Wernicke’s Encephalopathy in Disguise: Unmasking an Atypical Presentation and Etiology

Case Diagnosis: Wernicke’s Encephalopathy

Case Description or Program Description: A 21-year-old female with past medical history of type 1 diabetes mellitus and asthma presented to the hospital with poor oral intake, vomiting, generalized weakness and weight loss resulting in diabetic ketoacidosis (DKA). She was admitted to the ICU and her DKA resolved, but her hospital course was complicated by worsened lower extremity weakness, urinary incontinence, confusion, and hallucinations. MRI of the spine was unremarkable, but MRI of the brain revealed enhancement of bilateral mammillary bodies. The patient’s vitamin B1 level was 17 nmol/L (normal range: 70 - 185 nmol/L). A clinical diagnosis of Wernicke’s Encephalopathy (WE) was made, but etiology remained unknown. Due to persistent transaminitis, an MRI MRCP was ordered, showing evidence of a small bowel obstruction. Endoscopy confirmed the obstruction to be a large trichobezoar that, due to its size, interfered with thiamine absorption and required surgical removal.

Setting: Acute inpatient rehabilitation

Assessment/Results: Upon rehab admission, the patient had impairments in memory, attention to detail, executive functions, dysmetria, dysdiadochokinesia, ataxia, and decreased extremity strength and tone. An electrodiagnostic study found polyneuropathy affecting the lower limbs, characteristic of thiamine deficiency. Additionally, her results demonstrated bilateral femoral neuropathy, likely due to diabetic amyotrophy, further worsening her weakness. Overtime with therapy, the patient improved in mobility, proximal muscle strength and tone, gait stability, and activities of daily living.

Discussion (relevance): Despite early thiamine treatment for WE, patients still face challenges in the acute and post-acute phase of clinical care. These complications vary from severe infections, global delirium, bowel and bladder incontinence, gait instability, apathy, memory, focus, information processing, and expressive language. A multi-disciplinary treatment approach that integrates multiple specialties, is essential for patients with WE.

Conclusions: In conclusion, this case report highlights the importance of early recognition of atypical presentations of WE and the unique challenges they pose in the acute rehabilitation setting.