A Psychiatric Presentation of We rn icke's Encephalopathy Following Intravenous Fluid Administration Douglas Gee nans, D.O. Abstr act Psychiatrists ar efrequenlly challenged to differentiateprimarypsychiatricsymptomsfrom those that arise secondary to medical illness. Errors in clinical assessment can lead to significant morbidity and even mortality. Wernicke's e nce phalopathy is a medical con dition that presen ts, in part, as psychiatric symptomatology. Despite an estimated incidence of 2%, 80% qf the casesare undiagnosed. O f its classic triad, ophthalmoplegia and ataxia call be quite subtle, oreven absent, whereas mental status changes are present in all but 10% ofc ases. Th is disorder, although widely re cogni zed as a complication of al coholism, hasmany lessfte quently co nsi dered etiologies, including iatrogenic causes, which may constitute a largefraction of the unrecognized cases. The author looks at a case ofW emicke's ence phalopathy that was iatrogenically induced and presented aspsychiatric symptomatology. Werni cke's encephalopathy is a medical condition which re sult s from impaired int estina l absorpt ion of thiamin e. Its pr imary manif est ati ons are n eur ological and psych iatri c, however its n euro logical sequelae (ophthalmoplegia and a tax ia) are often subt le and a high index of suspicion is essential to consider the diagnosis (I). Dist u rba nces of consciousness and me ntatio n ar e typical and present in all but 10 pe rce n t of pat ient s (2) . Th e following case illust r at es a prim arily psychiatri c presen- tat ion of the illness, following int ravenous fluid a dminist ration, in a 3 1-yea r-old man with hyperemesis and protract ed hiccups. CASE REPORT The pati ent , a 31-year-old man , present ed to the eme rge ncy room with a chief complaint of in tr actable hiccups which had progr essed to pro tra cted vomiting, res ultin g in a 15 pound wei ght loss over two wee ks. Physical and labora t ory examination on admission revealed a mod erat e ly d eh ydrat ed man with no abnor ma lities in his ment al s tate . H e ad m i tted to history of alcohol use but cl aim ed to have been sober for one year. He was admi tte d to the hospit al and hydr ated with two liters of 05 1 /2 NS. Fourte en hours aft er admi ssion, he becam e more agitated and complained of "li ttle fuzzy things" crawling on his skin. As he became more disorga nized and confused, sof t re strain ts were used to control his act ivity. Ben zodi azepi nes and low-dose antip sychot ics wer e employed in an a tte mpt to control his hallu cinations with no effect. At th at tim e, psychi atri c consu ltat ion was r equ est ed . 20
Transcript
A Psychiatric Presentation ofWernicke'sEncephalopathy Following Intravenous
Fluid Administration
Douglas Geenans, D.O.
Abstract
Psychiatrists arefrequenlly challenged to differentiateprimarypsychiatricsymptomsfrom thosethat arise secondary to medical illness. Errors in clinical assessment can lead to significantmorbidity and even mortality. Wernicke's encephalopathy is a medical condition that presents, inpart, as psychiatric symptomatology. Despite an estimated incidence of2%, 80% qf the cases areundiagnosed. Of its classic triad, ophthalmoplegia and ataxia call be quite subtle, oreven absent,whereas mental status changes are present in all but 10%ofcases. This disorder, although widelyrecognized as a complication ofalcoholism, has many lessftequently considered etiologies, includingiatrogenic causes, which may constitute a largefraction ofthe unrecognized cases. The authorlooksat a caseofWemicke's encephalopathy that was iatrogenically induced andpresentedaspsychiatricsymptomatology.
Wernicke's ence phalopa thy is a medi ca l condition which results from impairedintestinal absorpt ion of thiamine. It s pr imary manifest ations a re neurological andpsych iatric, however its neurologica l seque lae (ophtha lmo pleg ia a nd a taxia) areofte n subt le and a high ind ex of suspicion is essen tia l to conside r th e diagnosis (I).Dist urbances of consciousness an d mentation are typica l and pr esen t in all but 10pe rce nt of pat ients (2) . The following ca se illust rates a primarily psych iatric presentat ion of the illn ess, followin g int ravenou s fluid administ ration, in a 3 1-yea r-old manwith hypere mesis and protract ed hiccups.
CASE REPORT
T he patient , a 3 1-year-old man, pr esented to th e eme rgency room with a chief comp la intof intract abl e hiccu ps which had progress ed to protracted vom iti ng, resulting in a 15 pou ndweight loss over two wee ks. Physical and laboratory exa m ina t ion on ad m issio n reveal ed amoderately deh ydrat ed man with no abnormalit ies in his mental state . H e ad mitted to historyof alcohol use but claim ed to hav e been sobe r for on e year.
H e was ad m itted to th e hospit al a nd hydrat ed with two lit e rs of 0 5 1/2 NS. Fourteenhours aft er admission , he becam e mo re ag ita te d a nd com plai ne d of " little fuzzy things"cra wling on his skin. As he became mo re disor ga niz ed a nd confuse d, soft restrain ts were usedto cont ro l his act ivity . Ben zodi azepi nes a nd low-dose antipsychot ics wer e employed in ana tte m pt to cont rol his hallu cina t ions with no effec t. At th at tim e, psychi atric consu ltat ion wasrequest ed .
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PSYCH IATRIC PRESENTATION OF WERNICKE'S ENCEPHALOPATHY 21
T he patient was found to be actively hallucin ating with both visu al a nd tact ile ha lluc inations. He was confused, disoriented, and ac tive ly confabula t ing . His speech was dysarthric. Hisirritability and agita t ion made a ph ysica l exa mina t ion quite difficult . Vit al signs were withinnormal lim its a nd stat C BC , urine dru g screen , and blood che m ist ry pr ofile were with in norm allim it s. Fu r th er cognit ive eva lua t ion was impossible given his disorga niz ed state.
G iven th e pr om inent visual an d ta ctile hallucina t ions, an or ganic fact or was soug ht. Atemporal rela tionship was established be tween medi cal int erv ention and th e onset of symptoms. A more thoro ugh exa m ina t ion of his eyes was performed revealing subt le weak ness ofth e lat eral rect i bilat erally. Sin ce he had been in restraints for two days, a ta xia had not bee nnot ed by the a tt end ing staff, however when assisted in ambu lation, he was found to bemarkedly a taxic.
Based on these findings, a diagnosis of Wernicke's ence pha lopa thy was made andthiamine, 100 mgs. IV was started daily. Aft er three days, th e patient beca m e lucid andbaseline mental sta te was rees tablished . The only residual was his dysarthric speech which wasla ter identified as an ea rly sym pto m of Am yotrophic La teral Sclerosis.
DISC USSIO N
Hist orically, Wernicke firs t described "polioencep ha litis hem orrhagica superioris"encephalopa thy in t hree pa ti en ts. Two were alcoho lics a nd on e was a young wom anwith persist ent vomiting followin g th e ingesti on of sulfuric acid . Sin ce tha t time,Wernicke's encep halopa thy has been mos t commonly de scribed with a lcoho lism, butit can be associate d with any condition th a t affects in tes t inal absorption of th ia mine,i.e. , pr olon ged starvatio n (4), hyperemesis gravidarum (5) , gast ro plas ty (6), anddiarrhea (7). These less com mo nly iden t ified et iolog ies may const itu te a largefracti on of th e unrecognized ca ses (8). In 1974, Ebcls rep or ted 22 un ex pected autops ycases of Wernicke's ence phalopa thy; alcoho l was a causative factor in only four (9).
In addit ion to the pr eviou sly me nt ioned et iologi es, iatrogeni c ca uses arise fro mparenteral a lime nta t ion a nd fluid admi nistration wit ho ut vitamin supplem entation( 10). During normal ca rbohydra te metab olism , thia m ine is consume d as an enzymatic cofac tor for transketolase in th e pentose phosphat e pathway a nd for pyruvatedecarboxylase a nd a lpha ket oglutara te in th e t r ica rboxy lic acid cycle (12). Wh en ala rge or conce nt rated glucose bolu s is administere d to th e malnourished , asy mptomatic patient , thi amine sto res in th e br ain are rapidly ex ha usted , aerobic glycolysis issubse que nt ly inhibit ed , a nd nervou s tissu e dysfun cti on occurs manifesting as th esym ptoms of Wernicke 's ence phalopa thy (II ).
Although Wernicke' s ence phalopa thy is classica lly described as th e triad ofophthalmo pleg ia, a ta xia, and mental confus ion, anyone of these symptoms may beth e initial manifesta tion (2) . This "classic t r iad " however, is frequent ly not obvious.Man y patients may ex hibit only partial findings a nd some may have none. Harperreviewed th e clinical records of 13 1 cases of Wernicke's ence pha lopa thy diagnosed a ta u to psy, a nd found th at only 16% of patients had th e classic t riad and 19% had nodocumented clinical signs (8) . The ocula r manifest ations- nystagmus, and weaknessor paralysis of th e external rectus m uscles, or of conj ugate gaze-are most useful inmaking a definitive diagnosis (2) . Bu t th ese sym pto ms ca n be subt le a nd easily
22 J EFFERSON J OURNAL OF PSYCHIATRY
missed, especia lly if th e patient is so cognitively impaired th at th ey cannot cooperatewith th e examinat ion. In addition , a tax ia, in it s mildest form , ca n easily be misseda nd onl y demonstrated by tandem wa lking (2) .
Mental disturbances may be the most useful in incr easin g th e clini cian 'ssu spi cion , as th ey are pr esent in a ll but 10% of pat ients (2). T he most commo nderangement is globa l confus ion manifest ed by di sori enta tion , mis identification ofthose around th e patient , a nd difficulty in grasping th e meaning of the immediat esituation (2) . About 15% of patients sh ow sign s of alcoho l withdrawal , i.e., hallucination s a nd othe r disorders of perception (2) .
Rapid assessme n t a nd correc t ion of W ernicke 's ence pha lopathy is imperative asit is considere d a medi cal emergen cy, wh ere delays in treat ment con tribute to a10-20% mortality rate (2) . T o this end, a high ind ex of suspicion m ust a lways bepresent wh en faced wit h a patient who presen ts with a sudden cha nge in men talsta tus . Sp ecial em phas is must be placed on th e conte x t in which sym ptoms began.Does th e patient have an alc oh ol history? Are th e hallucin a tions typica l of afun cti on al psych osis (a ud itory) or a re th ey more cons istent wit h organicit y (tactileand visual) ? T ry to es tablish a temporal relationship to medi cal int erven t ion. Last ly,if psychopharmacologic interventions have been used unsuccessfully, consider othe re t iolog ies .
The goal of treatment in th e ac u te ph ase of Wernicke 's ence phalopa thy is topr event Korsakoff's psychosis . Once this a m nes t ic synd ro me occurs , com ple te recovery is only 20%. Of th e remainder, some improve slig h tly a nd ot hers re main in theneed of total nursin g ca re or progress to death (2) .
SU MlvlARY
Despite clinicians' awaren ess of Wernicke 's encephalopat hy a nd its classi c t riad(oph thalmo plegia , a taxia, confus ion), th e diagn osis is mad e in only 20% of th e cases.This may be a fun cti on of a subclinical, limi ted sym pto ms, or at ypical p resentat ion s,or a lack of cons ide ring th e diagn osis in th e abse nce of alcoho lism . Pr edisposingfactors to Wernicke 's ence phalopa t hy include st arvation , vomit ing , d iarrhea , and GIsurg ica l procedures. Iatrogenic ca uses res u lt from th e repl acemen t of fluid s es pecia lly glucose in th e ab sen ce of vit amin supplementat ion. Awa reness of th e variou set iologies a nd the variety of pr esentations may contribu te to clinicians' ability tomake this elus ive di agn osis.
REFERENCES
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PSYCHIATRI C PRESENTATION OF WERNICKE'S ENCEPHALOPATHY 23
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