Case Presentation: A 43-year-old male with roux-en-y gastric bypass fourteen years ago with complications and multiple adhesions, hiatal hernia associated with nausea and vomiting, and subsequent small bowel resection last year, started to experience cognitive changes and short-term memory loss. He has also experienced problems with balance, generalized weakness, and unintentional 60-pound weight loss. His physical exam was notable for horizontal nystagmus, decrease in strength and decrease sensation to cold on the right upper and bilateral lower extremities. He was unable to stand and had to drag his right lower extremity while shuffling his left leg. Concern for chronic inflammatory demyelinating polyneuropathy (CIDP) prompted MRI of the brain, cervical and thoracic spine that was unrevealing. Electromyography showed reduced conduction velocity. CSF analysis from lumbar puncture was inconclusive for CIDP. B12, folate, iron, copper, and B1 levels were all normal. High suspicion for Wernicke’s triad prompted treatment with thiamine intravenous 500mg every 8 hours for 3 days and 100mg daily thereafter. By hospital day 8, the patient endorsed symptomatic improvement and was ambulating with moderate assistance compared to day 1 where he could barely stand. The patient was discharged with intramuscular thiamine and close follow up with his primary physician. At 6-month follow up, he continues to work with physical therapy, has gained 50lbs, and continues to be on 200mg of IV thiamine daily.

Discussion: Thiamine deficiency has been a well-known cause of Wernickes Encephalopathy (WE) associated with alcohol abuse. However, recent literature has shown that thiamine deficiency should be suspected more so in heart failure patients on diuretics, the critically ill, the elderly, and bariatric surgery. With growing obesity rates and the propensity to undergo gastric bypass, especially roux-en-Y, there is a growing concern of missed thiamine deficiency that can lead to irreversible neurological consequences. Blood levels of thiamine can be inaccurate, therefore normal blood levels may not reflect the actual low brain thiamine levels, and WE cannot always be excluded.

Conclusions: This case highlights the importance of a detailed history and physical to generate the differential diagnosis. Relying on expensive technological methods can lead to premature closure and a convoluted clinical course with significant morbidity. WE encompasses a neurologic sequela of ataxia, confusion, and nystagmus which is a rare occurrence after bariatric surgery that can easily be overlooked. By attuning our diagnostic acumen within the context of recent small bowel resection and nausea/vomiting, we can achieve the correct diagnosis and gear our treatment to a high dose parenteral thiamine that can be life-saving.