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Wernicke’s encephalopathy

Background knowledge ๐Ÿง 

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 ๐ŸŒก๏ธ

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 ๐Ÿงช

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 ๐Ÿฅผ

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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