Hearing loss in Wernicke encephalopathy

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.

On the dynamic and even reversible nature of Leigh syndrome: Lessons from human imaging and mouse models

Leigh syndrome (LS) is a neurodegenerative disease characterized by bilaterally symmetric brainstem or basal ganglia lesions. More than 80 genes, largely impacting mitochondrial energy metabolism, can underlie LS, and no approved medicines exist. Described 70 years ago, LS was initially diagnosed by the characteristic, necrotic lesions on autopsy. It has been broadly assumed that antemortem neuroimaging abnormalities in these regions correspond to end-stage histopathology. However, clinical observations and animal studies suggest that neuroimaging findings may represent an intermediate state, that is more dynamic than previously appreciated, and even reversible. We review this literature, discuss related conditions that are treatable, and present two new LS cases with radiographic improvement. We review studies in which hypoxia reverses advanced LS in a mouse model. The fluctuating and potentially reversible nature of radiographic LS lesions will be important in clinical trial design. Better understanding of this plasticity could lead to new therapies.

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.

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-induced hearing loss complicating sleeve gastrectomy

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).

I can't hear you, you said I had what?: A case report and literature review

We report the case of a 46-year old African American woman who presented to the emergency department with one week of progressive bilateral deafness associated with worsening gait abnormalities, visual changes, and confusion. She was diagnosed with Wernicke encephalopathy (WE) attributed to alcohol abuse; her symptoms, including hearing loss, improved with thiamine replacement. WE, a condition due to thiamine deficiency, commonly affects those with alcohol use disorder or gastric bypass history. Though traditionally associated with a triad of encephalopathy, ophthalmoplegia, and ataxia, it can be more rarely associated with auditory deficits or other neurologic findings. Though hearing loss has previously been reported as a rare symptom of WE, it has not been described in WE due to alcohol abuse. We performed a review of the literature to determine if WE associated with hearing loss had been previously reported.

Resolved External Ophthalmoplegia and Hearing Loss in Wernicke's Encephalopathy With Thiamine Replacement

BACKGROUND

Wernicke encephalopathy (WE) is classically described by a clinical triad consisting of confusion, ataxia, and ophthalmoplegia, but recent reports emphasize a history of malnutrition along with 2 elements of the WE triad (Caine's criteria) to enhance diagnostic sensitivity. The ophthalmoplegia, vestibular, and auditory expeditious improvement with intravenous thiamine usually confirms the diagnosis; serum levels generally provide additional diagnostic certainty.

METHODS

Here, we discuss the case of a woman with a distant history of gastric sleeve, poor nutrition and protracted vomiting, who developed acute confusion, imbalance, near-total external ophthalmoplegia (EO), and hearing loss. The baseline thiamine level was 28 πmol/L (Normal: 70-180 πmol/L). We performed serial neurological, vestibular, and audiological examination to document over 5 days, the effect of intravenous (IV) thiamine, and again at 3 months with continued oral supplementation. We provide serial documentation with photographs and video recording of oculomotor abnormalities, audiometric testing, and a video of horizontal head impulse testing, and imaging findings.

RESULTS

Over the course of 5 days of IV thiamine supplementation, we demonstrate our patient's resolution of near complete EO. We assessed vestibular paresis with horizontal head impulse testing, after complete resolution of the EO. The initially positive bilateral h-HIT showed decreased gain and overt corrective saccades, it clinically resolved by day 5, but video h-HIT testing demonstrated persistent decreased horizontal vestibulo-ocular reflex (VOR) gain and covert horizontal saccades, which persisted at the 3-month examination. By contrast, the vertical VOR gain was normal without corrective saccades. Bedside audiometry completed during the acute phase demonstrated severely restricted auditory speech comprehension, which normalized 3 months later. Severe truncal ataxia improved as well.

CONCLUSIONS

This case is an example of how awareness of the variations in the clinical presentation of WE can be crucial in achieving an early diagnosis and obtaining better outcomes. A history of the poor nutritional status can be an important clue to aid in this early diagnosis.

Sensorineural Hearing Loss and Wernicke Encephalopathy: A Case Report and Literature Review

Sensorineural hearing loss (SNHL) is seldom associated with Wernicke encephalopathy (WE) or thiamine deficiency. While thiamine deficiency and repletion are often considered prior to dextrose infusions in patients with chronic alcohol abuse to prevent WE, they are often overlooked in non-alcoholic patients who are also at risk for malnutrition. In this paper we describe a case of a non-alcoholic 28-year-old female status post-sleeve gastrectomy who developed SNHL in the setting of thiamine deficiency and WE, with ongoing hearing impairment requiring hearing aids despite thiamine repletion.

Wernicke's Encephalopathy Presenting as Sensorineural Hearing Loss

Sleeve gastrectomy is a restrictive-type weight loss surgery that can result in nutritional deficiencies, such as vitamin B1 (thiamine) deficiency. Although Wernicke’s encephalopathy is a known complication following bariatric surgery, bilateral sensorineural hearing loss is a rare presenting symptom of this condition. We present a case of a patient two months postoperative following a sleeve gastrectomy whose chief complaint was hearing loss. While initial laboratory evaluation of her complaint showed elevated inflammatory markers, prompting an autoimmune workup, ultimately the diagnosis of Wernicke’s encephalopathy was confirmed by a low thiamine level and magnetic resonance imaging findings. A correction of the patient’s thiamine deficiency led to an improvement of her symptoms.