(710) A Diagnostic Puzzle: Wernicke Encephalopathy Presenting With Thalamic Hemorrhage

Introduction: Wernicke’s encephalopathy (WE) is a serious and potentially fatal condition caused by thiamine deficiency which can lead to irreversible brain damage and death in about 20% cases. Although often linked to chronic alcohol use, it can also be seen in those with eating disorders, starvation, gastrointestinal diseases, and terminal malignancies. Diagnosis is primarily based on clinical symptoms, with the classic triad of ocular abnormalities, gait imbalance, and mental status changes seen only in 16-33% of patients. We present a rare case of Wernicke’s encephalopathy manifesting as bilateral thalamic hemorrhage.

Description: A 45-year-old female with bipolar disorder presented with altered mental status. No significant past medical or social history per family. Vital signs were notable for BP 109/52 and HR 132 Physical exam including neurologic exam was unremarkable except for drowsiness. Labs revealed leukocytosis, metabolic acidosis, and hypernatremia. She remained hypotensive despite fluid resuscitation and broad-spectrum antibiotics and required pressors. Toxicology tests and initial radiology, including a head CT, were unremarkable. She remained encephalopathic and was intubated for airway protection. Blood cultures grew S.Epidermidis. Echocardiogram showed no valvular vegetation. Despite no sedatives, she stayed unresponsive, EEG showed diffuse encephalopathy. An MRI of the brain revealed a 3x2x2cm acute intraparenchymal hematoma in the bilateral thalami with extensive intraventricular extension. Increased signal intensity in midbrain tegmentum and colliculi led to the diagnosis of WE, with serum thiamine returning low, IV thiamine was started. Further history revealed severe depression and frequent meal skipping over the past 4 months, but no alcohol use. Despite appropriate care, she passed away.

Discussion: Our patient had presenting symptoms suggestive of sepsis and no history of alcohol use making the diagnosis of WE challenging. Due to a low suspicion of WE, she received D5 ½ NS for hypernatremia and NG tube feeds which worsened her condition. MRI in WE typically reveals hyperintense, bilaterally symmetrical lesions in the paraventricular regions of the thalamus, hypothalamus, mammillary bodies, and periaqueductal grey area. Presentation as bilateral thalamic hematomas is rare.