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Wernicke Encephalopathy Clinical Presentation

  • Author: Philip N Salen, MD; Chief Editor: Robert E O'Connor, MD, MPH  more...
 
Updated: Oct 28, 2015
 

History

The three components of the classic triad of WE are encephalopathy, ataxic gait, and some variant of oculomotor dysfunction. However, a complicating factor of WE identification is that its presentation may not be associated with the classical clinical triad in up to 90% of patients.

Consideration for WE should be given to patients with any evidence of long-term alcohol abuse or malnutrition and any of the following: acute confusion, ataxia, ophthalmoplegia, memory disturbance, hypothermia with hypotension, and delirium tremens.

A high proportion of patients with acute WE who survive develop WKS, characterized by potentially irreversible retrograde amnesia (inability to recall information) and anterograde amnesia (inability to assimilate new information), with varying degrees of other cognitive deficits.[13]

Consider WE when any patient with long-term malnutrition presents with confusion or altered metal status. Significant overlap exists between WE and Korsakoff psychosis. For this reason, the two entities are often described together as WKS.

Alcohol abuse, AIDS, malignancy, hyperemesis gravidarum, prolonged total parenteral nutrition, iatrogenic glucose loading in any predisposed patient, and other disorders associated with grossly impaired nutritional status are associated with WKS.

Bariatric surgery (there are more than 100,000 weight-loss procedures performed annually in the United States) has been associated with both malnutrition and WE.[9] Post–bariatric surgery patients have a limited capacity for food intake during the initial weeks after a bariatric procedure and a body's reserves of thiamine can be depleted after only 20 days of inadequate supply. Post–bariatric surgery patients may still be frankly obese when presenting with WE symptoms caused by thiamine deficiency.[9]

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Physical Examination

Ocular abnormalities are the hallmarks of WE. The oculomotor manifestations are: nystagmus, bilateral lateral rectus palsies, and conjugate gaze palsies reflecting cranial nerve involvement of the oculomotor, abducens, and vestibular nuclei. Less frequently noted manifestations are: pupillary abnormalities such as sluggishly reactive pupils, ptosis, scotomata, and anisocoria. The most common ocular abnormality is nystagmus, not abducens (Cranial Nerve VI) ophthalmoplegia.[6]

Encephalopathy is characterized by a global confusional state, disinterest, inattentiveness, or agitation. The most common presenting symptoms of WE are mental status changes.[6] Stupor and coma are rare.

Gait ataxia is often a presenting physical examination manifestation.[8] Ataxia is likely to be a combination of polyneuropathy, cerebellar damage, and vestibular paresis. Vestibular function, usually without hearing loss, is universally impaired in the acute manifestation of WE. In less severe cases, patients walk slowly with a broad-based gait. However, gait and stance may be so impaired as to make walking impossible. Cerebellar testing in bed with finger-to-nose and heel-to-shin tests may not illicit any notable deficit; thus, it is important to test for truncal ataxia with the patient sitting or standing.[13]

In addition to ophthalmoplegia and ataxia, 80% of adults will have some degree of peripheral neuropathy, which may include weakness, foot drop, and decreased proprioception.

Thiamine deficiency has recently been associated with a gastrointestinal syndrome of nausea, vomiting, abdominal pain, and lactic acidosis.[4]

Other symptoms that may occur in addition to, or in place of, the classic triad include hypothermia, hypotension, and coma.[13] Thiamine deficiency often affects the temperature-regulating center in the brainstem, which can result in hypothermia.

Hypotension can be secondary to thiamine deficiency either through cardiovascular beriberi or thiamine deficiency–induced autonomic dysfunction.[8] Coma is rarely the sole manifestation of WE.

Of patients surviving WE, an important percentage will manifest WKS, characterized by the following: retrograde amnesia (inability to recall information), anterograde amnesia (inability to assimilate new information), decreased spontaneity and initiative, and confabulation.

Other manifestations of thiamine deficiency involve the cardiovascular system (wet beriberi) and peripheral nervous system (nutritional polyneuropathy).

Manifestations of thiamine deficiency in infants are constipation, agitation, apathy, vomiting, lack of appetite, and later, diarrhea, grunting, nystagmus, convulsions, unconsciousness, and cardiomyopathy.[2]

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Contributor Information and Disclosures
Author

Philip N Salen, MD Clinical Professor, Department of Emergency Medicine, PA Program, DeSales University; Adjunct Clinical Associate Professor, Department of Emergency Medicine, Temple University School of Medicine; Research Director, Emergency Medicine Education, St Luke's Hospital

Philip N Salen, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Association for Physician Leadership, American Heart Association, Medical Society of Delaware, Society for Academic Emergency Medicine, Wilderness Medical Society, American Medical Association, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Peter MC DeBlieux, MD Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University School of Medicine in New Orleans

Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

References
  1. Attard O, Dietemann JL, Diemunsch P, Pottecher T, Meyer A, Calon BL. Wernicke encephalopathy: a complication of parenteral nutrition diagnosed by magnetic resonance imaging. Anesthesiology. 2006 Oct. 105(4):847-8. [Medline].

  2. Fattal-Valevski A, Kesler A, Sela BA, et al. Outbreak of life-threatening thiamine deficiency in infants in Israel caused by a defective soy-based formula. Pediatrics. 2005 Feb. 115(2):e233-8. [Medline].

  3. [Guideline] Day E, Bentham PW, Callaghan R, Kuruvilla T, George S. Thiamine for prevention and treatment of Wernicke- Korsakoff Syndrome in people who abuse alcohol (Cochrane Review ). The Cochrane Library. 2013. 7:1-20.

  4. Donnino M. Gastrointestinal beriberi: a previously unrecognized syndrome. Ann Intern Med. 2004 Dec 7. 141(11):898-9. [Medline].

  5. Donnino MW, Miller J, Garcia AJ, et al. Distinctive acid-base pattern in Wernicke's encephalopathy. Ann Emerg Med. 2007 Dec. 50(6):722-5. [Medline].

  6. Donnino MW, Vega J, Miller J, et al. Myths and misconceptions of Wernicke's encephalopathy: what every emergency physician should know. Ann Emerg Med. 2007 Dec. 50(6):715-21. [Medline].

  7. Buscaglia J, Faris J. Unsteady, unfocused, and unable to hear. Am J Med. 2005 Nov. 118(11):1215-7. [Medline].

  8. Decker MJ, Isaacman DJ. A common cause of altered mental status occurring at an uncommon age. Pediatr Emerg Care. 2000 Apr. 16(2):94-6. [Medline].

  9. Aasheim ET. Wernicke encephalopathy after bariatric surgery: a systematic review. Ann Surg. 2008 Nov. 248(5):714-20. [Medline].

  10. Hung SC, Hung SH, Tarng DC, Yang WC, Chen TW, Huang TP. Thiamine deficiency and unexplained encephalopathy in hemodialysis and peritoneal dialysis patients. Am J Kidney Dis. 2001 Nov. 38(5):941-7. [Medline].

  11. Thomson AD, Cook CC, Touquet R, et al. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke's encephalopathy in the accident and Emergency Department. Alcohol Alcohol. 2002 Nov-Dec. 37(6):513-21. [Medline].

  12. Azim W, Walker R. Wernicke's encephalopathy: a frequently missed problem. Hosp Med. 2003 Jun. 64(6):326-7. [Medline].

  13. Antunez E, Estruch R, Cardenal C, et al. Usefulness of CT and MR imaging in the diagnosis of acute Wernicke's encephalopathy. AJR Am J Roentgenol. 1998 Oct. 171(4):1131-7. [Medline].

  14. Attard O, Dietemann JL, Diemunsch P, Pottecher T, Meyer A, Calon BL. Wernicke encephalopathy: a complication of parenteral nutrition diagnosed by magnetic resonance imaging. Anesthesiology. 2006 Oct. 105(4):847-8. [Medline].

  15. Kaineg B, Hudgins PA. Images in clinical medicine. Wernicke's encephalopathy. N Engl J Med. 2005 May 12. 352(19):e18. [Medline].

  16. Roh JH, Kim JH, Koo Y, Seo WK, Lee JM, Lee YH, et al. Teaching NeuroImage: Diverse MRI signal intensities with Wernicke encephalopathy. Neurology. 2008 Apr 8. 70(15):e48. [Medline].

 
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This MRI shows typical high signal intensities (SIs) in the medial thalamus (A), periaqueductal gray (B), mamillary bodies (C), cerebellar vermis (B, C, D), and paravermian superior cerebellum (D). All the lesions represent high SIs on the DWI (E–H). The ADC images of the cerebellar vermis (K, L) and paravermian superior cerebellum (L) show low SIs (arrowheads), whereas other described areas (I, J) show iso-SIs (arrows). Image courtesy of Neurology. Apr 8 2008;70(15):e48.
 
 
 
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