Category: Clinical Sciences/Health Conditions
Case Diagnosis: Non-Alcoholic Wernicke's Encephalopathy
29-year-old non-pregnant female with history of gastritis and 40-pound weight loss following tonsillectomy three months prior to presentation was transferred from a community hospital with intractable vomiting and confusion. Initial infectious and neurologic work-up were negative. EEG demonstrated global slowing. Brain imaging revealed a left basal ganglia cyst and bilateral dorsomedial thalami T2 FLAIR abnormalities consistent with Wernicke’s encephalopathy (WE). Patient was treated with high-dose intravenous thiamine. Further workup found elevated anti-Gliadin antibodies with low vitamin D and vitamin B12. Complications included dysphagia, extrapyramidal side effects from anti-nausea medication, and refeeding syndrome. Initial functional assessments demonstrated ataxia, oculomotor derangements, need for moderate assistance with ambulation and stair negotiation, maximum assistance for functional transfers, and minimum assistance for self-care tasks. Three weeks of neurorehabilitation allowed for discharge home with a regular diet, modified independence in self-care and transfers, and independent mobility with a wheeled walker.
WE is caused by thiamine deficiency, related most often to alcoholism, and characterized by ataxia, nystagmus, ophthalmoplegia, and confusion. Cases not associated with alcoholism include hyperemesis gravidarum and inflammatory bowel disease.
This case of non-alcoholic WE represents a unique cascade of pre-disposing events never described in the literature. The nitrous oxide (NO) anesthesia used for the tonsillectomy led to a known side effect of NO inhalation which is irreversible oxidation of cyanocobalamin rendering it inactive. This led to vitamin B12 deficiency causing posterior hypopharyngeal dysphagia potentiating the presentation of intractable nausea and vomiting. Undiagnosed celiac disease left her vulnerable to malnutrition, leading to further hypovitaminosis and eventual thiamine deficiency.
There is a dearth of literature describing neurorehabilitation for patients with WE. The loss of function associated with WE would have been devastating for this young and employed mother of two children. While she received delayed diagnosis, she represents a positive outcome of neurorehabilitation.
Andrew McCoy– Resident, University of Pittsburgh Medical Center
Joseph Staszel– Resident Physician, University of Pittsburgh Medical Center, Department of Physical Medicine & Rehabilitation
Rohit Navlani– Resident Physician, UPMC
Gary Galang– Assistant Professor, University of Pittsburgh