P0633 - Altered mental status and weakness in an adolescent

Introduction
We present the case of a 24-year-old woman who developed Wernicke’s encephalopathy (WE) from a combination of restrictive eating and alcohol abuse.

Case Description
A 24-year-old woman with a history of depression presented to the ER with 7 days of worsening lower extremity pain and difficulty walking. She had been in her usual state of health until 6 months prior when she developed progressive lower extremity paresthesias. Two months later she had a seizure for which she was briefly hospitalized and started on an anti-epileptic. At that time an MRI brain, EEG, and EMG were all normal. She was also noted to have pancytopenia. Since that hospitalization her paresthesias continued to worsen.

On presentation to the ER, neurologic exam of her lower extremities was limited by pain. While in the ER, she had a generalized tonic-clonic seizure. Her labs were notable for pancytopenia and an elevated ethanol level. Two days into the admission she developed hallucinations, agitation, and nystagmus overnight. She was monitored on the alcohol-withdrawal protocol and treated with lorazepam. The patient disclosed drinking a few glasses of wine per night and a history of anorexia. Based on her nystagmus, confusion, and gait abnormalities in the setting of an elevated ethanol level and anorexia, she was diagnosed with WE, and started on thiamine IV, B6, B12, and folate. Laboratory studies revealed low thiamine, B6, and folate levels. Her mental status and nystagmus improved quickly with vitamin supplementation. Her pancytopenia and lower extremity paresthesias improved gradually after discharge.

Discussion
WE is most frequently diagnosed in middle-aged men with Alcohol Use Disorder who fit the classic triad of opthalmoplegia, mental status changes, and ataxia. This patient does not fit the typical illness script for WE based on her age, gender, and lack of a prior alcohol-abuse history. However, she was particularly vulnerable to WE given her underlying eating disorder in the context of alcohol abuse. Diagnosis of WE can be challenging and it is often missed. The Caine Criteria are broader and more sensitive for diagnosing WE. The Caine Criteria include eye signs, cerebellar signs, memory impairment or confusion, and nutritional deficiency; 2 of 4 are required for diagnosis. Since thiamine treatment has minimal risks, it is important to identify and treat these patients.

Conclusions
WE is difficult to diagnose and missing the diagnosis can be fatal. Fortunately, thiamine is a low-risk and readily available treatment. This case provides an example of a patient who did not fit the classic image of a patient with WE. By broadening our diagnostic criteria, we can more effectively identify and treat patients with WE.

Isenberg-Grzeda, et al (2012). Wernicke-Korsakoff-Syndrome: Under-Recognized and Under-Treated. Psychosomatics, 53(6), 507–516.