Case Presentation: 65 year old woman with history of mood disorder on abilify and cogentin presented with altered sensorium. Patient was exhibiting disorderly behavior and having visual hallucinations at home. Patient had multiple emergency room visits and two hospital admissions for nausea and vomiting in the past one month where she was diagnosed with UTI and treated with Rocephin. Patient reportedly had history of alcohol use of unclear amount. Clinical exam was significant for frail appearing woman in comatose state noted to have anisocoria.. Her workup for acute encephalopathy including CT brain, metabolic profile, urine drug screen, ethanol levels were all negative except electrolyte abnormalities. She had an elevated white count of 18,000. She was afebrile on admission however became hypothermic and hypotensive shortly after. Infectious workup including blood cultures, urine cultures, chest X-ray, COVID, lumbar puncture were negative. Patient was empirically treated with broad spectrum antibiotics – vancomycin and zosyn. Due to no change in her mentation MRI brain was obtained which noted increased signal intensity in the medial aspect of thalami bilaterally, within periventricular white matter surrounding third ventricle and periaquductal gray matter suspicious for wernickes encephalopathy (WE). Due to delay in diagnosis patient had an aspiration event and a fatal outcome.

Discussion: WE is diagnosed in only 15% of cases before death. Alcoholism is the most common etiologic factor of WE in United States, but it can occur in any nutritional deficiency state. It is a clinical diagnosis that includes a triad of mental status change, ocular dysfunction, and gait apraxia, which is present in only 10% of cases and is more common in alcoholics. Hypothermia, hypotension, and coma can be a part of the clinical presentation which are also common in sepsis hence delaying diagnosis. Primary treatment includes timely administration of thiamine.

Conclusions: WE should be considered in the differential in alcoholic and malnourished patients presenting as sepsis. Appropriate treatment should be started in timely manner to avoid bad outcome.