Difference between revisions of "Wernicke-Korsakoff syndrome"

(Prevention)
 
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**Malabsorption (post-gastrectomy, [[IBD]], [[pancreatitis]]
 
**Malabsorption (post-gastrectomy, [[IBD]], [[pancreatitis]]
 
**Increased metabolic requirements (malignancy, [[thyrotoxicosis]])
 
**Increased metabolic requirements (malignancy, [[thyrotoxicosis]])
**Thiamine losses (hemodialysis)
+
**Thiamine losses ([[hemodialysis]])
**Miscellaneous: AIDS, liver disease
+
**Miscellaneous: [[AIDS]], liver disease
  
 
==Clinical Features==
 
==Clinical Features==
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*Classic triad: [[encephalopathy]], oculomotor dysfunction, gait [[ataxia]]
 
*Classic triad: [[encephalopathy]], oculomotor dysfunction, gait [[ataxia]]
 
*wer'''NIC'''ke mnemonic:  
 
*wer'''NIC'''ke mnemonic:  
**'''N'''ystagmus/ophthalmoplegia
+
**[[nystagmus|'''N'''ystagmus]]/ophthalmoplegia
 
***Ocular findings may also include bilateral 6th nerve palsy, conjugate gaze palsy, pupillary abnormality, retinal hemorrhage, ptosis.   
 
***Ocular findings may also include bilateral 6th nerve palsy, conjugate gaze palsy, pupillary abnormality, retinal hemorrhage, ptosis.   
**'''I'''ncoordination/ataxia
+
**'''I'''ncoordination/[[ataxia]]
**'''C'''onfusion/memory impairment
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**[[confusion|'''C'''onfusion]]/memory impairment
 
*Other symptoms:  
 
*Other symptoms:  
**[[Hypotension]], tachycardia, ECG abnormalities
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**[[Hypotension]], [[tachycardia]], ECG abnormalities
 
**[[Dyspnea]] on exertion, [[CHF]] symptoms
 
**[[Dyspnea]] on exertion, [[CHF]] symptoms
**Hypothermia,
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**[[Hypothermia]]
 
**Dry/wet [[beriberi]]
 
**Dry/wet [[beriberi]]
 
**[[Coma]]
 
**[[Coma]]
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==Disposition==
 
==Disposition==
 
*Admit
 
*Admit
 +
*<25% of patients show recovery, 50% show partial recovery, the remainder show no response despite treatment<ref>https://www.alz.org/alzheimers-dementia/what-is-dementia/types-of-dementia/korsakoff-syndrome</ref>
  
 
==Prevention==
 
==Prevention==

Latest revision as of 17:23, 3 October 2019

Background

  • Wernicke’s Encephalopathy: acute neurologic symptoms caused by thiamine deficiency
  • Korsakoff’s Psychosis: chronic neurologic symptoms caused by thiamine deficiency
  • Wernicke-Korsakoff Syndrome (WKS): presence of Wernicke's Encephalopathy + Korsakoff's Psychosis simultaneously

Epidemiology

  • Only 20% identified before death, failure of diagnosis leads to 20% mortality and 75% permanent damage

Pathophysiology

  • Thiamine plays critical role in:
    • Energy production pathways (Kreb's cycle, pentose phosphate pathway, alpha-ketoglutarate dehydrogenase, pyruvate dehydrogenase)
    • Lipid metabolism (including myelin sheath formation)
      • Alterations in myelination leads to peripheral neuropathy
  • Brain lesions/atrophy usually occur in: mamillary bodies (nearly all cases), thalamus, periaqueductal gray matter, 3rd/4th ventricle, cerebellum, frontal lobe

Causes

  • Thiamine (vitamin B1) deficiency caused by
    • Insufficient intake (e.g. chronic alcoholism, starvation/anorexia, severe vomiting/diarrhea, unbalanced TPN)
    • Malabsorption (post-gastrectomy, IBD, pancreatitis
    • Increased metabolic requirements (malignancy, thyrotoxicosis)
    • Thiamine losses (hemodialysis)
    • Miscellaneous: AIDS, liver disease

Clinical Features

Wernicke’s Encephalopathy

Korsakoff’s Psychosis

  • Antero/retrograde amnesia
  • Confabulation, confusion, apathy

Differential Diagnosis

Ethanol related disease processes

Vitamin deficiencies

Evaluation

  • Clinical diagnosis
  • Wernicke's Encephalopathy - at least 2 of the following:[1]:
    • Nutritional deficiency
    • Ocular findings (ophthalmoplegia, nystagmus)
    • Ataxia
    • Mental status change

Management

If you suspect, then treat! Confirming diagnosis is difficult, treatment is low risk and effective, and morbidity/mortality is high if untreated

  • Thiamine 500mg IV over 30 min TID x 2 days, then 500mg IV/IM q day for 5 days, then 100mg PO q day until patient no longer at risk
    • Give magnesium; hypomagnesemic state may be resistant to thiamine administration
    • Treatment can take days to weeks to work if at all (despite accurate diagnosis)
    • Give thiamine BEFORE glucose in patients requiring glucose who are at risk for thiamine deficiency; glucose without thiamine can precipitate/worsen WE by driving thiamine intracellularly

Disposition

  • Admit
  • <25% of patients show recovery, 50% show partial recovery, the remainder show no response despite treatment[2]

Prevention

Vitamin Prophylaxis for Chronic alcoholics

  • At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
  • Give multivitamin PO; patient at risk for other vitamin deficiencies

Banana bag

The majority of chronic alcoholics do NOT require a banana bag[3][4]

See Also

Ethanol related disease processes

Video

References

  1. Isenberg-Grzeda E, Kutner HE, Nicolson SE. Wernicke-Korsakoff-syndrome: under-recognized and under-treated. Psychosomatics. 2012 Nov-Dec;53(6):507-16.
  2. https://www.alz.org/alzheimers-dementia/what-is-dementia/types-of-dementia/korsakoff-syndrome
  3. Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
  4. Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.