Wernicke Encephalopathy

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

Background

Thiamine (vitamin B-1) deficiency can result in Wernicke's Encephalopathy (WE), a serious neurologic disorder. Dr Carl Wernicke, a Polish neurologist, described it in 1881 as a triad of acute mental confusion, ataxia, and ophthalmoplegia. Korsakoff amnestic syndrome is a late neuropsychiatric manifestation of WE with memory loss and confabulation; sometimes, the condition is referred to as Wernicke-Korsakoff syndrome (WKS) or psychosis. (See Clinical.)

In the Western world, thiamine deficiency is characteristically associated with chronic alcoholism, because it affects thiamine uptake and utilization. However, WE may develop in nonalcoholic conditions, such as prolonged starvation, hyperemesis gravidarum, bariatric surgery, and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), and can even develop in healthy infants given the wrong formulas. (See Etiology and History.)[1]

Frequently unrecognized, WE is more prevalent than commonly supposed. Epidemics of WE can occur, as evidenced by a report of Israeli infants with infantile thiamine deficiency who were fed formula deficient in thiamine. (See Epidemiology.)[2]

Complications

Complications of WE may include the following:

  • Hypotension
  • Hypothermia
  • WKS
  • Alcohol withdrawal [3]
  • Acute precipitation of WE
  • Congestive heart failure
  • Gastrointestinal beriberi [4]
  • Lactic acidosis [5]

In addition, the administration of dextrose in the setting of thiamine deficiency can be harmful because glucose oxidation is a thiamine-intensive process that may drive the insufficient circulating vitamin B-1 intracellularly, thereby precipitating neurologic injury. (See Etiology.)[2]

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Etiology

Thiamine plays a vital role in the metabolism of carbohydrates. Thiamine is a cofactor for several essential enzymes in the Krebs cycle and the pentose phosphate pathway, including alpha-ketoglutarate dehydrogenase, pyruvate dehydrogenase, and transketolase.[6] In the setting of thiamine deficiency, thiamine-dependent cellular systems begin to fail, resulting eventually in cell death. Because thiamine-dependent enzymes play an essential role in cerebral energy utilization, thiamine deficiency may propagate brain tissue injury by inhibiting metabolism in brain regions with higher metabolic demands and high thiamine turnover.[6]

Pyruvate dehydrogenase and alpha-ketoglutarate are essential enzymes in the Krebs cycle, and the lack of these enzymes alters cerebral energy utilization. If cells with high metabolic requirements have inadequate stores of thiamine to draw from, energy production drops, and neuronal damage ensues. Increased cell death then feeds the localized vasogenic response.[7] Additionally, the reduced production of succinate, which plays a role in gamma-aminobutyric acid (GABA) metabolism and the electrical stimulation of neurons, leads to further central nervous system injury.

Increased lactic acid production ensues in the absence of pyruvate dehydrogenase function, as the reduced conversion of pyruvate to acetyl coenzyme A results in less efficient oxidative phosphorylation.[8]

Thiamine pyrophosphate is also essential for nucleotide synthesis, production of nicotinamide adenine dinucleotide phosphate (NADPH), and maintenance of reduced glutathione within erythrocytes.[8]

Causes

In the Western world, thiamine deficiency is characteristically associated with chronic alcoholism, because it affects thiamine uptake and utilization.[1] In long-term alcoholics, malnutrition can reduce intestinal thiamine absorption by 70%, decreasing serum levels of thiamine to between 30% and 98% below the lower level established for normal subjects. Thiamine acts as a coenzyme in the metabolism of glucose and lipids, and, as stores of water-soluble vitamins are limited in the body, deficiency can present within 2 to 3 weeks of cessation of intake.[3]

Chronic alcohol consumption does not necessarily result in WE if dietary thiamine intake is adequate. It may induce thiamine deficiency through several potential mechanisms: genetic predisposition, replacement of vitamin-containing foods by the high calorific value of alcohol, impaired absorption of thiamine from the gut, impairment of storage by the liver, thiamine transport problems, other nutritional deficiencies, decreased phosphorylation to thiamine pyrophosphate and excessive requirements for the metabolism of alcohol.[3]

WE may develop in nonalcoholic conditions, such as prolonged starvation, hyperemesis gravidarum, and bariatric surgery.[1] The numerous reports of severe thiamine deficiency after obesity surgery have led to the expression "bariatric beriberi.”[9] Other causes of thiamine deficiency include total parenteral nutrition deficient in thiamine, formula deficient in thiamine, and hemodialysis-induced thiamine deficiency in patients with end-stage renal disease.

Other uncommon etiologies of WE are: forced or self-imposed starvation, protein-energy malnutrition resulting from inadequate diet or malabsorption (from celiac sprue), conditions associated with protracted vomiting (eg, hyperemesis gravidarum), carbohydrate loading in the presence of marginal thiamine stores (feeding after starvation), other gastric bypass surgeries, absence of thiamine from the diet as demonstrated by a case series of infants fed formula without the addition of thiamine,[2] and congenital transketolase function abnormalities. A correlation between hemodialysis and WE has been demonstrated possibly secondary to inadvertent dialysis of the water-soluble thiamine combined with malnutrition in the end-stage renal disease population.[10]

The most common inciting factor precipitating WE in the setting of thiamine deficiency is infection. Concomitant illnesses, such as pneumonia or even meningitis, do not exclude a co-diagnosis of WE.[6]

Iatrogenic exacerbation of WE can occur with prolonged glucose or carbohydrate loading in the setting of thiamine deficiency. However, a single, acute administration of glucose does not appear to cause this effect. Nutritionally deficient patients receiving glucose should also receive thiamine, but urgent administration of glucose should not be delayed pending thiamine administration.[6]

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Epidemiology

Occurrence in the United States

Autopsy series identifying typical brainstem lesions of WE have placed the incidence of the condition between 0.8% and 2.8% of the general population. However, the incidence can be as high as 12.5% in a population of alcoholics.[11] WE has been described in many other situations where nutrition has been compromised. These cases include patients with AIDS, individuals receiving hemodialysis, persons with hyperemesis gravidarum, and patients with malignancy with or without chemotherapy.

The overall prevalence of WE averages approximately 2%, although this figure is variable and may be decreasing secondary to nutritional supplements in processed foods.[6]

International occurrence

The incidence of WE is believed to be higher in developing nations than more modern nations because of the higher incidence of malnutrition and less vitamin supplementation in poorer regions; however, it may not be diagnosed as frequently in these settings because of more limited access to healthcare.

Sex-, age, and race-related demographics

The male-to-female ratio for WE is 1.7:1, likely owing to alcoholism being 3-4 times more frequent in men than in women.

Average age at onset of WE is 50 years. However, WE can occur in small numbers in unusual situations, such as in total parenteral nutrition ̶ dependent patients during a multivitamin shortage, in persons with hyperemesis gravidarum, or in infants who are fed thiamine-deficient infant formula.[2] WE typically occurs in adults with risk factors (alcoholism, post bariatric surgery, malnutrition), but can occur even in formula-fed infants if their formula lacks thiamine supplementation.

Race does not predispose to WE.

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Prognosis

WE is a significantly disabling and potentially lethal condition that can be prevented or reversed if identified and treated early in the course of illness. Administration of thiamine improves the patient’s condition to some degree in many cases; however, neurologic dysfunction can persist even after treatment.[6] WE ataxia and ophthalmoplegia usually resolve briskly, within hours, after thiamine repletion if administered early in the disease course; the global confusional state also appears to improve rapidly within hours of thiamine treatment. However, impairment of memory and learning responds more slowly and often incompletely, suggesting a different mechanism of effect.[3]

WE patients have significant morbidity and mortality related to their thiamine deficiency, particularly if there are no early signs of neurologic improvement after thiamine repletion. Among patients surviving WE, a percentage develop WKS. Patients with Korsakoff psychosis often have permanent neurological disability and require long-term institutionalization. Only about 20% eventually recover completely during long-term follow-up care.

Persistent residual manifestations of WE that are not identified and treated early in the disease include nystagmus, gait ataxia, and Korsakoff syndrome.[6]

Late-stage WE is associated with elevated spinal fluid protein levels and diffuse slowing of postsynaptic potentials on electroencephalography.[9]

Studies suggest that up to 80% of patients with WE may not be diagnosed, which make estimates of morbidity and mortality rates unreliable.[12]

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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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