Wernicke encephalopathy is an acute, reversible, neurologic condition that arises because of a severe deficiency of thiamine (vitamin B1). This condition is most commonly seen in people with excessive alcohol use. The classic triad of symptoms is encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in 1/3 of patients. Korsakoff syndrome is a severe and late neuropsychiatric manifestation of Wernicke encephalopathyEncephalopathyHyper-IgM Syndrome. Korsakoff syndrome presents with personality changes, anterograde and retrograde amnesia, and confabulation. Some of these changes are irreversible. Both Wernicke encephalopathyEncephalopathyHyper-IgM Syndrome and Korsakoff syndrome may be diagnosed clinically. Treatment includes absolute abstinence from alcohol and thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies supplementation.
Wernicke encephalopathyEncephalopathyHyper-IgM Syndrome and Korsakoff syndrome are neurologic conditions that arise because of thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies (vitamin B1) deficiency.
Korsakoff syndrome is an irreversible syndrome that is caused by more severe or prolonged thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies deficiency and occurs after incomplete recovery from Wernicke encephalopathyEncephalopathyHyper-IgM Syndrome.
Epidemiology
IncidenceIncidenceThe number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time.Measures of Disease Frequency of Wernicke lesions: 0.8%–2.8% of autopsies in general population
Korsakoff syndrome impacts up to 12.5% of individuals with chronic alcohol use disorderAlcohol use disorderAlcohol is one of the most commonly used addictive substances in the world. Alcohol use disorder (AUD) is defined as pathologic consumption of alcohol leading to impaired daily functioning. Acute alcohol intoxication presents with impairment in speech and motor functions and can be managed in most cases with supportive care. Alcohol Use Disorder.
Wernicke encephalopathyEncephalopathyHyper-IgM Syndrome and Korsakoff syndrome are caused by a severe deficiency of thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies. This deficiency is most commonly due to:
Chronic alcohol use:
Inadequate intake
Poor absorptionAbsorptionAbsorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation.Digestion and Absorption
Decreased hepatic storage
Improper utilization
Inadequate intake of thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies:
AnorexiaAnorexiaThe lack or loss of appetite accompanied by an aversion to food and the inability to eat. It is the defining characteristic of the disorder anorexia nervosa.Anorexia Nervosa
Starvation
Thiamine-deficient diets
MalnutritionMalnutritionMalnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema).Malnutrition in children in resource-limited countries
Increased loss of thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies:
DiarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
Hyperemesis
DialysisDialysisRenal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD).Peritoneal Dialysis and Hemodialysis
The pathologic sequelae of Wernicke encephalopathyEncephalopathyHyper-IgM Syndrome and Korsakoff syndrome stem from the downstream effects of thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies deficiency in the brainBrainThe part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem.Nervous System: Anatomy, Structure, and Classification.
ThiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies is converted into its more active form, thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies pyrophosphate (TPPTPPThrombotic thrombocytopenic purpura (TTP) is a life-threatening condition due to either a congenital or an acquired deficiency of ADAMTS-13, a metalloproteinase that cleaves multimers of von Willebrand factor (VWF). The large multimers then aggregate excessive platelets resulting in microvascular thrombosis and an increase in consumption of platelets. Thrombotic Thrombocytopenic Purpura).
TPPTPPThrombotic thrombocytopenic purpura (TTP) is a life-threatening condition due to either a congenital or an acquired deficiency of ADAMTS-13, a metalloproteinase that cleaves multimers of von Willebrand factor (VWF). The large multimers then aggregate excessive platelets resulting in microvascular thrombosis and an increase in consumption of platelets. Thrombotic Thrombocytopenic Purpura is an essential coenzyme involved in cerebral metabolism.
TPPTPPThrombotic thrombocytopenic purpura (TTP) is a life-threatening condition due to either a congenital or an acquired deficiency of ADAMTS-13, a metalloproteinase that cleaves multimers of von Willebrand factor (VWF). The large multimers then aggregate excessive platelets resulting in microvascular thrombosis and an increase in consumption of platelets. Thrombotic Thrombocytopenic Purpura deficiency leads to:
↓ Cerebral glucoseGlucoseA primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement.Lactose Intolerance metabolism and depleted ATP
↑ Free radicalsFree radicalsHighly reactive molecules with an unsatisfied electron valence pair. Free radicals are produced in both normal and pathological processes. They are proven or suspected agents of tissue damage in a wide variety of circumstances including radiation, damage from environment chemicals, and aging. Natural and pharmacological prevention of free radical damage is being actively investigated.Ischemic Cell Damage
↓ Neurotransmitter production
Impaired lipid metabolismLipid MetabolismLipid metabolism is the processing of lipids for energy use, energy storage, and structural component production. Lipid metabolism uses fats from dietary sources or from fat stores in the body. A complex series of processes involving digestion, absorption, and transport are required for the proper metabolism of lipids. Lipid Metabolism
The deficiencies in TPPTPPThrombotic thrombocytopenic purpura (TTP) is a life-threatening condition due to either a congenital or an acquired deficiency of ADAMTS-13, a metalloproteinase that cleaves multimers of von Willebrand factor (VWF). The large multimers then aggregate excessive platelets resulting in microvascular thrombosis and an increase in consumption of platelets. Thrombotic Thrombocytopenic Purpura injure neuronal elements, including myelin sheaths and the blood–brain barrierBlood–Brain BarrierMeningitis in Children, ultimately impairing neuronal conduction.
Wernicke lesions are most often found in the:
Periventricular region
DiencephalonDiencephalonThe paired caudal parts of the prosencephalon from which the thalamus; hypothalamus; epithalamus; and subthalamus are derived.Development of the Nervous System and Face (thalamusThalamusThe thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem.Thalamus: Anatomy, hypothalamusHypothalamusThe hypothalamus is a collection of various nuclei within the diencephalon in the center of the brain. The hypothalamus plays a vital role in endocrine regulation as the primary regulator of the pituitary gland, and it is the major point of integration between the central nervous and endocrine systems.Hypothalamus, epithalamus, subthalamus)
MidbrainMidbrainThe middle of the three primitive cerebral vesicles of the embryonic brain. Without further subdivision, midbrain develops into a short, constricted portion connecting the pons and the diencephalon. Midbrain contains two major parts, the dorsal tectum mesencephali and the ventral tegmentum mesencephali, housing components of auditory, visual, and other sensorimotor systems.Brain Stem: Anatomy
In Korsakoff syndrome, long-term damage to components of the limbic systemLimbic systemThe limbic system is a neuronal network that mediates emotion and motivation, while also playing a role in learning and memory. The extended neural network is vital to numerous basic psychological functions and plays an invaluable role in processing and responding to environmental stimuli.Limbic System: Anatomy (mammillary bodiesMammillary bodiesA pair of nuclei and associated gray matter in the interpeduncular space rostral to the posterior perforated substance in the posterior hypothalamus.Limbic System: Anatomy, anterior thalamic nucleiAnterior thalamic nucleiThree nuclei located beneath the dorsal surface of the most rostral part of the thalamus. The group includes the anterodorsal nucleus, anteromedial nucleus, and anteroventral nucleus. All receive connections from the mamillary body and brain fornix, and project fibers to the cingulate body.Thalamus: Anatomy) leads to:
MemoryMemoryComplex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory.Psychiatric Assessment loss
Apathy
Emotional upset
The location of the lesions predicts the symptoms of disease:
Medullary lesions → ataxiaAtaxiaImpairment of the ability to perform smoothly coordinated voluntary movements. This condition may affect the limbs, trunk, eyes, pharynx, larynx, and other structures. Ataxia may result from impaired sensory or motor function. Sensory ataxia may result from posterior column injury or peripheral nerve diseases. Motor ataxia may be associated with cerebellar diseases; cerebral cortex diseases; thalamic diseases; basal ganglia diseases; injury to the red nucleus; and other conditions.Ataxia-telangiectasia
Mammillary body lesions → amnestic syndrome
Sagittal cut of diencephalon with hypothalamic nuclei:
The structure is strongly impacted in Wernicke encephalopathy.
Image by Lecturio.
Clinical Presentation
History
Suspected in individuals with a history of:
Chronic excessive alcohol consumption
MalnutritionMalnutritionMalnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema).Malnutrition in children in resource-limited countries/malabsorptionMalabsorptionGeneral term for a group of malnutrition syndromes caused by failure of normal intestinal absorption of nutrients.Malabsorption and Maldigestion:
History of bowel resection
History of bariatric surgeryBariatric surgeryBariatric surgery refers to a group of invasive procedures used to surgically reduce the size of the stomach to produce early satiety, decrease food intake (restrictive type) and/or alter digestion, and artificially induce malabsorption of nutrients (malabsorptive type). The ultimate goal of bariatric surgery is drastic weight loss. Bariatric Surgery
History of inflammatory bowel disease
History often provided by caregivers, family, first responders:
Confabulation (memoryMemoryComplex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory.Psychiatric Assessment fabrication to make up for memoryMemoryComplex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory.Psychiatric Assessment lapses)
Personality changes, including apathy, indifference, and executive function
HallucinationsHallucinationsSubjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders.Schizophrenia
In cases of alcohol dependence, may present with acute withdrawal symptoms and/or deliriumDeliriumDelirium is a medical condition characterized by acute disturbances in attention and awareness. Symptoms may fluctuate during the course of a day and involve memory deficits and disorientation. Delirium tremens
NystagmusNystagmusInvoluntary movements of the eye that are divided into two types, jerk and pendular. Jerk nystagmus has a slow phase in one direction followed by a corrective fast phase in the opposite direction, and is usually caused by central or peripheral vestibular dysfunction. Pendular nystagmus features oscillations that are of equal velocity in both directions and this condition is often associated with visual loss early in life.Albinism
DiplopiaDiplopiaA visual symptom in which a single object is perceived by the visual cortex as two objects rather than one. Disorders associated with this condition include refractive errors; strabismus; oculomotor nerve diseases; trochlear nerve diseases; abducens nerve diseases; and diseases of the brain stem and occipital lobe.Myasthenia Gravis
Gait ataxiaGait ataxiaImpairment of the ability to coordinate the movements required for normal ambulation (walking) which may result from impairments of motor function or sensory feedback. This condition may be associated with brain diseases (including cerebellar diseases and basal ganglia diseases); spinal cord diseases; or peripheral nervous system diseases.Friedreich Ataxia:
HypotensionHypotensionHypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
SyncopeSyncopeSyncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope
HypothermiaHypothermiaHypothermia can be defined as a drop in the core body temperature below 35°C (95°F) and is classified into mild, moderate, severe, and profound forms based on the degree of temperature decrease. Hypothermia
Peripheral neuropathyNeuropathyLeprosy (particularly of lower extremities)
TachycardiaTachycardiaAbnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia.Sepsis in Children
Exertional dyspneaDyspneaDyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
Korsakoff syndrome (irreversible)
Confabulation (using fabricated memories to “fill in the gaps”)
Retrograde = impaired access to previously held memories
Personality changes (if frontal lobeFrontal lobeThe part of the cerebral hemisphere anterior to the central sulcus, and anterior and superior to the lateral sulcus.Cerebral Cortex: Anatomy affected):
Apathy
Indifference
Decreased executive function
HallucinationsHallucinationsSubjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders.Schizophrenia
Hold a strong clinical suspicion if the aforementioned symptoms are present in individuals with excessive alcohol intake or malnutritionMalnutritionMalnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema).Malnutrition in children in resource-limited countries.
Ambiguous cases can be supported by laboratory tests, but awaiting results should NOT delay treatment.
Laboratory tests:
↓ Serum thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies levels (measure prior to thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies supplementation)
↓ Erythrocyte transketolaseTransketolaseAn enzyme of the transferase class that catalyzes the conversion of sedoheptulose 7-phosphate and d-glyceraldehyde 3-phosphate to d-ribose 5-phosphate and d-xylulose 5-phosphate in the pentose phosphate pathway.Pentose Phosphate Pathway activity
↑ Serum lactate and pyruvatePyruvateDerivatives of pyruvic acid, including its salts and esters.Glycolysis
Liver function testsLiver function testsLiver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases.Liver Function Tests (altered levels may indicate alcohol-related dysfunction)
NeuroimagingNeuroimagingNon-invasive methods of visualizing the central nervous system, especially the brain, by various imaging modalities.Febrile Infant:
CT has little value.
MRI findings are highly specific and may show:
↑ Signal in mammillary bodiesMammillary bodiesA pair of nuclei and associated gray matter in the interpeduncular space rostral to the posterior perforated substance in the posterior hypothalamus.Limbic System: Anatomy and thalami
Wernicke’s encephalopathy:
MRI of head demonstrating periventricular hyperintensities at the medial thalami bilaterally, consistent with Wernicke’s encephalopathy. Orange arrows identifying areas of abnormality.
Image: “Bilateral Blindness Following Chemoradiation for Locally Advanced Oropharyngeal Carcinoma” by Zeng KL, Kuruvilla S, Sanatani M, Louie AV. License: CC BY 3.0
CT scan of Wernicke encephalopathy showing faded hyperdensity of the mammillary bodies and symmetrical hemorrhagic lesions in the quadrigeminal plate
Image: “Fig1: CT scan shows faded hyperdensity of the mammillary bodies and symmetrical hemorrhagic lesions in the quadrigeminal plate.” by Stefano Busani et al. License: CC BY 4.0
Additional evaluation
The following should be considered based on the individual’s history and presentation. These tests are not required for the diagnosis of WE, but they are often used to rule out other conditions, particularly if the diagnosis is unclear.
Serum alcohol level → alcohol intoxicationAlcohol intoxicationAn acute brain syndrome which results from the excessive ingestion of ethanol or alcoholic beverages.Alcohol Use Disorder
CBC, liver function testsLiver function testsLiver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases.Liver Function Tests, and measurement of serum chemistry levels to evaluate for stigmata of chronic liverLiverThe liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy disease.
AmmoniaAmmoniaA colorless alkaline gas. It is formed in the body during decomposition of organic materials during a large number of metabolically important reactions. Note that the aqueous form of ammonia is referred to as ammonium hydroxide.Acid-Base Balance level → hepatic encephalopathyEncephalopathyHyper-IgM Syndrome
Thyroid function testsThyroid Function TestsBlood tests used to evaluate the functioning of the thyroid gland.Ion Channel Myopathy → hypothyroidismHypothyroidismHypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism/myxedema comaMyxedema ComaHypothyroidism
Vitamin B12 level
UrinalysisUrinalysisExamination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically.Urinary Tract Infections (UTIs) in Children/urine cultureUrine cultureUrinary Tract Infections (UTIs) → infection
Blood gas → acid–base disturbances
Chest X-rayX-rayPenetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source.Pulmonary Function Tests → infection
Lumbar punctureLumbar PunctureFebrile Infant → if there is concern for meningitisMeningitisMeningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis
Management
In addition to treatment of the presenting encephalopathyEncephalopathyHyper-IgM Syndrome, the clinicianClinicianA physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients.Clinician–Patient Relationship should also have a high clinical suspicion for acute alcohol intoxicationAlcohol intoxicationAn acute brain syndrome which results from the excessive ingestion of ethanol or alcoholic beverages.Alcohol Use Disorder, hepatic encephalopathyEncephalopathyHyper-IgM Syndrome, alcohol withdrawalAlcohol withdrawalWith chronic alcohol use, body increases activity of excitatory receptors (e.g., glutamate) while decreasing activation of inhibitory receptors (e.g., GABA). Cessation of alcohol use leads to unchecked glutamate activation, presenting as withdrawal.Alcohol Use Disorder syndrome, and alcoholicAlcoholicPersons who have a history of physical or psychological dependence on ethanol.Mallory-Weiss Syndrome (Mallory-Weiss Tear)ketoacidosisKetoacidosisA life-threatening complication of diabetes mellitus, primarily of type 1 diabetes mellitus with severe insulin deficiency and extreme hyperglycemia. It is characterized by ketosis; dehydration; and depressed consciousness leading to coma.Metabolic Acidosis and treat these accordingly
Treatment should be prompt to prevent progression to permanent memoryMemoryComplex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory.Psychiatric Assessment deficits.
Immediate thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies supplementation:
Route: IV or IM
Duration: Continue treatment until symptoms resolve (or minimum of 5 days, whichever is longer).
Laboratory studies evaluating thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies level and other vitamin/mineral levels (e.g., magnesiumMagnesiumA metallic element that has the atomic symbol mg, atomic number 12, and atomic weight 24. 31. It is important for the activity of many enzymes, especially those involved in oxidative phosphorylation.Electrolytes)
Provide multivitamin and electrolyte supplementation, as appropriate
Hypoglycemic individuals should be given glucoseGlucoseA primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement.Lactose Intolerance AFTER thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies because glucoseGlucoseA primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement.Lactose Intolerance will deplete remaining stores of thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies and worsen encephalopathyEncephalopathyHyper-IgM Syndrome
Initial management of Korsakoff syndrome
Korsakoff syndrome may require lifelong care, as memoryMemoryComplex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory.Psychiatric Assessment deficits are often permanent.
ThiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies (IV or IM)
Psychiatric evaluation and therapy
Administration of acetylcholinesterase inhibitors may be considered to improve cognitive functioning.
Provide a list of local Alcoholics AnonymousAlcoholics AnonymousAn organization of self-proclaimed alcoholics who meet frequently to reinforce their practice of abstinence.Alcoholic Liver Disease meetings and/or contact info.
Patient education:
Abstinence from alcohol (absolute in Korsakoff syndrome)
Diet (may require referral to a dietitian)
Oral vitamin supplementation:
Long-term thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies supplementation
Multivitamin supplements, depending on diet
Rehabilitation services:
MemoryMemoryComplex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory.Psychiatric Assessment
Walking
PrognosisPrognosisA prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations.Non-Hodgkin Lymphomas
Generally reversible if treatment is initiated promptly
Oculomotor function resolves.
AtaxiaAtaxiaImpairment of the ability to perform smoothly coordinated voluntary movements. This condition may affect the limbs, trunk, eyes, pharynx, larynx, and other structures. Ataxia may result from impaired sensory or motor function. Sensory ataxia may result from posterior column injury or peripheral nerve diseases. Motor ataxia may be associated with cerebellar diseases; cerebral cortex diseases; thalamic diseases; basal ganglia diseases; injury to the red nucleus; and other conditions.Ataxia-telangiectasia and confusion may persist for days to months.
Korsakoff syndrome:
Symptoms may be irreversible.
ResearchResearchCritical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws.Conflict of Interest has shown promise for memoryMemoryComplex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory.Psychiatric Assessment rehabilitation.
Differential Diagnosis
Cerebellar stroke: cerebrovascular event leading to impaired perfusion of O2 to the posterior fossa of the brainBrainThe part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem.Nervous System: Anatomy, Structure, and Classification. Cerebellar strokes account for 1%–4% of all strokes and can be thromboembolic or hemorrhagic in nature. Symptoms include headacheHeadacheThe symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders.Brain Abscess, vomitingVomitingThe forcible expulsion of the contents of the stomach through the mouth.Hypokalemia, vertigoVertigoVertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo, unilateral hearing lossUnilateral hearing lossPartial or complete hearing loss in one ear.Hearing Loss, and contralateral sensorySensoryNeurons which conduct nerve impulses to the central nervous system.Nervous System: Histology loss (painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways and temperature). Diagnosis is clinical and confirmed by neuroimagingNeuroimagingNon-invasive methods of visualizing the central nervous system, especially the brain, by various imaging modalities.Febrile Infant. Acute thrombolytic therapy can be used in selected acute cases. Long-term management consists of risk factor modification of further ischemic events.
DeliriumDeliriumDelirium is a medical condition characterized by acute disturbances in attention and awareness. Symptoms may fluctuate during the course of a day and involve memory deficits and disorientation. Delirium tremens: severe form of ethanolEthanolA clear, colorless liquid rapidly absorbed from the gastrointestinal tract and distributed throughout the body. It has bactericidal activity and is used often as a topical disinfectant. It is widely used as a solvent and preservative in pharmaceutical preparations as well as serving as the primary ingredient in alcoholic beverages.Ethanol Metabolism withdrawal characterized by tremorTremorCyclical movement of a body part that can represent either a physiologic process or a manifestation of disease. Intention or action tremor, a common manifestation of cerebellar diseases, is aggravated by movement. In contrast, resting tremor is maximal when there is no attempt at voluntary movement, and occurs as a relatively frequent manifestation of parkinson disease.Myotonic Dystrophies, anxietyAnxietyFeelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders.Generalized Anxiety Disorder, nauseaNauseaAn unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses.Antiemetics, vomitingVomitingThe forcible expulsion of the contents of the stomach through the mouth.Hypokalemia, insomniaInsomniaInsomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking.Insomnia, auditory hallucinationsHallucinationsSubjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders.Schizophrenia, diaphoresis, and severe hypertensionSevere hypertensionA confirmed blood pressure ≥ 180 mm Hg systolic and/or ≥ 120 mm Hg diastolic.Uncontrolled Hypertension. Diagnosis is clinical but supported by laboratory evaluation and neuroimagingNeuroimagingNon-invasive methods of visualizing the central nervous system, especially the brain, by various imaging modalities.Febrile Infant. Treatment includes IV fluidsIV fluidsIntravenous fluids are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids for rehydrationRehydrationDengue Virus, thiamineThiamineAlso known as thiamine or thiamin, it is a vitamin C12H17N4OSCl of the vitamin B complex that is essential to normal metabolism and nerve function and is widespread in plants and animalsWater-soluble Vitamins and their Deficiencies and magnesiumMagnesiumA metallic element that has the atomic symbol mg, atomic number 12, and atomic weight 24. 31. It is important for the activity of many enzymes, especially those involved in oxidative phosphorylation.Electrolytes supplementation, and benzodiazepinesBenzodiazepinesBenzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines for agitationAgitationA feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions.St. Louis Encephalitis Virus and seizure prophylaxisProphylaxisCephalosporins.
Hepatic encephalopathyEncephalopathyHyper-IgM Syndrome:altered mental statusAltered Mental StatusSepsis in Children in the setting of chronic liverLiverThe liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy disease due to elevated ammoniaAmmoniaA colorless alkaline gas. It is formed in the body during decomposition of organic materials during a large number of metabolically important reactions. Note that the aqueous form of ammonia is referred to as ammonium hydroxide.Acid-Base Balance levels. May be associated with ataxiaAtaxiaImpairment of the ability to perform smoothly coordinated voluntary movements. This condition may affect the limbs, trunk, eyes, pharynx, larynx, and other structures. Ataxia may result from impaired sensory or motor function. Sensory ataxia may result from posterior column injury or peripheral nerve diseases. Motor ataxia may be associated with cerebellar diseases; cerebral cortex diseases; thalamic diseases; basal ganglia diseases; injury to the red nucleus; and other conditions.Ataxia-telangiectasia, personality changes, and altered level of consciousnessAltered Level of ConsciousnessIntracerebral Hemorrhage. Diagnosis is clinical but supported by evidence of hepatic decompensation and elevated serum ammoniaAmmoniaA colorless alkaline gas. It is formed in the body during decomposition of organic materials during a large number of metabolically important reactions. Note that the aqueous form of ammonia is referred to as ammonium hydroxide.Acid-Base Balance. LactuloseLactuloseA synthetic disaccharide used in the treatment of constipation and hepatic encephalopathy. It has also been used in the diagnosis of gastrointestinal disorders.Laxatives is the mainstay of acute management for lowering ammoniaAmmoniaA colorless alkaline gas. It is formed in the body during decomposition of organic materials during a large number of metabolically important reactions. Note that the aqueous form of ammonia is referred to as ammonium hydroxide.Acid-Base Balance levels. Long-term management consists of efforts to stabilize hepatic function and hepatic transplantation.
Lewy body dementiaDementiaMajor neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide.Major Neurocognitive Disorders: condition associated with deposition of Lewy bodiesLewy bodiesIntracytoplasmic, eosinophilic, round to elongated inclusions found in vacuoles of injured or fragmented neurons. The presence of lewy bodies is the histological marker of the degenerative changes in lewy body disease and parkinson disease but they may be seen in other neurological conditions. They are typically found in the substantia nigra and locus coeruleus but they are also seen in the basal forebrain, hypothalamic nuclei, and neocortex.Parkinson’s Disease (clumps of protein) in the cortical region of the brainBrainThe part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem.Nervous System: Anatomy, Structure, and Classification. Lewy body dementiaDementiaMajor neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide.Major Neurocognitive Disorders is a progressive disease that presents with dementiaDementiaMajor neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide.Major Neurocognitive Disorders, cognitive decline, and visual hallucinationsHallucinationsSubjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders.Schizophrenia. Diagnosis is based on the clinical presentation. The time frame of symptom onset is an important piece of the history, as this entity presents more gradually than Wernicke/Korsakoff syndrome. There is no cure for Lewy body dementiaDementiaMajor neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide.Major Neurocognitive Disorders. Treatment is supportive and aimed at reducing behavioral changes.
Sabatini, J. S., Schutz-Pereira, G. L., Feltrin, F., Teive, H., Camargo, C. (2016). Wernicke’s encephalopathy with chorea: neuroimaging findings. Dementia & neuropsychologia. Retrieved May 20, 2025, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5619281/