Case Presentation: A 36-year-old woman with medical history only significant for obesity presents with confusion and difficulty ambulating one week prior to our evaluation. Two months ago, she underwent an uneventful laparoscopic sleeve gastrectomy for morbid obesity (BMI ~40.4). After further discussion with her family it was revealed she had worsening nausea and vomiting after her surgery, which prevented her from taking the vitamins that were prescribed. In addition, she had increasing difficulty remember the names of her children and important events, as well as trouble ambulating independently.
Physical examination was significant for orientation to self, but not to place or time. On neurologic exam, she was found to have intact sensation and motor strength, with a positive Babinski sign, horizontal nystagmus and dysmetria of the upper and lower extremities bilaterally. The remainder of the exam was within normal limits.
CT Scan and MRI of the head were unremarkable. Lumbar Puncture was not consistent with aseptic or bacterial meningitis. HIV, West-Nile IgM and Lyme titers were also negative. She was treated with a two-day course of 500mg of thiamine IV three times per day, followed by 250mg of thiamine IV daily for five days and ultimately oral supplementation upon discharge. She was found to have a thiamine level of 30.5. Improvement in memory and orientation were noted in day 2 of hospitalization. By Day 4 she was able to ambulate with the use of a cane. She was eventually discharge 8 days after admission.
Discussion: Thiamine is a water-soluble vitamin, which is necessary in several steps of carbohydrate metabolism and is present in a number of organs. Deficiencies are usually seen in chronic alcoholism, fasting, prolonged parenteral nutrition, AIDS and dialysis. Complications of thiamine deficiency include beriberi, optic neuropathy, Wernicke’s Encephalopathy (WE) and Wernicke-Korsakoff Syndrome.
First described by Carl Wernicke, WE refers to a neurological disorder marked by mental confusion, abnormal eye movements and unsteady gait. It is believed that B1 deficiency leads to neuronal injury in areas of high metabolic activity and thus high thiamine turnover.
A normal blood thiamine level does not exclude the diagnosis of WE, as this does not reflect thiamine levels in the brain. MRI typically shows abnormalities surrounding the aqueduct, third ventricles, mamillary bodies and dorsal medulla, with a sensitivity and specificity of 53% and 93%, respectively. Thus the diagnosis is primarily a clinical diagnosis with the rapid improvement with IV thiamine. To my knowledge only about 13 cases of WE associated with sleeve gastrectomy have been documented.
Conclusions: We present a case of WE secondary to complications of sleeve gastrectomy. A high index of suspicion for WE must be maintained in patients who have undergone bariatric surgery. Results vary in regarding permanent neurologic sequelae, but prompt treatment may decrease that risk.