Wernicke-Korsakoff syndrome: Difference between revisions
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*Wernicke-Korsakoff Syndrome (WKS): presence of WE + KP simultaneously | *Wernicke-Korsakoff Syndrome (WKS): presence of WE + KP simultaneously | ||
==Epidemiology== | ===Epidemiology=== | ||
*Only 20% identified before death, failure of dx leads to 20% mortality and 75% permanent damage | *Only 20% identified before death, failure of dx leads to 20% mortality and 75% permanent damage | ||
===Pathophysiology=== | |||
*Brain lesions/atrophy occurs: mamillary bodies (nearly all cases), thalamus, periaqueductal gray matter, 3rd/4th ventricle, cerebellum, frontal lobe | |||
==Causes== | ==Causes== | ||
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**Chronic alcoholism, dieting/fasting/starvation, anorexia, vomiting/diarrhea, unbalanced TPN, GI surgery, malignancy, dialysis, AIDS, IBD, pancreatitis, liver disease, thyrotoxicosis | **Chronic alcoholism, dieting/fasting/starvation, anorexia, vomiting/diarrhea, unbalanced TPN, GI surgery, malignancy, dialysis, AIDS, IBD, pancreatitis, liver disease, thyrotoxicosis | ||
== | ==Clinical Features== | ||
===Wernicke’s Encephalopathy=== | ===Wernicke’s Encephalopathy=== | ||
*Classic triad: encephalopathy, oculomotor dysfunction, gait ataxia | *Classic triad: encephalopathy, oculomotor dysfunction, gait ataxia | ||
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*Sx: combination of WE and KP | *Sx: combination of WE and KP | ||
== | ==Differential Diagnosis== | ||
==Diagnosis== | |||
WE/KP/WKS = clinical diagnoses | |||
If suspect | ==Treatment== | ||
''If you suspect WE/KP/WKS then treat it! Diagnosis is clinical and difficult to confirm, treatment is simple/inexpensive/effective, there is little risk to treatment, and the risk of morbidity/mortality from not treating is high'' | |||
*Suspected WE/KP/WKS: thiamine 500 mg IV over 30 min TID x 2 days, then 500 mg IV/IM q day for 5 days, then 100 mg PO q day until pt no longer at risk | |||
**Give magnesium; hypomagnesemic state may be resistant to thiamine administration | |||
**Treatment can take days to weeks to work if at all (despite accurate diagnosis) | |||
**Give thiamine BEFORE glucose in patients requiring glucose who are at risk for thiamine deficiency; glucose without thiamine can precipitate/worsen WE by driving thiamine intracellularly | |||
===Vitamin Prophylaxis for Alcoholics=== | |||
*For the majority of chronic alcoholics, you should not administer a banana bag (thiamine 100 mg + magnesium 2-4 g + folate 1 mg + multivitamin; all in 1L NS or D5W)<ref>Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Rreview. The Journal of Emergency Medicine. 1998; 16(3):419–424.</ref><ref>Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.</ref> | *For the majority of chronic alcoholics, you should not administer a banana bag (thiamine 100 mg + magnesium 2-4 g + folate 1 mg + multivitamin; all in 1L NS or D5W)<ref>Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Rreview. The Journal of Emergency Medicine. 1998; 16(3):419–424.</ref><ref>Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.</ref> | ||
**At risk for thiamine deficiency but no symptoms: thiamine 100 mg PO q day | |||
* | **Give multivitamin; pt at risk for other vitamin deficiencies | ||
==See Also== | ==See Also== | ||
Revision as of 12:54, 26 April 2015
Background
- Wernicke’s Encephalopathy (WE): ACUTE neuro/cardiovascular sx caused by thiamine deficiency
- Korsakoff’s Psychosis (KP): CHRONIC neurologic symptoms caused by thiamine deficiency
- Wernicke-Korsakoff Syndrome (WKS): presence of WE + KP simultaneously
Epidemiology
- Only 20% identified before death, failure of dx leads to 20% mortality and 75% permanent damage
Pathophysiology
- Brain lesions/atrophy occurs: mamillary bodies (nearly all cases), thalamus, periaqueductal gray matter, 3rd/4th ventricle, cerebellum, frontal lobe
Causes
- Anything that causes thiamine (vitamin B1) deficiency: poor dietary intake, malabsorption, increased metabolic requirement
- Chronic alcoholism, dieting/fasting/starvation, anorexia, vomiting/diarrhea, unbalanced TPN, GI surgery, malignancy, dialysis, AIDS, IBD, pancreatitis, liver disease, thyrotoxicosis
Clinical Features
Wernicke’s Encephalopathy
- Classic triad: encephalopathy, oculomotor dysfunction, gait ataxia
- werNICke mnemonic:
- N: Nystagmus/ophthalmoplegia
- I: Incoordination/ataxia
- C: Confusion/memory impairment
- Other sx: hypotension, tachycardia, EKG abnormalities, DOE, CHF sx, hypothermia, coma, dry/wet Beriberi
Korsakoff’s Psychosis
- Sx: anterograde/retrograde amnesia, confabulation, confusion, apathy
Wernicke-Korsakoff Syndrome
- Sx: combination of WE and KP
Differential Diagnosis
Diagnosis
WE/KP/WKS = clinical diagnoses
Treatment
If you suspect WE/KP/WKS then treat it! Diagnosis is clinical and difficult to confirm, treatment is simple/inexpensive/effective, there is little risk to treatment, and the risk of morbidity/mortality from not treating is high
- Suspected WE/KP/WKS: thiamine 500 mg IV over 30 min TID x 2 days, then 500 mg IV/IM q day for 5 days, then 100 mg PO q day until pt no longer at risk
- Give magnesium; hypomagnesemic state may be resistant to thiamine administration
- Treatment can take days to weeks to work if at all (despite accurate diagnosis)
- Give thiamine BEFORE glucose in patients requiring glucose who are at risk for thiamine deficiency; glucose without thiamine can precipitate/worsen WE by driving thiamine intracellularly
Vitamin Prophylaxis for Alcoholics
- For the majority of chronic alcoholics, you should not administer a banana bag (thiamine 100 mg + magnesium 2-4 g + folate 1 mg + multivitamin; all in 1L NS or D5W)[1][2]
- At risk for thiamine deficiency but no symptoms: thiamine 100 mg PO q day
- Give multivitamin; pt at risk for other vitamin deficiencies