Non-alcoholic Wernicke’s Encephalopathy and Magnetic Resonance Imaging Brain: Can Neuroimaging Help in Decision Making and Troubleshooting?

Abstract

Summary: We present 4 hospitalized patients with chronic illness without social history of alcoholism. These patients suddenly developed altered mental status and drowsiness. Clinical examination was inconclusive and patients were diagnosed as Wernicke’s encephalopathy on typical Magnetic Resonance Imaging (MRI) features. Background: Wernicke’s encephalopathy (WE) is acute encephalopathy primarily caused by acute thiamine deficiency. It’s a neurological emergency; thiamine replacement can prevent permanent neurological damage and even death. Chronic alcoholism is most common cause; others include prolonged starvation, malignancy, prolonged parenteral nutrition and bowel surgeries. Despite over a century of reports, diagnosis is not uncommonly delayed, if overlooked altogether. In Pakistan, alcohol is prohibited and majority population is non-alcoholic, clinical suspicion of WE is usually low leading to delay in diagnosis. The real challenge comes when patient has multiple comorbidities and admitted in intensive care receiving total parenteral nutrition or chemotherapy secondary to bowel surgeries or treatment of malignancy. We present 4 cases after obtaining informed and written consent. All were nonalcoholic; presented with multiple comorbidities. During hospital stay, in addition to primary complaints, these patients developed altered mental status and drowsiness. These patients were administered thiamine replacement on basis of Magnetic Resonance Imaging findings and rapid clinical response was documented. Unfortunately 1 out of 4 patients succumbed to death due to other co-morbidities; remaining recovered. Conclusion: Non-alcoholic WE has relatively high mortality because of delayed diagnosis and lack of clinical suspicion. Mortality and morbidity decreases with an earlier diagnosis based on MRI and simultaneous prompt treatment with thiamine administration.