Teaching NeuroImage: Nonalcoholic Wernicke Encephalopathy

A 40-year-old woman with chronic gastritis who did not have alcoholism had lost 50 pounds in the past 45 days and presented with dyscoordination and diplopia. Examination showed confabulation, ophthalmoplegia, nystagmus, and appendicular ataxia. Brain MRI (Figure) showed diffusion-weighted imaging and fluid-attenuated inversion recovery abnormalities suggestive of Wernicke encephalopathy (WE). With classic triad of WE and MRI findings, IV thiamine 500 mg TID was administered for 3 days, followed by maintenance oral thiamine. The patient showed substantial improvement. Thiamine replacement therapy should be considered in patients with malnutrition or malabsorption as it is important in maintaining cellular osmotic gradients. Thiamine deficiency may lead to cytotoxic edema, especially in high metabolic demand regions such as thalami and mammillary bodies.1