Wernicke’s encephalopathy associated with alcoholism and precipitated by intravenous glucose

Background: Wernicke’s encephalopathy is a rare, potentially fatal condition caused by thiamine deficiency. It can be precipitated by administering glucose to alcoholics without thiamine. [1] Clinical diagnosis requires at least two of the following: dietary deficiency, eye signs (gaze palsy, total ophthalmoplegia, nystagmus), cerebellar signs, and altered mental state. [2] Magnetic Resonance Imaging (MRI) of the brain is specific but not sensitive. [3] It is important to commence parenteral thiamine promptly to avoid permanent neurological deficits. Purpose: To report a patient with Wernicke’s encephalopathy precipitated by intravenous glucose that was reversed with thiamine. Synopsis: A 53-year-old chronic alcoholic male patient was referred for diplopia. He had been consuming only alcohol for the past 2 weeks without any food. Intravenous (IV) 5% dextrose and ondanesetron were administered elsewhere for weakness and vomiting. A day later, he could not walk or move his eyes. On examination, he was noted to have a vision of 6/6 Oculus Uterque (OU). Horizontal gaze was absent with normal vertical movements. The remainder of the ocular exam was normal. He had gait ataxia. MRI of the brain was normal. His blood thiamine levels were low – 26.6 µg/L (reference 33.1–60.7 µg/L). 100 mg intramuscular thiamine was given twice daily for 3 days along with oral multivitamins. He had a complete recovery after the fourth dose – [Video 1]. Highlights: Wernicke’s encephalopathy should be suspected in the presence of suggestive clinical features in at-risk patients – alcoholics, malnourishment, recurrent vomiting, gastric surgery, among others. Thiamine should be given concurrently with intravenous glucose to alcoholics. [1,2] Video link: https://youtu.be/ACwbRTUI5W4