(445) Hidden in Nutrition: Unveiling Wernicke Encephalopathy With PPN

Introduction: Wernicke's encephalopathy (WE) is an acute neurological disorder resulting from thiamine deficiency. It typically presents with ataxia, confusion, and nystagmus, though rarer manifestations such as cardiomyopathy and coma are also reported. While WE is commonly associated with alcohol use disorder, other etiologies include severe vomiting, prolonged fasting or starvation, and post-gastric surgery. Although primarily observed after prolonged total parenteral nutrition (TPN) without adequate thiamine, cases have also been noted following peripheral parenteral nutrition (PPN). This report details a case of WE presenting alongside a catatonic phase of schizophrenia, induced by prolonged starvation during PPN administration.

Description: A 29-year-old male with schizophrenia presented with encephalopathy and he was refusing medication and diet for 10 days, resulting in an 80 lb weight loss. On examination, he was hypotehrmic (34.9), and a GCS of 11, agitated with severe memory impairment. Laboratory results that was significant were BUN (65 mg/dL), creatinine (1.60 mg/dL), and lactate (4.2 mmol/L), CT of the brain was unremarkable, and other labs, including urine drug screen, were normal. He was initiated with Clinimix for parenteral nutrition. No antipsychotic treatment was initiated due to his catatonic state. On day 3, he developed respiratory arrest and required intubation. Brain MRI revealed severe Wernicke's encephalopathy with hemorrhagic transformation. The patient was treated with high-dose IV thiamine (500 mg q8h), resulting in significant improvement within 48 hours. By day 11, he was extubated, alert, and able to engage in conversation.

Discussion: Parenteral nutrition is crucial when enteral nutrition is not feasible. TPN includes multivitamins, but Clinimix (PPN) does not. For patients on Clinimix, thiamine and other vitamins should be supplemented, especially after 5-7 days of starvation. ASPEN recommends 100 mg/day of thiamine before glucose administration. The patient's underlying psychiatric condition, normal BMI, and atypical presentation complicated the diagnosis of Wernicke's encephalopathy (WE). This case underscores the need for supplemental multivitamins or thiamine in patients receiving PPN and experiencing prolonged starvation.