Review Question - QID 212825

This patient is presenting with confusion, ataxia, and ophthalmoplegia, which is concerning for Wernicke encephalopathy. This must be immediately treated with IV thiamine (prior to treating other nutritional deficiencies).

Wernicke-Korsakoff syndrome typically occurs in alcoholics secondary to a poor diet and low thiamine levels. Patients can present initially with ataxia, ophthalmoplegia, and nystagmus which can progress to amnesia and psychosis (Korsakoff psychosis). Any patient suspected of having Wernicke-Korsakoff syndrome should be promptly given high dose IV thiamine. There is a theoretical concern that administration of glucose/dextrose prior to thiamine could exacerbate symptoms and further deplete thiamine levels, thus it is generally preferred to give thiamine first or at least at the same time as dextrose. Patients with Wernicke-Korsakoff syndrome should also be thoroughly worked up and treated for other nutritional and electrolyte deficiencies, which are common in this malnourished population.

Incorrect Answers:
Answer 1: Dextrose should be given to this patient; however, given the theoretical concern that dextrose could worsen this patient’s thiamine deficiency and precipitate Korsakoff psychosis, thiamine should be given first (or at least at the same time as dextrose). If this patient were seizing from hypoglycemia, then dextrose administration may be a better initial treatment.

Answer 2: Folate, as well as a multivitamin, should be given to this malnourished patient with megaloblastic anemia; however, it is more urgent to first treat this patient’s Wernicke syndrome which is an acute condition requiring treatment.

Answer 3: Magnesium should be repleted in this patient; however, it is more urgent to first treat this patient’s Wernicke syndrome. This patient’s normal ECG makes magnesium repletion less important (although it would be emergently required if this patient were in torsades des pointes or had a prolonged QT interval).

Answer 5: Vitamin C is certainly needed in this patient who is also suffering from scurvy given his perifollicular hemorrhages, bruising, and bleeding gums. In actuality, this patient would be started on thiamine, a multivitamin, folate, and vitamin C at the same time; however, the best next step in management is to treat the direst condition affecting this patient which is Wernicke syndrome.

Bullet Summary:
After stabilizing the patient, the best initial step in management in Wernicke-Korsakoff syndrome is the administration of thiamine.