Wernicke’s encephalopathy

Medicine > Neurosciences

Background knowledge 🧠

Definition

Wernicke’s encephalopathy is an acute neurological disorder caused by thiamine (vitamin B1) deficiency
It is characterized by a triad of ophthalmoplegia, ataxia, and confusion
Commonly associated with chronic alcoholism, but can also occur in malnutrition and hyperemesis gravidarum

Epidemiology

Prevalence higher in populations with chronic alcoholism
Also seen in malnourished individuals, bariatric surgery patients, and those with hyperemesis gravidarum
Exact incidence is difficult to determine due to underdiagnosis
Can occur at any age, but more common in adults

Aetiology and Pathophysiology

Thiamine deficiency impairs glucose metabolism in the brain
Leads to neuronal damage and death, particularly in the thalamus and hypothalamus
Commonly caused by chronic alcohol abuse, which interferes with thiamine absorption and storage
Other causes include malnutrition, prolonged vomiting, and malabsorption syndromes

Clinical Features 🌡️

Symptoms

Confusion and cognitive impairment
Gait ataxia and balance issues
Ophthalmoplegia (typically lateral rectus muscle weakness)
Nystagmus
Peripheral neuropathy
Hypothermia and hypotension (in severe cases)

Signs

Confusion or disorientation
Ataxic gait
Ophthalmoplegia (partial or complete paralysis of eye movements)
Nystagmus (rapid involuntary eye movements)
Hyporeflexia or areflexia
Altered mental state

Investigations 🧪

Tests

Clinical diagnosis based on history and examination
Serum thiamine levels (may be low but not always reliable)
MRI brain: may show characteristic changes in the thalamus, mammillary bodies, and periaqueductal area
Consider other investigations to rule out differential diagnoses (e.g., CT head, lumbar puncture)

Management 🥼

Management

Intravenous thiamine (as Pabrinex or equivalent), later followed by oral thiamine and B vitamin supplementation
Correct associated electrolyte deficiencies (e.g., magnesium)
Monitor and support nutritional intake
Manage complications (e.g., electrolyte imbalances, infections)
Long-term abstinence from alcohol if alcohol-related
Psychiatric support and rehabilitation

Complications

Korsakoff syndrome (chronic memory disorder)
Permanent neurological deficits
Alcohol withdrawal syndrome (if alcohol-related)
Increased risk of infections
Nutritional deficiencies
Death (if untreated or severe)

Prognosis

Early treatment can lead to significant improvement or resolution of symptoms
Delay in treatment can result in permanent damage
Long-term outcomes depend on cause and patient adherence to management plan
Regular follow-up and supportive care are essential

Key Points

Wernicke’s encephalopathy is a medical emergency requiring prompt thiamine administration
Commonly associated with chronic alcoholism but can occur in other settings
Early recognition and treatment are crucial to prevent permanent damage
Multidisciplinary approach improves patient outcomes
Patient education on nutrition and alcohol abstinence is essential

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