 mg 3 times per day in adults.

A Case of Wernicke Encephalopathy Secondary to Anorexia Nervosa Complicated by Refeeding Syndrome and Takotsubo Cardiomyopathy

Patient: Female, 20-year-old

Final Diagnosis: Anorexia nervosa • refeeding syndrome • takotsubo cardiomyopathy • Wernicke encephalopathy

Symptoms: Altered mental status • lethargy • weight loss

Medication: —

Clinical Procedure: —

Specialty: Critical Care Medicine

Non-alcoholic beriberi, Wernicke encephalopathy and long-term eating disorder: case report and a mini-review

INTRODUCTION

Nowadays, reports of beriberi are rare in developed countries. Wernicke encephalopathy may be present in about 25% of patients with beriberi.

CASE REPORT

We report the case of a woman with history of depression and chronic eating disorder, who complained Wernicke encephalopathy and beriberi. Sural nerve and muscular biopsy were performed, showing severe axonal neuropathy. Thiamine supplementation was started with rapid improvement of the pulmonary and cardiac affections; improvement of peripheral neuropathy was incomplete.

CONCLUSIONS

Thiamine deficiency can be misdiagnosed. Beriberi is an important cause of acute flaccid paralysis; hence, clinicians should consider this diagnosis and prompt start thiamine treatment to avoid permanent neurological sequelae.

Wernicke's encephalopathy in Crohn's disease and ulcerative colitis

Crohn's disease (CD) and ulcerative colitis (UC) are chronic and debilitating inflammatory conditions of the gastrointestinal tract. Thiamine can deplete rapidly in CD and UC, which can lead to Wernicke's encephalopathy (WE), is an acute neurologic disorder. Our objective was to systematically review the presentation of WE in CD and UC. We conducted our search from inception using the MeSH terms "Crohn's disease," "ulcerative colitis," and "Wernicke's encephalopathy." Our search yielded 28 case studies reporting on 31 cases. CD was diagnosed in 21 cases, and UC in 10. The first signs of WE were nausea and vomiting (13 cases), double vision (10), blurred vision (10), and hearing loss (4). In 12 cases, partial or complete bowel resection was one of the etiologies of thiamine depletion. In nine cases, thiamine was not supplemented intramuscularly or intravenously while parenteral nutrition or glucose was given to the patient. In 10 cases, detailed descriptions of thiamine treatment were given. Thiamine treatment at suboptimal levels (7 of 10 cases) turned out to lead to residual cognitive deficits in three cases. In three cases with optimal treatment (1500 mg/d intravenously), complete remission of WE symptoms was achieved. Rapid treatment with high doses (500 mg, 3 times/d) of thiamine saves lives, and treats WE in its core symptomatology.

Case report of anorexia nervosa showing periventricular gliosis at autopsy

Anorexia nervosa (AN) is a serious eating disorder characterized by self-starvation and extreme weight loss. It has the highest mortality rate among all psychiatric disorders. Recent research indicates that malnutrition in AN patients induces various kinds of functional brain damage, but the pathophysiology of AN remains unclear. We report here the neuropathological findings of a 31-year-old Japanese woman. At age 24, she had a fear of gaining weight and reduced her dietary intake; she had extremely low body weight associated with overeating then self-induced vomiting. She was clinically diagnosed as having AN and was admitted to a psychiatric hospital with severe depression and suicidal thoughts. At age 31, she died despite intensive physical care and psychotherapy. Neuropathological examination revealed increased capillary blood vessels and slight fibrillary gliosis in the mammillary bodies, with similarities to Wernicke encephalopathy. The brainstem exhibited the characteristic features of central pontine myelinolysis, characterized by a sharply demarcated region of myelin pallor and relative sparing of axons. Senile changes, including neurofibrillary tangles/senile plaques, were not significant. Severe fibrillary gliosis was prominent around periventricular regions, including the caudate nucleus and nucleus accumbens, which are associated with cognition, emotion, and emotional behaviors via the dopaminergic pathways. These findings indicate that prolonged malnutrition in AN patients may induce brain damage, leading to dysfunction of the reward-related dopaminergic pathways. Furthermore, they represent the first pathological evidence that dysfunction of the cortico-limbic-striatal circuitry is involved in the pathophysiology of psychiatric symptoms in AN patients.

The contribution of mamillary body damage to Wernicke's encephalopathy and Korsakoff's syndrome

Histopathological alterations of the mamillary bodies are the most conspicuous and the most consistent neuropathological features of several disorders that occur after severe thiamine deficiency, such as Wernicke's encephalopathy and Korsakoff's syndrome. Moreover, they are among the few abnormalities that are visible to the naked eye in these disorders. With a lifetime prevalence of approximately 1.3%, Wernicke's encephalopathy is by far the most frequent cause of damage to the mamillary bodies in humans. Still, there is a persisting uncertainty with regard to the development and the clinical consequences of this damage, because it is virtually impossible to study in isolation. As a rule, it always occurs alongside neuropathology in other subcortical gray matter structures, notably the medial thalamus. Converging evidence from other pathologies and animal experiments is needed to assess the clinical impact of mamillary body damage and to determine which functions can be attributed to these structures in healthy subjects. In this chapter, we describe the history and the current state of knowledge with regard to thiamine deficiency disorders and the contribution of mamillary body damage to their clinical presentations.

The Inferior Colliculus in Alcoholism and Beyond

Post-mortem neuropathological and in vivo neuroimaging methods have demonstrated the vulnerability of the inferior colliculus to the sequelae of thiamine deficiency as occurs in Wernicke-Korsakoff Syndrome (WKS). A rich literature in animal models ranging from mice to monkeys-including our neuroimaging studies in rats-has shown involvement of the inferior colliculi in the neural response to thiamine depletion, frequently accomplished with pyrithiamine, an inhibitor of thiamine metabolism. In uncomplicated alcoholism (i.e., absent diagnosable neurological concomitants), the literature citing involvement of the inferior colliculus is scarce, has nearly all been accomplished in preclinical models, and is predominately discussed in the context of ethanol withdrawal. Our recent work using novel, voxel-based analysis of structural Magnetic Resonance Imaging (MRI) has demonstrated significant, persistent shrinkage of the inferior colliculus using acute and chronic ethanol exposure paradigms in two strains of rats. We speculate that these consistent findings should be considered from the perspective of the inferior colliculi having a relatively high CNS metabolic rate. As such, they are especially vulnerable to hypoxic injury and may be provide a common anatomical link among a variety of disparate insults. An argument will be made that the inferior colliculi have functions, possibly related to auditory gating, necessary for awareness of the external environment. Multimodal imaging including diffusion methods to provide more accurate in vivo visualization and quantification of the inferior colliculi may clarify the roles of brain stem nuclei such as the inferior colliculi in alcoholism and other neuropathologies marked by altered metabolism.

Wernicke's Encephalopathy in Alcohol Use Disorder Patients after Liver Transplantation: A Case Series and Review of Literature

Wernicke’s encephalopathy (WE) is an acute neurological disorder resulting from thiamine deficiency, commonly found in alcohol use disorder (AUD) patients. Liver transplantation (LT) could represent a risk factor for the onset of WE in AUD patients, due to the onset of chronic depletion of thiamine in this population and the high metabolic demand of surgery and the postoperative period. However, few data are available about the risk of the onset of WE in AUD patients after LT. Here we report three cases of AUD patients who developed WE with confusion and delirium after LT. Prompt parenteral administration of thiamine led to a rapid improvement of the clinical condition and a complete remission of neurological symptoms after 3–4 days. In addition, a search of the available English literature was conducted in order to perform a review of the possible association between the onset of WE and LT in AUD patients. A prophylactic treatment regimen based on the administration of thiamine could be suggested in AUD patients before and after LT. Further studies are needed to determine the optimal regimen of thiamine in the prevention of WE in this setting.

Medical management of eating disorders: an update

PURPOSE OF REVIEW

Eating disorders are associated with numerous medical complications. The aim of this study was to review recent progress in improving the medical management of patients with eating disorders.

RECENT FINDINGS

With close medical monitoring and electrolyte supplementation, accelerated refeeding protocols improve weight restoration without increasing the risk of refeeding syndrome. Olanzapine improves weight restoration better than placebo, without leading to adverse metabolic effects seen in individuals not in starvation. Alterations of the gut microbiome in anorexia nervosa have been demonstrated, but their clinical relevance remains unclear.

SUMMARY

Medical complications of eating disorders may facilitate the first contact with health professionals and treatment initiation. Medical complications of anorexia nervosa generally occur due to starvation, malnutrition and their associated physiological effects, whereas medical complications of bulimia nervosa are generally due to purging behaviors. Most medical complications in patients with binge eating disorder are secondary to obesity. Most medical complications of eating disorders can be effectively treated with nutritional management, weight normalization and the termination of purging behaviors. In summary, eating disorders are associated with many medical complications that have to be carefully assessed and managed as early as possible to improve long-term outcomes.

Thiamine Deficiency in Adolescents with Eating Disorders: A Prospective Cohort Study

Background: Pediatric eating disorders (PED) patients are prone to nutritional deficiencies. Thiamine deficiency is well described in other malnutrition states but is not routinely screened for in PED. In the current study we evaluated the prevalence of thiamine deficiency among PED patients on their first admission to an outpatient day hospital for eating disorders (DH). Methods: In this prospective cohort study, we measured whole blood thiamine pyrophosphate concentrations (TPP) in addition to a routine laboratory workup in 69 girls on their first admission to DH. Two subgroup analyses were performed: (I) Patients with a previous dietary intervention (“diet” group, n = 30) or naïve-to-treatment patients (“naïve” group, n = 39) and (II) Type of PED: Restrictive (group R, n = 44) or binge-eating/purging (group BP, n = 25). Results: Thiamine deficiency was identified in four girls (6%), all in the “naïve” group. Three of them had BP, and one had R. Patients in the “diet” group had a significantly higher TPP compared to the “naïve” group (55.5 µg/L vs. 46.7 µg/L, p = 0.004). TPP levels returned to normal after two weeks of the treatment program in all deficient patients. Conclusion: Thiamine deficiency was uncommon among PED patients and was easily replenished. Screening for deficiency should be performed among treatment-naïve patients. Keynotes: Whole blood thiamine pyrophosphate concentrations (TPP) are seldom screened for among PED patients. In the current study, we detected thiamine deficiency in only 6% of patients on their first admission to an outpatient day hospital for eating disorders. All deficient patients did not have a recent dietary intervention. We recommend considering screening for thiamine deficiency in treatment-naïve PED patients.

Wernicke's encephalopathy due to malnutrition and parenteral nutrition in a patient with cerebral infarction: A case report

INTRODUCTION

Wernicke's encephalopathy (WE) is a severe neuropsychiatric disorder, which results from a nutritional deficiency of thiamine. The occurrence of WE is rarely reported in patients with cerebral infarction, who often have complications of malnutrition. Cerebral infarction is a neurological disease, patients with cerebral infarction may show symptoms such as disturbance of consciousness and gait instability, which is difficult to differentiate from WE. Thus, early recognition and differential diagnosis of WE are important. We report a rare case of cerebral infarction patient who developed WE due to malnutrition and parenteral nutrition.

PATIENT CONCERNS

A 65-year-old woman was admitted to our hospital with cerebral infarction. She had lost 15 kg of weight in the past month or so and was diagnosed with malnutrition. In order to correct malnutrition, parenteral nutrition and intravenous glucose without thiamine were administered. Cognitive dysfunction, laloplegia, sleep rhythm inversion, somnolence and bilateral lower limbs weakness were presented 20 days after admission.

DIAGNOSIS

Brain magnetic resonance imaging confirmed the diagnosis of WE.

INTERVENTIONS

The patient was given thiamine and nutrition support therapy.

OUTCOMES

The patient's cognitive impairment, laloplegia and sleep condition improved within 4 days. Neurological status continued to improve and physical activity recovered gradually within 2 weeks. She received rehabilitation training when her condition was relatively stable, and her muscle strength of limbs and physical function gradually improved.

CONCLUSION

Infarction-related malnutrition may result in nutrient deficiency-related neurological complications, such as WE. Thus, it is important to pay close attention to the nutritional status of patients with cerebral infarction. In addition, early recognition and differential diagnosis of WE in patients with infarction-related malnutrition are necessary, early treatment of replete thiamine supplementation and nutrition support therapy can reduce the risk of WE and improve the prognosis.

An audit of the changes in thiamine levels during higher caloric nutritional rehabilitation of adolescent patients hospitalised with a restrictive eating disorder

BACKGROUND

Routine supplementation of thiamine in patients with restrictive eating disorders prior to initiation of nutritional rehabilitation, is an example of a clinical guideline based on expert opinion rather than evidence-based recommendations. This study investigates whether adolescents hospitalised with a restrictive eating disorder commenced on a higher caloric refeeding regimen, present with or develop thiamine deficiency during their admission.

METHODS

An eighteen month retrospective audit of 119 consecutive admissions for nutritional rehabilitation was conducted on patients admitted with an eating disorder in a large tertiary teaching hospital in Western Sydney. Data from paper-based and electronic medical records were collected. Baseline and weekly blood thiamine levels were documented, as well as patient demographic information including admission weight, age, length of stay, percentage median body mass index, weight change throughout admission and caloric prescription.

RESULTS

Sixty admissions met inclusion criteria, mean age 17.2 years (SD 1.2); 88% female; BMI 16.8 kg/m² (SD 1.8) on admission. A linear mixed effects model identified that median thiamine levels increased by 9.2 nmol/L per week (p < 0.001). No patient developed thiamine deficiency during their admission, one patient was admitted with thiamine levels below the normal range at 62 nmol (normal range 67 - 200 nmol/L) which resolved by the second week of admission. In 15 out of 60 patients (25%), thiamine levels were observed to rise above the upper limit.

CONCLUSIONS

Nutritional management of 60 malnourished adolescents hospitalised with an eating disorder was conducted safely with the provision of only 10 mg thiamine in a multivitamin daily, and no additional thiamine supplementation. The high caloric refeeding protocol, inclusive of a daily multivitamin, provided adequate thiamine to prevent thiamine deficiency. Further research should examine thiamine requirements in an exclusive severely malnourished population to assess the need for thiamine replacement in the most vulnerable group.

A case of nonalcoholic Wernicke’s encephalopathy due to an extreme diet based on magnetic resonance imaging features

Wernicke’s encephalopathy is a rare occurrence in Indonesia because alcohol consumption is very low. However, in Indonesia, Wernicke’s encephalopathy could be triggered by an inadequate intake of thiamine (vitamin B1) due to an extreme diet for several months. It is a case of a 31-year-old male, who presented to the emergency room with a decreased level of consciousness. According to the family, for the last few weeks, he has become less responsive and less attentive. Fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) revealed a unique picture with symmetrical lesions in the bilateral medial thalamus, mammillary bodies, periaqueductal gray matter, and the dorsal surface of the medulla oblongata. Clinically, there is no neck stiffness and no fever. The laboratory results from the blood and cerebrospinal fluid have ruled out meningitis. Treatment with thiamine 200 mg t.i.d. has shown an excellent response and significant clinical improvement. The earlier thiamine substitution treatment is started, the better the outcome because thiamine will prevent further injury to the brain and enhance recovery.

Wernicke Encephalopathy-Clinical Pearls

Wernicke encephalopathy (WE) was first described by Carl Wernicke in 1881. WE is caused by thiamine deficiency. Alcoholism is the most common etiologic factor associated with WE in the United States, but it can occur in any patient with a nutritional deficiency state such as hyperemesis gravidarum, intestinal obstruction, and malignancy. WE is a clinical diagnosis. The common findings include mental status changes, ocular dysfunction, and a gait apraxia, present in only 10% of cases. Only a few cases of WE are diagnosed before death. Approximately 80% of patients with untreated WE have development of Korsakoff syndrome, which is characterized by memory impairment associated with confabulation. The initial clinical diagnosis of WE is critical, keeping in mind that the classic triad of symptoms is often absent. Recognition of nutritional deficiency and any portion of the classic triad should prompt treatment. Additionally, hypothermia, hypotension, and coma should raise clinical suspicion for the disease. Primary treatment includes timely administration of thiamine, for which the route and dosage remain controversial. Clinical judgment should be exercised in diagnosis and treatment (dosage, frequency, route of administration and duration) in all cases of WE. Overdiagnosis and overtreatment may be preferred to prevent prolonged or persistent neurocognitive impairments given the excellent safety profile of thiamine. Further prospective research is warranted to better understand the disease biology, risk factors, and treatment recommendations.

Micronutrients Deficiencies in 374 Severely Malnourished Anorexia Nervosa Inpatients

Introduction: Anorexia nervosa (AN) is a complex psychiatric disorder, which can lead to specific somatic complications. Undernutrition is a major diagnostic criteria of AN which can be associated with several micronutrients deficiencies. Objectives: This study aimed to determinate the prevalence of micronutrients deficiencies and to compare the differences between the two subtypes of AN (restricting type (AN-R) and binge-eating/purging type (AN-BP)). Methods: We report a large retrospective, monocentric study of patients hospitalized in a highly specialized nutrition unit between January 2011 and August 2017 for severe malnutrition treatment in the context of anorexia nervosa. Results: Three hundred and seventy-four patients (360 (96%) women, 14 (4%) men), age: 31.3 ± 12.9 years, Body Mass Index (BMI): 12.5 ± 1.7 kg/m² were included; 253 (68%) patients had AN-R subtype while, 121 (32%) had AN-BP. Zinc had the highest deficiency prevalence 64.3%, followed by vitamin D (54.2%), copper (37.1%), selenium (20.5%), vitamin B1 (15%), vitamin B12 (4.7%), and vitamin B9 (8.9%). Patients with AN-BP type had longer disease duration, were older, and had a lower left ventricular ejection fraction (LVEF) (p < 0.001, p = 0.029, p = 0.009), when compared with AN-R type, patients who instead, had significantly higher Alanine Aminotransferase (ALT) and Brain Natriuretic Peptide (BNP) levels (p < 0.001, p < 0.021). In the AN-BP subgroup, as compared to AN-R, lower selenium (p < 0.001) and vitamin B12 plasma concentration (p < 0.036) were observed, whereas lower copper plasma concentration was observed in patients with AN-R type (p < 0.022). No significant differences were observed for zinc, vitamin B9, vitamin D, and vitamin B1 concentrations between the two types of AN patients. Conclusion: Severely malnourished AN patients have many micronutrient deficiencies. Differences between AN subtypes are identified. Micronutrients status of AN patients should be monitored and supplemented to prevent deficiencies related complications and to improve nutritional status. Prospective studies are needed to explore the symptoms and consequences of each deficiency, which can aggravate the prognosis during recovery.

Medication in AN: A Multidisciplinary Overview of Meta-Analyses and Systematic Reviews

Drugs are widely prescribed for anorexia nervosa in the nutritional, somatic, and psychiatric fields. There is no systematic overview in the literature, which simultaneously covers all these types of medication. The main aims of this paper are (1) to offer clinicians an overview of the evidence-based data in the literature concerning the medication (psychotropic drugs and medication for somatic and nutritional complications) in the field of anorexia nervosa since the 1960s, (2) to draw practical conclusions for everyday practise and future research. Searches were performed on three online databases, namely MEDLINE, Epistemonikos and Web of Science. Papers published between September 2011 and January 2019 were considered. Evidence-based data were identified from meta-analyses, if there were none, from systematic reviews, and otherwise from trials (randomized or if not open-label studies). Evidence-based results are scarce. No psychotropic medication has proved efficacious in terms of weight gain, and there is only weak data suggesting it can alleviate certain psychiatric symptoms. Concerning nutritional and somatic conditions, while there is no specific, approved medication, it seems essential not to neglect the interest of innovative therapeutic strategies to treat multi-organic comorbidities. In the final section we discuss how to use these medications in the overall approach to the treatment of anorexia nervosa.