Wernicke's

[Celexa]

So, I had my first case of 100%, undoubtedly wernicke's encephalopathy this week. Damndest thing. Don't want to be too detailed and identifying but the pt had risk factors and was on PO thiamine. But they were also had been altered for more than a week. It was clearly a medical delirium, not a psychiatric illness. Didn't resemble the textbook for wernicke's encephalopathy much other than being altered. Prominent visual hallucinations. Various medical things going on, but nothing that could be correlated by timeline to the mental status.

I said, screw it, IV thiamine never hurt anyone. Patient had dramatic improvement over the next 24 hours and while not back to baseline the improvement has been stable. Humbling, considering how close I was to not making that recommendation.

Before this I'd had lots of cases where wernicke's was discussed in the differential, and plenty of given IV thiamine to, but none where it was this clear cut that the thiamine was the intervention that changed things.

Curious what other people's experience with wernicke's has been. Textbook teaching is that most cases don't have the triad, but given the variability in presentation, I wonder if there are any useful aspects to looking for specific clinical features in the symptoms at all, and instead going forward for unexplained deliriums I may base the decision to give thiamine solely on risk factors and not exam.

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[ObsequiousAplomb]

Did you end up giving high dose IV thiamine? Or by IV, do you mean like a banana bag? Imo, every alcoholic should occasionally get the high dose IV thiamine if they have a history of DTs. I don't know that the literature says that though. There's gotta be a reason so few patients actually ever get it when, as you said, it's much more often just one or two elements of the triad and it's so dirt cheap.

 

[Celexa]

Did you end up giving high dose IV thiamine? Or by IV, do you mean like a banana bag? Imo, every alcoholic should occasionally get the high dose IV thiamine if they have a history of DTs. I don't know that the literature says that though. There's gotta be a reason so few patients actually ever get it when, as you said, it's much more often just one or two elements of the triad and it's so dirt cheap.

I told the team to give true wernicke's treatment dosing--just went with uptodate dosing--500mg IV tid x3 days, then 250mg IV for five days. I am considering what my rec will be after that, because I think this patient either will need sustained high dose oral or maybe oral won't cut it at all? Going to hit up the pharmacists next week.

There was an IV thiamine shortage a few years ago that remains the most frustrating/scary shortage that directly impacted my clinical practice in career so far, but as far as I know that is resolved, so I'm not sure where the reluctance to do IV comes from.

 

[nexus73]

I saw a patient take somewhere between 3-4 weeks to clear up from Wernickes. Totally disoriented, confabulating, visual hallucinations. One day walked in to her room and she was just back. “Why am I in the hospital? How did I get to [our city]?”

Complicated by the fact she had a hx of bipolar so medicine wanted to transfer to psych because “she’s manic”

 

[Stagg737]

Where I did residency some guys in the year ahead of me did a QI project on it that won an award. Found that something like 60% of cases were being missed when strict criteria for evaluation was implemented and that it's more common than we think. Another co-resident the year under me got published for a case with normal serum thiamine but still Wernicke's per clinical picture and MRI findings. Patient recovered after IV thiamine.

Ime, it's much more common than we probably realize and I agree with OA that I have a low threshold for recommending it as it's an easy and safe therapy that can make such a massive difference (some data suggests that ~50% of people who experience WE will go on to develop Korsakoff's). Diagnostically, the nystagmus is meh. However, if they've got significant gait instability or disorientation then I'm recommending IV thiamine (especially if they've got both).

 

[clozareal]

Is there any downside to high dose IV thiamine other than cost and supply stewardship?

 

[splik]

Is there any downside to high dose IV thiamine other than cost and supply stewardship?

There is small risk of anaphylaxis but in general it’s better to give in any case where wernickes is a reasonable differential dx. Have been asked to review multiple malpractice cases related to failure to dx and treat wernickes in a timely manner.

 

[clozareal]

There is small risk of anaphylaxis but in general it’s better to give in any case where wernickes is a reasonable differential dx. Have been asked to review multiple malpractice cases related to failure to dx and treat wernickes in a timely manner.

what better place to have anaphylaxis than in a hospital

 

[Tangerine123]

I've only seen 1. Patient with know Wernicke in the past. Admitted for alcohol detox. He was fine by admission, but starting the 2nd day he developed the textbook triad. Improved after IV Thiamine. MRI showed mammillary body damage.

it was ridiculous how "textbook" it was. So much so that It will be hard to forget how to identify and handle it now.

 

[ObsequiousAplomb]

I've only seen 1. Patient with know Wernicke in the past. Admitted for alcohol detox. He was fine by admission, but starting the 2nd day he developed the textbook triad. Improved after IV Thiamine. MRI showed mammillary body damage.

it was ridiculous how "textbook" it was. So much so that It will be hard to forget how to identify and handle it now.

That's really only helpful for the textbook presentations, right?

 

[TheRightMedication]

"there is a new cognitive disorder, though its in the context of EtOH use and an exam that does not support a dx of Wernicke's otherwise. IV thiamine, however, is a low risk intervention with potentially high benefits. Rec > iv thiamine."

I've written notes like that a hundred times. The neuro team at that time had a similar approach.

And that's just based off of the clinical situation. I hadn't even thought about doing it as defensive medicine, but if that's what motivates us to do it so be it.

 

[docksan]

Funny, I just saw a Wernicke's patient this past week.

 

[ObsequiousAplomb]

Having had a number of severe Korsakoff's patients in the state hospital setting, this topic really does get me fired up. It's fascinating seeing a 40 year old person be that gravely disabled. A few threads back people were asking about the worst prognosis in psychiatry. While I guess this is a neurological disorder, since the patients tend to be cared for in psychiatric settings I'm calling this one psychiatric and it's my nomination for the worst prognosis.

 

[dgdg]

Good catch Celexa, you saved a life.
I rarely diagnosed this when I was a hospitalist for a few years, but as a part time hospice physician, I see it periodically in the Korsakoff phase.
I think these posts make a good point that Wernicke's encephalopathy is difficult to diagnose, life threatening, easy to administer treatment, and can affect not just alcoholics. Once the acute phase is over without treatment, chance of recovery is negligible.
Similar process reminds me of an outpatient a local specialist referred to me (internist) for auditory hallucinations to harm himself and depression. Not sure why they did not just refer to psychiatry first. Routine labs with specialist were fine (CBC, MCV). I checked B12 which was not detectable x2 (Vegan). After a couple months of B12 injections, psychosis was cured.

 

[Celexa]

Appreciate the discussion. New question--in a patient who developed wernicke's while on PO thiamine 100mg daily, what oral dosing would you keep them on in the future?

 

[ObsequiousAplomb]

Appreciate the discussion. New question--in a patient who developed wernicke's while on PO thiamine 100mg daily, what oral dosing would you keep them on in the future?

I was under the impression higher oral doses didn't necessarily matter. Something about absorption. I was told that once by a VA pharmacist and I accepted it at face value. So there isn't much of a reason to go above 300 mg PO per day, the only way to get more is parenteral. If that's not the case, I hope someone corrects me.

 

[splik]

Appreciate the discussion. New question--in a patient who developed wernicke's while on PO thiamine 100mg daily, what oral dosing would you keep them on in the future?

Once they've finished their parental thiamine, you put them on 100mg TID for the rest of the hospital course and forever after.

 

[whopper]

While I worked in the hospital, anyone with a drinking problem who showed any signs of confusion pretty much always got IM thiamine if no one did a banana bag. Why? Like was said above, what harm will it cause? Thiamine in cheap, it's not dangerous, and if you miss Wernicke's there could be majorly bad consequences.

As mentioned, the problem with oral thiamine is the reason why there's a deficiency is alcohol can damage the small intestine (edited for grammar) hurting it's ability to absorb thiamine, so then what's the point of oral thiamine? I'd give it anyways just in case, but don't expect it to be absorbed well unless the patient stops drinking alcohol giving the SI time to heal.

BTW, while in college, I drank a few shots of vodka on an empty stomach, next day had bloody stool, and for the next month despite eating 4+ huge meals a day, I was still losing weight. I figured the vodka might've damaged my SI.

 

[docksan]

While I worked in the hospital, anyone with a drinking problem who showed any signs of confusion pretty much always got IM thiamine if no one did a banana bag. Why? Like was said above, what harm will it cause? Thiamine in cheap, it's not dangerous, and if you miss Wernicke's there could be majorly bad consequences.

As mentioned, the problem with oral thiamine is the reason why there's a deficiency is alcohol can damage the small intestine making hurting it's ability to absorb thiamine, so then what's the point of oral thiamine? I'd give it anyways just in case, but don't expect it to be absorbed well unless the patient stops drinking alcohol giving the SI time to heal.

BTW, while in college, I drank a few shots of vodka on an empty stomach, next day had bloody stool, and for the next month despite eating 4+ huge meals a day, I was still losing weight. I figured the vodka might've damaged my SI.

This, except I never did anything like that with alcohol. People really underestimate what it can do even in a period of 3-4 weeks.

 

[whopper]

I never saw a thiamine deficiency ever in anyone where the problem was beer. I've only seen it if it was hard liquor. I'd still be liberal with giving out thiamine. If the patient didn't need it you didn't cause any real harm. If you missed a thiamine deficiency the patient could suffer the consequences for the rest of their life.

 

[Stagg737]

Appreciate the discussion. New question--in a patient who developed wernicke's while on PO thiamine 100mg daily, what oral dosing would you keep them on in the future?

Like Whopper said, for some people PO isn't going to work. For that person I'd recommend they get regular IM thiamine. I've had a couple of patients who chronically received IM thiamine weekly to monthly. Most of them were d/t concurrent GI disorders, but I do recall one at our VA in residency who got them every few weeks and GI issues seemed to be caused by AUD.