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Wernicke's Encephalopathy
Aka: Wernicke's Encephalopathy, Wernicke Encephalopathy, Wernickes Encephalopathy, Acute Thiamine Deficiency
- See Also
- Vitamin B1 (Thiamine)
- Chronic Thiamine deficiency (Beriberi)
- History
- First described in 1881 by Dr. Carl Wernicke (polish neurologist) who recognized the classic triad
- Cause
- Acute Thiamine Deficiency associated with Alcoholism
- Contrast with Chronic Thiamine deficiency (Beriberi)
- May also occur with malnourishment (similar causes of Beriberi)
- Hyperemesis Gravidarum
- Bariatric Surgery
- Chemotherapy
- Antiretroviral therapy
- Anorexia Nervosa
- Elderly with constrained diet
- AIDS
- Signs
- Classic Triad (full triad present in less than one third of cases)
- Mnemonic: WACO (Wernicke's Ataxia Confusion Ophthalmoplegia)
- Ataxia
- Wide based unsteady gait
- Other coordination testing may be normal (e.g. normal Finger-Nose-Finger)
- Mental status changes or Altered Level of Consciousness
- Confusion or Delirium
- Apathy
- Inattention
- Drowsiness
- Decreased speech
- Short Term Memory deficit
- Ophthalmoplegia
- Horizontal Nystagmus is most common (but Vertical Nystagmus may also be present)
- Lateral Rectus Palsy (internal Strabismus, Conjugate Gaze Palsy, variably present)
- Other findings
- See Beriberi
- Hypothermia
- Hyperhidrosis
- Neuropsychiatric symptoms (psychomotor slowing, Seizures, depression, Dysphagia)
- Differential Diagnosis
- See Ataxia
- See Delirium
- See Altered Level of Consciousness
- See Ophthalmoplegia or Nystagmus
- Labs
- See Lab Markers of Malnutrition
- See Delirium
- Imaging
- CT Head
- Initial imaging to exclude acute cause (e.g. Intracranial Hemorrhage)
- MRI Brain
- Mammillary Body T2 contrast enhancement (2 brightly enhancing ovoid bodies at anterior Midbrain)
- Mammillary Body enhancement present in 58% of those with Wernicke's Encephalopathy
- Other regions with variable involvement
- Medial Thalamus
- Periventricular Third Ventricle
- Periaqueduct
- Tectal Plate
- Dorsal Medulla
- References
- Zuccoli (2007) Am J Neuroradiol 28(7): 1328-31 [PubMed]
- Complications
- Associated Mortality
- Korsakoff's Disease (Wernicke-Korsakoff Syndrome or Korsakoff's Psychosis)
- Life-long neurologic Impairment
- Associated with learning difficulties, memory difficulties, confabulation (invented memories)
- Management
- Emergent Thiamine Dosing
- Start immediately without delay
- Glucose or dextrose given before Thiamine can precipitate encephalopathy
- Initial
- Thiamine 500 mg IV every 8 hours for 3 days (or more)
- Next
- Thiamine 50-100 mg orally, IV or IM daily
- Other management
- Magnesium
- Resources
- Wernicke Encephalopathy (NIH Stat Pearls)
- https://www.ncbi.nlm.nih.gov/books/NBK470344/
- References
- Broder (2020) Crit Dec Emerg Med 34(9): 18-9
- Rendon et al. (2017) Crit Dec Emerg Med 31(6): 15-21