eMedicine Specialties > Emergency Medicine > Neurology

Wernicke Encephalopathy: Follow-up

Author: Philip N Salen, MD, Clinical Professor, Department of Emergency Medicine, PA Program, Desales University; Adjunct Clinical Associate Professor, Department of Emergency Medicine, Temple University Medical School; Research Director, Emergency Medicine Education, Saint Luke's Hospital
Contributor Information and Disclosures

Updated: Jan 13, 2009

Follow-up

Further Inpatient Care

  • Depending on mental status and ability to protect his or her airway, admit patients with suspected or confirmed Wernicke encephalopathy to an internal medicine or neurology service.
  • Admission ensures that the patient receives continued intravenous thiamine and magnesium administration, observation for possible development of Korsakoff psychosis, and evaluation for possible cardiovascular beriberi.

Further Outpatient Care

  • Refer patients with alcoholism to alcohol-cessation programs and monitor for signs of alcohol withdrawal.
  • Patients who are malnourished, whether from alcohol or other causes, should continue to receive thiamine supplementation on an outpatient basis.

Inpatient & Outpatient Medications

  • Administer daily oral thiamine (100 mg) on a long-term outpatient basis.
  • Inpatient therapy of infants with thiamine deficiency involves administration of high-dose thiamine 50 mg/day for 2 weeks.6

Deterrence/Prevention

  • Patients should avoid alcohol consumption and other behaviors that predispose to thiamine deficiency.
  • In the United States, many foods (but not alcoholic beverages) are supplemented with multiple vitamins and minerals. Some health policy experts have hypothesized that fortifying alcoholic beverages with thiamine would lower healthcare costs.

Complications

  • Korsakoff psychosis
  • Alcohol withdrawal
  • Acute precipitation of Wernicke encephalopathy
  • Congestive heart failure
  • The administration of dextrose in the setting of thiamine deficiency can be harmful because glucose oxidation is a thiamine-intensive process that may drive the insufficient circulating vitamin B-1 intracellularly, thereby precipitating neurologic injury.6
  • Gastrointestinal beriberi8
  • Lactic acidosis9

Prognosis

  • Administration of thiamine improves disease to some degree in almost all cases; however, persistent neurologic dysfunction is common.1 Ophthalmoplegia usually resolves briskly; the initial presentation of global confusion often improves within hours or days.
  • Patients with Wernicke encephalopathy have a significant morbidity and mortality rate, especially if no early signs of neurologic improvement are present after repletion of thiamine.
  • Of patients surviving Wernicke encephalopathy, a percentage will develop Korsakoff psychosis.
  • Typical residual findings from Wernicke encephalopathy include nystagmus, gait ataxia, and Korsakoff syndrome.1
  • Of patients with Korsakoff psychosis, a significant number do not recover and require long-term institutionalization. Only about 20% eventually recover completely during long-term follow-up care.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider Wernicke encephalopathy as a cause of altered mental status is a pitfall. Acute Wernicke encephalopathy should be ruled out in all alcoholic patients with any neurologic symptoms, especially in those with evidence of caloric or protein malnutrition or of peripheral neuropathy.7
  • Acute Wernicke encephalopathy may be precipitated rapidly in high-risk patients after instituting intravenous therapy with glucose-containing solutions, resulting in rapid changes in cognitive function and ocular characteristics.
  • Because Wernicke encephalopathy is reversible, the diagnosis of subclinical cases would permit treatment and probably cure the patient.7
  • Neither a normal CT scan of the brain nor a normal MRI do not exclude or rule out either acute or chronic Wernicke-Korsakoff syndrome.7
 


More on Wernicke Encephalopathy

Overview: Wernicke Encephalopathy
Differential Diagnoses & Workup: Wernicke Encephalopathy
Treatment & Medication: Wernicke Encephalopathy
Follow-up: Wernicke Encephalopathy
References
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References

  1. Donnino MW, Vega J, Miller J, et al. Myths and misconceptions of Wernicke's encephalopathy: what every emergency physician should know. Ann Emerg Med. Dec 2007;50(6):715-21. [Medline].

  2. Buscaglia J, Faris J. Unsteady, unfocused, and unable to hear. Am J Med. Nov 2005;118(11):1215-7. [Medline].

  3. Decker MJ, Isaacman DJ. A common cause of altered mental status occurring at an uncommon age. Pediatr Emerg Care. Apr 2000;16(2):94-6. [Medline].

  4. Thomson AD, Cook CC, Touquet R, et al. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke's encephalopathy in the accident and Emergency Department. Alcohol Alcohol. Nov-Dec 2002;37(6):513-21. [Medline].

  5. Azim W, Walker R. Wernicke's encephalopathy: a frequently missed problem. Hosp Med. Jun 2003;64(6):326-7. [Medline].

  6. Fattal-Valevski A, Kesler A, Sela BA, et al. Outbreak of life-threatening thiamine deficiency in infants in Israel caused by a defective soy-based formula. Pediatrics. Feb 2005;115(2):e233-8. [Medline].

  7. Antunez E, Estruch R, Cardenal C, et al. Usefulness of CT and MR imaging in the diagnosis of acute Wernicke's encephalopathy. AJR Am J Roentgenol. Oct 1998;171(4):1131-7. [Medline].

  8. Donnino M. Gastrointestinal beriberi: a previously unrecognized syndrome. Ann Intern Med. Dec 7 2004;141(11):898-9. [Medline].

  9. Donnino MW, Miller J, Garcia AJ, et al. Distinctive acid-base pattern in Wernicke's encephalopathy. Ann Emerg Med. Dec 2007;50(6):722-5. [Medline].

  10. Kaineg B, Hudgins PA. Images in clinical medicine. Wernicke's encephalopathy. N Engl J Med. May 12 2005;352(19):e18. [Medline].

  11. Blass JP, Gibson GE. Abnormality of a thiamine-requiring enzyme in patients with Wernicke-Korsakoff syndrome. N Engl J Med. Dec 22 1977;297(25):1367-70. [Medline].

  12. Henry GL. Coma and altered states of consciousness. In: Emergency Medicine. 4th ed. 1996:225-233.

  13. Hoffman RS. Thiamine hydrochloride. In: Goldfrank's Toxicologic Emergencies. 5th ed. 1994:825-6.

  14. Hung SC, Hung SH, Tarng DC, et al. Thiamine deficiency and unexplained encephalopathy in hemodialysis and peritoneal dialysis patients. Am J Kidney Dis. Nov 2001;38(5):941-7. [Medline].

  15. Marx JA. The varied faces of Wernicke's encephalopathy. J Emerg Med. 1985;3(5):411-3. [Medline].

  16. Reuler JB, Girard DE, Cooney TG. Current concepts. Wernicke's encephalopathy. N Engl J Med. Apr 18 1985;312(16):1035-9. [Medline].

  17. Victor M. Persistent altered mentation due to ethanol. Neurol Clin. Aug 1993;11(3):639-61. [Medline].

  18. Willett WC, Stampfer MJ. Clinical practice. What vitamins should I be taking, doctor?. N Engl J Med. Dec 20 2001;345(25):1819-24. [Medline].

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Further Reading

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Keywords

Wernicke encephalopathy, Wernicke's encephalopathy, Wernicke-Korsakoff syndrome, thiamine deficiency, vitamin B-1 deficiency, Wernicke's disease, Wernicke-Korsakoff psychosis, mental confusion, ataxia, ophthalmoplegia, Korsakoff's amnestic syndrome, Korsakoff amnestic syndrome, memory loss, confabulation, vitamin B deficiencies, alcoholism, malnutrition, AIDS

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Contributor Information and Disclosures

Author

Philip N Salen, MD, Clinical Professor, Department of Emergency Medicine, PA Program, Desales University; Adjunct Clinical Associate Professor, Department of Emergency Medicine, Temple University Medical School; Research Director, Emergency Medicine Education, Saint Luke's Hospital
Philip N Salen, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Peter MC DeBlieux, MD, Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University Health Sciences Center
Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Employment

 
 
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