(453) Wernicke Encephalopathy in a Schizophrenic Patient With Unexplained Coma: A Rare Diagnostic Puzzle

Introduction: Wernicke’s Encephalopathy (WE) is a severe neurological disorder caused by thiamine (Vitamin B-1) deficiency, crucial for various metabolic processes. Although often associated with chronic alcoholism, WE can also affect non-alcoholic individuals, especially those with severe malnutrition or psychiatric conditions. This case highlights the diagnostic challenges and atypical presentation of WE.

Description: A 31-year-old male with schizophrenia, hypertension, and duodenal ulcer was admitted to the ICU following cardiac arrest. He had lost 80 pounds over three months due to severe malnutrition and vomiting, with no history of alcohol use. Upon admission, he was comatose and unresponsive to deep stimulation. Neurological examination showed diminished reflexes and unreactive pupils. Initial lab tests revealed elevated lactic acid (3.1 mmol/L), while CT and echocardiography were unremarkable. A repeat CT suggested WE, and MRI confirmed acute cortical laminar necrosis and T2 hyperintensity in the mesial thalamus and periaqueductal region, indicative of thiamine deficiency. Despite falsely elevated thiamine serum levels from prior treatment, intravenous thiamine was administered. Improvement was noted by the fifth day, with partial responsiveness. However, due to ongoing impairment, a tracheostomy and PEG tube were required. Significant neurological deficits persisted despite treatment.

Discussion: The presence of schizophrenia and the absence of alcohol use complicated the diagnosis of WE. Initial symptoms were attributed to psychiatric illness but were likely early manifestations of WE. The classic triad of WE—ophthalmoplegia, ataxia, and confusion—was absent, and the condition progressed to coma, complicating early diagnosis. MRI is crucial for diagnosing WE and evaluating prognosis. Early and aggressive thiamine replacement is essential to prevent irreversible damage.This case underscores the importance of considering WE in non-alcoholic patients with psychiatric disorders and unexplained neurological symptoms. Prompt recognition and treatment are vital to preventing severe, irreversible outcomes. Vigilance in diagnosing WE, especially in atypical cases, is crucial for improving patient outcomes.