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Wernicke Encephalopathy
Key considerations: Wernicke encephalopathy (confusion + ophthalmoplegia + ataxia), Korsakoff psychosis (irreversible), Hypoglycemia mimicking presentation
Cannot miss
- Wernicke encephalopathy (confusion + ophthalmoplegia + ataxia)
- Korsakoff psychosis (irreversible)
- Hypoglycemia mimicking presentation
Likely diagnoses
- Wernicke encephalopathy
- Hepatic encephalopathy
- Intoxication
- Meningitis
Red flags
- Alcohol use disorder history
- Giving glucose before thiamine
- Classic triad present in only 16% of cases
- Hypothermia
Workup
- history: Alcohol use, nutritional status, recent illness/vomiting; exam: Mental status, extraocular movements (nystagmus, lateral gaze palsy), ataxia testing, hypothermia check; labs: Blood glucose, thiamine level (draw BEFORE replacing), LFTs, alcohol level, ammonia, magnesium, BMP; imaging: Head CT to rule out hemorrhage or mass; MRI brain (mammillary body and thalamic lesions — often normal early); bedside: Point-of-care glucose, temperature
Management
- immediate: Thiamine 500mg IV TID x 3 days BEFORE any glucose administration; Then glucose if hypoglycemic; Magnesium replacement (cofactor for thiamine metabolism); general: Continue thiamine 250mg IV daily for 5 additional days; Nutritional rehabilitation; Treat underlying alcohol use disorder; Folate and multivitamin supplementation
Disposition
- admit: All suspected Wernicke encephalopathy for IV thiamine and monitoring; discharge: Never acutely — requires inpatient IV thiamine; consults: Neurology, addiction medicine, nutrition
Clinical pearls
- The classic triad (confusion, ophthalmoplegia, ataxia) is present in only 16% of cases — treat empirically with thiamine in any alcoholic with altered mental status
- Glucose administration without thiamine depletes remaining thiamine stores and precipitates acute Wernicke
- Korsakoff syndrome (anterograde amnesia, confabulation) develops in 80% of untreated Wernicke patients and is largely irreversible
Source and review
- BMJ Best Practice Wernicke Encephalopathy 2023. Last reviewed: 2024-11-01