eMedicine Specialties > Psychiatry > Adult

Wernicke-Korsakoff Syndrome: Differential Diagnoses & Workup

Author: Glen L Xiong, MD, Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California Davis School of Medicine; Attending Psychiatrist, Sacramento Mental Health Treatment Center; Attending Physician, Sacramento County Primary Care Clinic
Coauthor(s): G Patrick Daubert, MD, Assistant Professor, Assistant Medical Director, Sacramento Division, California Poison Control System; Director of Clinical and Medical Toxicology Education, Department of Emergency Medicine, University of California, Davis Medical Center
Contributor Information and Disclosures

Updated: Nov 23, 2009

Differential Diagnoses

Alcohol-Related Psychosis
Encephalopathy, Hepatic
Alcoholism
Hypoglycemia
Delirium
Hyponatremia
Delirium Tremens
Postconcussive Syndrome
Delusional Disorder
Eating Disorder, Anorexia

Other Problems to Be Considered

Wernicke encephalopathy should be differentiated from acute delirium secondary to hypoxia, hypercarbia, CNS infections, and postictal state (seizure). Ataxic disorders also can result from cerebellar infarction. Ocular disorders also can result from vasculitis or infarction.

The differential diagnosis of Korsakoff psychosis includes the following:

Temporal lobe epilepsy
Temporal lobe infarction
Concussive head injury

Dementia with Lewy bodies
Transient global amnesia
Anoxic encephalopathy

Alzheimer disease
Third ventricle tumor
Herpes simplex virus

Workup

Laboratory Studies

  • Electrolytes: Initial laboratory studies are directed at the differential diagnostic possibilities that can be identified and corrected rapidly. Electrolyte studies are used to rule out an acute metabolic derangement causing mental confusion.
  • Serum thiamine levels have been used in case reports to confirm Wernicke-Korsakoff syndrome. However, studies have not directly examined the correlation between a critical serum thiamine level and the development of neurologic symptoms and Wernicke-Korsakoff syndrome itself. One small study did show that serum thiamine level correlated well with cerebellar vermal atrophy.11 For now, the role of serum thiamine level remain uncertain, though there might be role in confirming the diagnosis and/or to monitor adequacy of treatment.
  • Complete blood count: Rule out an acute infectious process, thrombocytosis, or erythrocytosis predisposing to thrombosis and infarction.
  • Coagulation panel: Evaluate for a potential bleeding diathesis.
  • Arterial blood gas: Evaluate for hypoxemia, hypercarbia, acidosis, or alkalosis.
  • Serum/urine toxic drug screen: Rule out acute toxic ingestion. This is most helpful if results are available rapidly.
  • Liver-associated enzymes: This may provide evidence of alcohol abuse or liver dysfunction.

Imaging Studies

  • CT brain scan (noncontrast): CT scan can help in rapid assessment for hemorrhage, mass effect, edema, and large subacute stroke.
  • MRI of the brain with contrast: MRI demonstrates acute lesions of Wernicke-Korsakoff syndrome in dorsal medial thalamic, periventricular region of the third ventricle, periaqueductal area, mamillary bodies, and dorsal medulla. Contrast enhancement of the mamillary bodies were correlated with alcohol12 and nonalcoholic causes13 so whether MRI findings may be specific to etiology of Wernicke-Korsakoff Syndrome remains uncertain. This can be a useful diagnostic procedure in patients presenting with suggestive history and stupor or coma, where ataxia and ophthalmoplegia are not detectable.

Procedures

Lumbar puncture/CSF analysis: Seriously consider this procedure for any confused patient with fever and/or headache, particularly elderly patients, to rule out infectious etiology. Patients with Wernicke-Korsakoff syndrome have a protein content that is within the reference range or mildly elevated without pleocytosis on CSF analysis.

More on Wernicke-Korsakoff Syndrome

Overview: Wernicke-Korsakoff Syndrome
Differential Diagnoses & Workup: Wernicke-Korsakoff Syndrome
Treatment & Medication: Wernicke-Korsakoff Syndrome
Follow-up: Wernicke-Korsakoff Syndrome
References
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Further Reading

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Keywords

Wernicke-Korsakoff syndrome, Wernicke encephalopathy, Wernicke's encephalopathy, polioencephalitis hemorrhagica superioris, Korsakoff's psychosis, Korsakoff psychosis, amnestic-confabulatory state, psychosis polyneuritica, thiamine deficiency, confusion, ataxia, nystagmus, alcoholism, Korsakoff amnestic state, confabulation, Korsakoff dementia, nutritional deficiency

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Contributor Information and Disclosures

Author

Glen L Xiong, MD, Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California Davis School of Medicine; Attending Psychiatrist, Sacramento Mental Health Treatment Center; Attending Physician, Sacramento County Primary Care Clinic
Glen L Xiong, MD is a member of the following medical societies: American College of Physicians, American Psychiatric Association, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

G Patrick Daubert, MD, Assistant Professor, Assistant Medical Director, Sacramento Division, California Poison Control System; Director of Clinical and Medical Toxicology Education, Department of Emergency Medicine, University of California, Davis Medical Center
G Patrick Daubert, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Ronald C Albucher, MD, Chief Medical Officer, Westside Community Services; Consulting Staff, California Pacific Medical Center
Ronald C Albucher, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine
David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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