Wernicke Encephalopathy in a Patient with Pulmonary and Abdominal Tuberculosis

Xue-Rong Chen, Yun-Cui Gan, Jing Jin, Zhi-Xin Qiu
2017 Chinese Medical Journal  
Wernicke encephalopathy (WE) is an acute or subacute neurological syndrome caused by thiamine (Vitamin B1) deficiency and is usually underestimated in clinical practice. WE is suspected in merely about 6% of non-alcoholic patients and one-third of alcoholic patients. [1] Non-alcoholic causes include gastrointestinal surgery and disease, malnutrition, cancer and chemotherapeutic treatments, and long-term parenteral nutrition. [2] However, few cases were reported about WE in patients with
more » ... osis. Early diagnosis and medication are vital for the prognosis of this disease. Written informed consent was obtained from the legally authorized representative of the patient for the publication of this case report. A 46-year-old man was admitted to hospital for cough, abdominal pain, and blurred vision. Five months before this visit, he had the onset of cough and fever. One month before the admission, he presented abdominal pain, nausea, vomit, fever, and melena. Mesenteric biopsy confirmed the diagnosis of abdominal tuberculosis. Four days before this visit, he presented blurred vision. The reason for blurred vision remained unclear. Medical history showed gastrointestinal bleeding, and others were unremarkable. The patient had a history of chronic alcoholism consumption for 20 years but stopped drinking 8 years ago. At admission, physical examination showed that he had slight mental confusion. However, other neurological examinations were unremarkable. Blood tests showed erythrocyte sedimentation rate (30.0 mm/h), C-reactive protein (23.3 mg/L). The results of routine hematological tests and arterial blood gas analysis were unremarkable. Tuberculosis infected T cells gamma interferon release test result was positive. The chest and abdominal computed tomography scan results were suggestive of pulmonary and abdominal tuberculosis. Vision acuity test showed hand movement in the right eye and CF/15 mm in the left eye. The test of anterior segment of eyeball was unremarkable. Ophthalmic fundus examination showed the disc was hyperemia and edema, and the margin was blurring with flame-shaped hemorrhages. Optic neuritis or encephalitis caused by intracranial lesions was suspected. After admission, he was given anti-tuberculosis medication and parenteral nutrition. At the 4 th day after admission, the patient suddenly developed headache and hematemesis. Brain computed tomography scan result was unremarkable. Brain magnetic resonance imaging (MRI) scan was not performed due to his noncooperation. The pressure of cerebrospinal fluid was 58 mmH 2 O (1 mmH 2 O = 0.0098 kPa). The routine test and biochemical indicators of cerebrospinal fluid were unremarkable. The result of occult blood test of vomit was positive. Fecal occult blood test result was negative. Gastrointestinal bleeding was considered. The reason for blurred vision and headache still remained unclear. Symptomatic and supportive treatments were administered to him, all of which were given through parenteral route. At the 7 th day after admission, his symptoms significantly got worse. At the same time, he developed diplopia and dysphoria. Physical examination showed nystagmus, unsteady gait, weakness of extremities, and negative pathological reflex. Arterial blood gas analysis result was suggestive of Type I respiratory failure. Other laboratory data were as follows: sodium ions (130.5 mmol/L), chloride ion (95.4 mmol/L), blood ammonia (27.0 μmol/L, reference range, 9.0-33.0 μmol/L), 25-OH-VD (20.5 nmol/L, reference range, 47.7-144.0 nmol/L), creatine kinase (52 IU/L), lactate dehydrogenase (118 IU/L),
doi:10.4103/0366-6999.218010 pmid:29133769 pmcid:PMC5695066 fatcat:3zrbanszavey5gfz4blnlko7im