Neuroscience · Year 2 · from Neuroscience
Case 1: Wernicke-Korsakoff Syndrome
Patient Presentation
Demographics: 58-year-old male
Chief Complaint: Confusion and inability to walk straight for 3 days
History of Present Illness: The patient was brought to the emergency department by his landlord who found him confused and stumbling around his apartment. The patient has a long history of alcohol use disorder, drinking approximately a fifth of vodka daily for the past 20 years. He reports poor appetite and has been eating minimally for the past several weeks. He is unable to provide a coherent history and appears disoriented. His landlord reports the patient seemed "not himself" for about a week before becoming acutely worse.
Physical Examination:
- Vital signs: BP 142/88, HR 98, T 37.4C, RR 18
- General: Thin, disheveled male, mildly confused
- Neurological:
- Mental status: Alert but disoriented to time and place; confabulates when asked about recent events (claims he went fishing yesterday when landlord confirms he has not left apartment)
- Cranial nerves: Horizontal nystagmus bilaterally; limited lateral gaze in both eyes (CN VI weakness); pupils reactive
- Motor: 5/5 strength in all extremities
- Gait: Wide-based ataxic gait; unable to perform tandem walk
- Coordination: Dysmetria on finger-to-nose testing bilaterally
Workup:
- Basic metabolic panel: Glucose 78, sodium 131 (low), otherwise unremarkable
- Complete blood count: MCV 104 fL (elevated, macrocytic)
- Liver function tests: AST 89, ALT 52, GGT 287 (elevated)
- Thiamine level: 45 nmol/L (low; normal 70-180)
- MRI brain: Symmetric T2/FLAIR hyperintensity in the bilateral medial thalami and periaqueductal gray matter; mammillary bodies appear atrophic with increased signal
Diagnosis: Wernicke encephalopathy progressing to Korsakoff syndrome
Treatment:
- High-dose IV thiamine (500 mg three times daily for 3 days, then 250 mg daily)
- Thiamine administered BEFORE glucose-containing IV fluids
- Magnesium supplementation (cofactor for thiamine utilization)
- Nutritional rehabilitation
- Alcohol cessation counseling
Clinical Course: After 5 days of treatment, the patient's eye movement abnormalities and ataxia improved significantly. However, he continued to demonstrate anterograde amnesia and confabulation, consistent with Korsakoff syndrome. At discharge to rehabilitation, he could not recall any of the medical staff despite daily interactions.
Clinical Pearl: The classic Wernicke triad is confusion, ophthalmoplegia, and ataxia, but the complete triad is present in only about 30% of cases. Thiamine must ALWAYS be given before glucose in suspected cases, as glucose metabolism consumes thiamine and can precipitate or worsen the syndrome. The mammillary bodies and medial thalami are preferentially affected due to their high metabolic demands and role in the Papez circuit.