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Worede A, Deress T, Wondifraw H, Fetene G, Berie A. Electrolyte imbalance and liver function test abnormalities among pregnant women with hyperemesis gravidarum at Wag-himra zone public hospitals, Northeast Ethiopia, 2023: a comparative cross-sectional study. Front Med (Lausanne) 2024; 11:1451036. [PMID: 39741505 PMCID: PMC11685153 DOI: 10.3389/fmed.2024.1451036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 12/03/2024] [Indexed: 01/03/2025] Open
Abstract
Background Hyperemesis gravidarum affects about 4.8% of pregnant women. It can lead to electrolyte imbalances and liver function disturbances, which may result in pregnancy complications. Despite its prevalence, data on these abnormalities in the study area is scarce. Therefore, the current study investigated these health concerns among HG-affected pregnant women in this region from June to October 2023. Method A comparative cross-sectional study was conducted on 123 study participants. Socio-demographic, clinical, and anthropometric data were collected using structured questionnaires. Blood samples were taken to determine liver function tests and electrolyte levels. Statistical analysis was performed using a one-way ANOVA with a Tuckey post hoc test, Kruskal-Wallis with a Mann-Whitney U test, and binary logistic regression analysis. A p-value of <0.05 with 95% confidence intervals was considered statistically significant. Results The results showed that pregnant women with hyperemesis gravidarum had significantly higher levels of AST and ALT and lower levels of Na+ and K+ compared to normal pregnant women and non-pregnant women. The abnormalities observed were elevated AST (48.8%), ALT (46.3%), and decreased Na+ (51.2%) and K+ (41.5%). Hyperemesis gravidarum was associated with both electrolyte imbalances and liver function test abnormalities. Conclusion Pregnant women with hyperemesis gravidarum experience electrolyte imbalances and liver function test abnormalities. Given the marked increase in liver enzymes and decrease in electrolyte levels, the authors recommend routine laboratory testing of liver function and electrolyte parameters for pregnant women with hyperemesis gravidarum is recommended.
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Affiliation(s)
- Abebaw Worede
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Teshiwal Deress
- Department of Quality Assurance and Laboratory Management, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Habtamu Wondifraw
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Getnet Fetene
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Alemseged Berie
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Jurcau MC, Jurcau A, Diaconu RG, Hogea VO, Nunkoo VS. A Systematic Review of Sporadic Creutzfeldt-Jakob Disease: Pathogenesis, Diagnosis, and Therapeutic Attempts. Neurol Int 2024; 16:1039-1065. [PMID: 39311352 PMCID: PMC11417857 DOI: 10.3390/neurolint16050079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2024] [Revised: 09/09/2024] [Accepted: 09/14/2024] [Indexed: 09/26/2024] Open
Abstract
Creutzfeldt-Jakob disease is a rare neurodegenerative and invariably fatal disease with a fulminant course once the first clinical symptoms emerge. Its incidence appears to be rising, although the increasing figures may be related to the improved diagnostic tools. Due to the highly variable clinical picture at onset, many specialty physicians should be aware of this disease and refer the patient to a neurologist for complete evaluation. The diagnostic criteria have been changed based on the considerable progress made in research on the pathogenesis and on the identification of reliable biomarkers. Moreover, accumulated knowledge on pathogenesis led to the identification of a series of possible therapeutic targets, although, given the low incidence and very rapid course, the evaluation of safety and efficacy of these therapeutic strategies is challenging.
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Affiliation(s)
- Maria Carolina Jurcau
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.C.J.)
| | - Anamaria Jurcau
- Department of Psycho-Neurosciences and Rehabilitation, University of Oradea, 410087 Oradea, Romania
| | - Razvan Gabriel Diaconu
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.C.J.)
| | - Vlad Octavian Hogea
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.C.J.)
| | - Vharoon Sharma Nunkoo
- Neurorehabilitation Ward, Clinical Emergency County Hospital Bihor, 410169 Oradea, Romania
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3
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Matsushima H, Kikuchi M, Shintani T. A Patient With Slow Communication and Difficulty Walking. JAMA Oncol 2024; 10:973-974. [PMID: 38780956 DOI: 10.1001/jamaoncol.2024.0978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
A 70-year-old woman with hypertension and dyslipidemia presented with slow communication and difficulty walking 90 days after 6 courses of postoperative chemotherapy following right breast cancer surgery. What is your diagnosis?
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Affiliation(s)
- Hirokazu Matsushima
- Department of Surgery, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Masayuki Kikuchi
- Department of Surgery, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Tsunehiro Shintani
- Department of Surgery, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
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Chaudhary AJ, Joyce KM, Haq K, Qureshi MH, Donthireddy V. Non-alcoholic Wernicke's Encephalopathy Masquerading As CNS Relapse of Acute Myeloid Leukemia. Cureus 2024; 16:e61184. [PMID: 38933646 PMCID: PMC11207165 DOI: 10.7759/cureus.61184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 06/28/2024] Open
Abstract
While Wernicke's encephalopathy (WE) is mostly caused by thiamine deficiency secondary to chronic alcohol use, other conditions that may affect one's nutritional status, such as bariatric surgery, hyperemesis gravidarum, chronic gastrointestinal disease, HIV/AIDS, and certain malignancies, may also lead to this outcome. We are discussing one such case, WE, in a young man with acute myeloid leukemia (AML) who underwent chemotherapy. The patient presented with blurred vision, paresthesia, weakness, and vomiting. Although he denied alcohol abuse, his symptoms, physical exam findings, and MRI results were consistent with WE. Treatment with thiamine resulted in a significant improvement in his visual disturbances and mental status. The authors highlight the importance of recognizing WE in non-alcoholic patients, particularly those undergoing prolonged hospitalization and chemotherapy, as nutritional deficiencies can develop. They recommend thiamine supplementation for patients receiving chemotherapy and those with poor oral intake. The case underscores the need for high clinical suspicion and early intervention in atypical cases of WE.
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Affiliation(s)
| | - Katherine M Joyce
- Emergency Medicine/Internal Medicine/Critical Care, Henry Ford Health System, Detroit, USA
| | - Kamran Haq
- Internal Medicine, Henry Ford Health System, Detroit, USA
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Clergue-Duval V, Coulbault L, Questel F, Cabé N, Laniepce A, Delage C, Boudehent C, Bloch V, Segobin S, Naassila M, Pitel AL, Vorspan F. Alcohol Withdrawal Is an Oxidative Stress Challenge for the Brain: Does It Pave the Way toward Severe Alcohol-Related Cognitive Impairment? Antioxidants (Basel) 2022; 11:2078. [PMID: 36290801 PMCID: PMC9598168 DOI: 10.3390/antiox11102078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/22/2022] [Accepted: 10/19/2022] [Indexed: 11/21/2022] Open
Abstract
Alcohol use is a leading cause of mortality, brain morbidity, neurological complications and minor to major neurocognitive disorders. Alcohol-related neurocognitive disorders are consecutive to the direct effect of chronic and excessive alcohol use, but not only. Indeed, patients with severe alcohol use disorders (AUD) associated with pharmacological dependence suffer from repetitive events of alcohol withdrawal (AW). If those AW are not managed by adequate medical and pharmacological treatment, they may evolve into severe AW, or be complicated by epileptic seizure or delirium tremens (DT). In addition, we suggest that AW favors the occurrence of Wernicke's encephalopathy (WE) in patients with known or unknown thiamine depletion. We reviewed the literature on oxidative stress as a core mechanism in brain suffering linked with those conditions: AW, epileptic seizure, DT and WE. Thus, we propose perspectives to further develop research projects aiming at better identifying oxidative stress brain damage related to AW, assessing the effect of repetitive episodes of AW, and their long-term cognitive consequences. This research field should develop neuroprotective strategies during AW itself or during the periwithdrawal period. This could contribute to the prevention of severe alcohol-related brain damage and cognitive impairments.
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Affiliation(s)
- Virgile Clergue-Duval
- Département de Psychiatrie et de Médecine Addictologique, Site Lariboisière Fernand-Widal, GHU APHP Nord–Université Paris Cité, APHP, F-75010 Paris, France
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université Paris Cité, F-75006 Paris, France
- FHU Network of Research in Substance Use Disorders (NOR-SUD), F-75006 Paris, France
- Resalcog (Réseau Pour la Prise en Charge Des Troubles Cognitifs Liés à L’alcool), F-75017 Paris, France
| | - Laurent Coulbault
- Normandie Univ, UNICAEN, INSERM, U1237, PhIND “Physiopathology and Imaging of Neurological Disorders”, Institut Blood and Brain @ Caen-Normandie, Cyceron, F-14074 Caen, France
- FHU Améliorer le Pronostic Des Troubles Addictifs et Mentaux Par Une Médecine Personnalisée (A2M2P), F-14074 Caen, France
| | - Frank Questel
- Département de Psychiatrie et de Médecine Addictologique, Site Lariboisière Fernand-Widal, GHU APHP Nord–Université Paris Cité, APHP, F-75010 Paris, France
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université Paris Cité, F-75006 Paris, France
- FHU Network of Research in Substance Use Disorders (NOR-SUD), F-75006 Paris, France
- Resalcog (Réseau Pour la Prise en Charge Des Troubles Cognitifs Liés à L’alcool), F-75017 Paris, France
| | - Nicolas Cabé
- Normandie Univ, UNICAEN, INSERM, U1237, PhIND “Physiopathology and Imaging of Neurological Disorders”, Institut Blood and Brain @ Caen-Normandie, Cyceron, F-14074 Caen, France
- FHU Améliorer le Pronostic Des Troubles Addictifs et Mentaux Par Une Médecine Personnalisée (A2M2P), F-14074 Caen, France
- Service d’Addictologie, Centre Hospitalier Universitaire de Caen, F-14000 Caen, France
| | - Alice Laniepce
- Normandie Univ, UNIROUEN, CRFDP (EA 7475), Rouen F-76000, France
| | - Clément Delage
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université Paris Cité, F-75006 Paris, France
- Service de Pharmacie, Site Lariboisière Fernand-Widal, GHU APHP Nord–Université Paris Cité, APHP, F-75010 Paris, France
- UFR de Pharmacie, Université Paris Cité, F-75006 Paris, France
| | - Céline Boudehent
- Normandie Univ, UNICAEN, INSERM, U1237, PhIND “Physiopathology and Imaging of Neurological Disorders”, Institut Blood and Brain @ Caen-Normandie, Cyceron, F-14074 Caen, France
| | - Vanessa Bloch
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université Paris Cité, F-75006 Paris, France
- FHU Network of Research in Substance Use Disorders (NOR-SUD), F-75006 Paris, France
- Service de Pharmacie, Site Lariboisière Fernand-Widal, GHU APHP Nord–Université Paris Cité, APHP, F-75010 Paris, France
- UFR de Pharmacie, Université Paris Cité, F-75006 Paris, France
| | - Shailendra Segobin
- FHU Améliorer le Pronostic Des Troubles Addictifs et Mentaux Par Une Médecine Personnalisée (A2M2P), F-14074 Caen, France
- Normandie Univ, UNICAEN, PSL Université Paris Cité, EPHE, INSERM, U1077, CHU de Caen, GIP Cyceron, Neuropsychologie et Imagerie de la Mémoire Humaine, F-14074 Caen, France
| | - Mickael Naassila
- FHU Améliorer le Pronostic Des Troubles Addictifs et Mentaux Par Une Médecine Personnalisée (A2M2P), F-14074 Caen, France
- Inserm UMRS-1247 Groupe de Recherche Sur L’alcool et Les Pharmacodépendances, Université de Picardie Jules Verne, F-80000 Amiens, France
- UFR de Pharmacie, Université de Picardie Jules Verne, F-80000 Amiens, France
| | - Anne-Lise Pitel
- Normandie Univ, UNICAEN, INSERM, U1237, PhIND “Physiopathology and Imaging of Neurological Disorders”, Institut Blood and Brain @ Caen-Normandie, Cyceron, F-14074 Caen, France
- FHU Améliorer le Pronostic Des Troubles Addictifs et Mentaux Par Une Médecine Personnalisée (A2M2P), F-14074 Caen, France
- Normandie Univ, UNICAEN, PSL Université Paris Cité, EPHE, INSERM, U1077, CHU de Caen, GIP Cyceron, Neuropsychologie et Imagerie de la Mémoire Humaine, F-14074 Caen, France
| | - Florence Vorspan
- Département de Psychiatrie et de Médecine Addictologique, Site Lariboisière Fernand-Widal, GHU APHP Nord–Université Paris Cité, APHP, F-75010 Paris, France
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université Paris Cité, F-75006 Paris, France
- FHU Network of Research in Substance Use Disorders (NOR-SUD), F-75006 Paris, France
- UFR de Médecine, Université Paris Cité, F-75006 Paris, France
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Brown S, Hutt-Williams S. Wernicke's encephalopathy in advanced cancer. BMJ Support Palliat Care 2022; 12:460-462. [PMID: 35831181 DOI: 10.1136/spcare-2022-003787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
Abstract
This 54-year-old woman with metastatic breast cancer presented with severe confusion, incontinence and self-neglect. MRI suggested Wernicke's encephalopathy (WE) without any history of alcohol misuse. The patient's symptoms seemed to not respond to acute treatment. Cancer progression was assumed to be causing her condition and she was discharged to a nursing home with community palliative care team follow-up. This case demonstrates the natural course of cancer-associated WE and eventual improvement with thiamine therapy. It also illustrates a role for specialist palliative care follow up for patients discharged to a nursing home for expected end-of-life care.
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Affiliation(s)
- Samantha Brown
- Palliative Medicine, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Suzanne Hutt-Williams
- Palliative Medicine, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
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7
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Hari T, Elsherbiny S. Bariatric surgery-what the ophthalmologist needs to know. Eye (Lond) 2022; 36:1147-1153. [PMID: 34675393 PMCID: PMC8529860 DOI: 10.1038/s41433-021-01811-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/06/2021] [Accepted: 10/05/2021] [Indexed: 11/09/2022] Open
Abstract
The incidence of bariatric surgery is increasing due to obesity being one of our top public health challenges. As such, bariatric-related ophthalmic changes are a potentially new clinical area of knowledge, with increasing published evidence on post-bariatric complications experienced by patients and identified by clinicians. We reviewed the available literature and summarised the different complications and potential recommendations. A search strategy was conducted with PubMed, Cochrane, Medline, Embase, Allied and Complementary Medicine and DH-DATA databases to look for papers answering our research question: "What are the ophthalmological complications for patients after bariatric surgery?". Our search gave a total of 59 relevant papers. Bariatric surgery, particularly subtypes that cause direct bypass of nutrients from the stomach, lead to nutritional deficiencies. Vitamin A, crucial for proper functioning of body systems and specialised cells, manifests ophthalmologically as corneal ulceration, nyctalopia, conjunctival xerosis and more. Thiamine levels are also depleted, leading to Wernicke's Encephalopathy. Pre-existing diabetic retinopathy is also noted to worsen sub acutely, although evidence is conflicting. Patients undergoing surgery to treat idiopathic intracranial hypertension would have reduced IOP and resolving papilloedema. Other comorbidities of obesity like HBA1C levels, obstructive sleep apnoea, and metabolic syndrome also resolve post-surgery. History taking remains the cornerstone of medical practice. From the evidence, we suggest consideration of pre-surgery screening for ophthalmic pathology and post-operative monitoring of disease progression. Real-world data needs to continuously be analysed to create definitive management pathways that can help clinicians recognise ophthalmic complications early, improving patient outcomes.
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Affiliation(s)
| | - Samer Elsherbiny
- Machen Eye Unit, South Warwickshire NHS Foundation Trust, Warwick, UK
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Iimura Y, Andoh S, Kawamata T, Sato A, Yokoyama K, Imai Y, Tojo A, Nojima M, Sugiura M, Kuroda S. Thiamine Deficiency and Neurological Symptoms in Patients with Hematological Cancer Receiving Chemotherapy: A Retrospective Analysis. J Neurosci Rural Pract 2021; 12:726-732. [PMID: 34737507 PMCID: PMC8559079 DOI: 10.1055/s-0041-1735825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objectives
Patients with hematological cancer receiving chemotherapy have a high risk of thiamine deficiency due to accelerated thiamine usage by tumor cells. Mild or severe thiamine deficiency can lead to varying degrees of neurological symptoms. We evaluated the relationship between thiamine deficiency and neurological symptoms, including mild or nonspecific symptoms, and the influence of chemotherapy on thiamine serum levels in patients with hematological cancer receiving chemotherapy.
Materials and Methods
We retrospectively identified 42 patients diagnosed with hematological cancer at our hospital, using electronic medical records collected from March 2019 to March 2020. We evaluated the risk factors associated with neurological symptoms (mild-to-severe cognitive impairment, attention impairment, and mood or emotional disorder), the relationship between the presence of neurological symptoms and thiamine serum levels, and changes in thiamine serum levels after chemotherapy.
Results
Thiamine deficiency was significantly associated with neurological symptoms. The thiamine serum levels in the group with neurological symptoms were significantly lower than those in the group without neurological symptoms. The Wilcoxon rank-sum test showed that thiamine serum levels after chemotherapy were significantly lower than those before administration of chemotherapy.
Conclusion
Thiamine serum levels in patients with hematological cancer may be used as a reference to maintain neurological status during chemotherapy.
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Affiliation(s)
- Yohei Iimura
- Department of Pharmacy, The IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Shohei Andoh
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Toyotaka Kawamata
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Aki Sato
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Kazuaki Yokoyama
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Yoichi Imai
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Arinobu Tojo
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Masanori Nojima
- Center for Translational Research, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Munetoshi Sugiura
- Department of Drug Safety and Risk Management, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Hachioji, Japan
| | - Seiichiro Kuroda
- Department of Pharmacy, The IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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9
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Nakamura ZM, Deal AM, Park EM, Quillen LJ, Chien SA, Stanton KE, McCabe SD, Heiling HM, Wood WA, Shea TC, Rosenstein DL. A randomized double-blind placebo-controlled trial of intravenous thiamine for prevention of delirium following allogeneic hematopoietic stem cell transplantation. J Psychosom Res 2021; 146:110503. [PMID: 33945982 PMCID: PMC8172461 DOI: 10.1016/j.jpsychores.2021.110503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine if high dose intravenous (IV) thiamine can prevent delirium during hospitalization following allogeneic HSCT. Secondarily, we evaluated the effects of high dose IV thiamine on thiamine levels and explored risk factors for delirium. METHODS Randomized, double-blind, placebo-controlled trial in patients undergoing allogeneic HSCT at a U.S. academic medical center between October 2017 and March 2020. 64 participants were randomized 1:1 to thiamine 200 mg IV three times daily for 7 days or placebo. We used the Delirium Rating Scale to assess for delirium. Delirium incidence was compared between groups using the chi-square test. Group differences in time to onset and duration of delirium were compared using the Kaplan-Meier method. Fisher's Exact and Wilcoxon Rank Sum tests were used to examine associations between pre-transplantation variables and delirium. RESULTS 61 participants were analyzed. Delirium incidence (25% vs. 21%, Chi-square (df = 1) = 0.12, p = 0.73), time to onset, duration, and severity were not different between study arms. Immediately following the intervention, thiamine levels were higher in the thiamine arm (275 vs. 73 nmol/L, t-test (df = 57) = 13.63, p < 0.0001), but not predictive of delirium. Variables associated with delirium in our sample included disease severity, corticosteroid exposure, infection, and pre-transplantation markers of nutrition. CONCLUSION High dose IV thiamine did not prevent delirium in patients receiving allogeneic HSCT. Given the multiple contributors to delirium in this population, further research regarding the efficacy of multicomponent interventions may be needed. TRIAL REGISTRATION Clinical Trials NCT03263442. FUNDING Rising Tide Foundation for Clinical Cancer Research.
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Affiliation(s)
- Zev M Nakamura
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura J Quillen
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie A Chien
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kate E Stanton
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean D McCabe
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hillary M Heiling
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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10
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Shah FA, Moronta S, Braford M, Fujikawa PY, Stocker G. Wernicke Encephalopathy in an Elderly Patient Due to Chronic Malnutrition From an Atypical Diet. Cureus 2021; 13:e14210. [PMID: 33948400 PMCID: PMC8086522 DOI: 10.7759/cureus.14210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/29/2022] Open
Abstract
Wernicke encephalopathy has traditionally been associated with chronic alcohol abuse leading to thiamine deficiency. Clinical symptoms include mentation change, gait ataxia, and oculomotor abnormalities. However, it is often an underdiagnosed condition in patients suffering from chronic malnutrition, especially in the West. We examine a unique case of non-alcoholic Wernicke encephalopathy in an elderly patient. The patient had a long history of chronic malnutrition due to her atypical diet, consuming an unbalanced diet deprived of thiamine, unbeknownst to her. She presented with symptoms of encephalopathy, recurrent falls, and pupillary changes. After exhausting all other therapeutic interventions, she received a thiamine infusion; her mentation and other symptoms improved dramatically. Thiamine deficiency can lead to severe complications, including Wernicke encephalopathy and cardiomyopathy. Wernicke encephalopathy can progress to Korsakoff syndrome, which is characterized by amnesia and confabulation. Case reports, such as ours, may remind clinicians to keep thiamine deficiency as a viable differential while evaluating acute encephalopathy, especially in the malnourished geriatric population.
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Affiliation(s)
- Farhan A Shah
- Internal Medicine, Lewis Gale Medical Center, Salem, USA
| | - Shaidy Moronta
- Internal Medicine, Edward Via College of Osteopathic Medicine, Blacksburg, USA
| | - Michalla Braford
- Internal Medicine, Edward Via College of Osteopathic Medicine, Salem, USA
| | | | - Gary Stocker
- Psychiatry, Lewis Gale Medical Center, Salem, USA
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Brown K, Everwine M, Nieves J. A Case of Wernicke Encephalopathy Secondary to Anorexia Nervosa Complicated by Refeeding Syndrome and Takotsubo Cardiomyopathy. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929891. [PMID: 33720925 PMCID: PMC7980084 DOI: 10.12659/ajcr.929891] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Patient: Female, 20-year-old Final Diagnosis: Anorexia nervosa • refeeding syndrome • takotsubo cardiomyopathy • Wernicke encephalopathy Symptoms: Altered mental status • lethargy • weight loss Medication: — Clinical Procedure: — Specialty: Critical Care Medicine
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Affiliation(s)
- Keith Brown
- Department of Internal Medicine, Rowan University School of Osteopathic Medicine at Jefferson Health New Jersey, Stratford, NJ, USA
| | - Matthew Everwine
- Department of Internal Medicine, Rowan University School of Osteopathic Medicine at Jefferson Health New Jersey, Stratford, NJ, USA
| | - Jose Nieves
- Department of Critical Care, Jefferson Health New Jersey, Washington Township, NJ, USA
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Bowden SC, Crowe SF. Editorial to the Special Issue “Improving the Reliability and Validity of Brief Cognitive Assessments”. AUSTRALIAN PSYCHOLOGIST 2020. [DOI: 10.1111/ap.12253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Stephen C Bowden
- Melbourne School of Psychological Sciences, University of Melbourne,
| | - Simon F Crowe
- School of Psychology and Public Health, La Trobe University,
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13
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Miyanaga R, Hisahara S, Ohhashi I, Yamamoto D, Matsumura A, Suzuki S, Tanimoto K, Hirakawa M, Kawamata J, Kato J, Shimohama S. Hyperemesis-induced Wernicke-Korsakoff Syndrome due to Hypergastrinemia during Long-term Treatment with Proton Pump Inhibitors. Intern Med 2020; 59:2783-2787. [PMID: 32669503 PMCID: PMC7691029 DOI: 10.2169/internalmedicine.5168-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
We herein report a patient with Wernicke-Korsakoff syndrome (WKS) who had neither a history of alcoholism or of history of gastric surgery. A 56-year-old woman was transferred to our hospital because of the loss of consciousness and she was diagnosed to have Wernicke encephalopathy. She showed proton pump inhibitor-induced refractory hypergastrinemia with the subsequent development of hyperemesis and a vitamin B1 deficiency.
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Affiliation(s)
- Rei Miyanaga
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Shin Hisahara
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Ikkei Ohhashi
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Daisuke Yamamoto
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Akihiro Matsumura
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Syuuichirou Suzuki
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Katsumasa Tanimoto
- Department of Orthopedics, Chitose City Hospital, Japan
- Department of Orthopedics, School of Medicine, Sapporo Medical University, Japan
| | - Masahiro Hirakawa
- Department of Medical Oncology, Department of Hematology, School of Medicine, Sapporo Medical University, Japan
| | - Jun Kawamata
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Junji Kato
- Department of Medical Oncology, Department of Hematology, School of Medicine, Sapporo Medical University, Japan
| | - Shun Shimohama
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
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14
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Abstract
Wernicke’s encephalopathy is caused by thiamine deficiency and has a
range of presenting features, including gait disturbance, altered
cognitive state, nystagmus and other eye movement disorders. In the
past, Wernicke’s encephalopathy was described almost exclusively in
the alcohol-dependent population. However, in current times,
Wernicke’s encephalopathy is also well recognized in many other
patient groups, including patients following bariatric surgery,
gastrointestinal surgery, cancer and pancreatitis. Early recognition
of Wernicke’s encephalopathy is vital, as prompt treatment can restore
cognitive or ocular function and can prevent permanent disability.
Unfortunately, Wernicke’s encephalopathy is often undiagnosed –
presumably because it is relatively uncommon and has a variable
clinical presentation. Clinical biochemists have a unique role in
advising clinicians about potential nutritional or metabolic causes of
unexplained neurological symptoms and to prompt consideration of
thiamine deficiency as a potential cause in high-risk patient groups.
The aim of this review is to summarize the clinical features,
diagnosis and treatment of Wernicke’s encephalopathy and to highlight
some non-traditional causes, such as after bariatric surgery.
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Affiliation(s)
- Sara Kohnke
- Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Claire L Meek
- Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.,Department of Clinical Biochemistry, North West Anglia NHS Foundation Trust, Peterborough City Hospital, Peterborough, UK.,Wolfson Diabetes and Endocrinology Clinic, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
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15
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Isen DR, Kline LB. Neuro-ophthalmic Manifestations of Wernicke Encephalopathy. Eye Brain 2020; 12:49-60. [PMID: 32636690 PMCID: PMC7335288 DOI: 10.2147/eb.s234078] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/09/2020] [Indexed: 12/18/2022] Open
Abstract
Wernicke encephalopathy (WE) is a life-threatening but reversible syndrome resulting from acute thiamine deficiency that is frequently overlooked and underdiagnosed. It is classically characterized by a triad of ocular dysfunction, ataxia, and altered mental status. However, less than 1/3 patients have the complete triad, so it is crucial to have a high index of suspicion. Awareness of the early signs of WE is essential to prevent clinical progression, as patients with the full triad already have a profoundly thiamine-deficient state. This review highlights the neuro-ophthalmic manifestations of WE to guide the clinician in identifying the condition. In addition, we provide an update regarding the clinical characteristics, pathophysiology, neuroimaging and laboratory findings, treatment options, and prognosis of WE.
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Affiliation(s)
- Danielle R Isen
- Department of Neurology, University of South Alabama School of Medicine, Mobile, AL, USA
| | - Lanning B Kline
- Department of Ophthalmology, University of Alabama School of Medicine, Birmingham, AL, USA
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16
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Cognitive and Motor Impairment Severity Related to Signs of Subclinical Wernicke's Encephalopathy in HIV Infection. J Acquir Immune Defic Syndr 2020; 81:345-354. [PMID: 30958387 DOI: 10.1097/qai.0000000000002043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wernicke's encephalopathy (WE) is a neurological condition resulting from thiamine deficiency. Although commonly associated with alcoholism, nonalcoholic WE has been described in individuals with HIV infection, but subclinical WE may be underdiagnosed. The current study questioned whether the presence of subclinical WE signs underlies cognitive and motor deficits in HIV individuals as observed in alcoholism. SETTING Fifty-six HIV-positive individuals (HIV+) and 53 HIV-negative controls (HIV-) were assessed on 6 cognitive and motor domains: attention/working memory, production, immediate and delayed episodic memory, visuospatial abilities, and upper-limb motor function. METHODS Based on a rating scheme by Caine et al, HIV+ individuals were categorized by subclinical WE risk factors (dietary deficiency, oculomotor abnormality, cerebellar dysfunction, and altered mental state). Performance was expressed as age- and education-corrected Z-scores standardized on controls. RESULTS Sorting by Caine criteria yielded 20 HIV+ as Caine 0 (ie, meeting no criteria), 22 as Caine 1 (ie, meeting one criterion), and 14 as Caine 2 (ie, meeting 2 criteria). Comparison among HIV+ Caine subgroups revealed a graded effect: Caine 0 performed at control levels, Caine 1 showed mild to moderate deficits on some domains, and Caine 2 showed the most severe deficits on each domain. CONCLUSION This graded severity pattern of performance among Caine subgroups suggests that signs of subclinical WE can partly explain the heterogeneity in HIV-related cognitive and motor impairment. This study highlights the utility of Caine criteria in identifying potential causes of HIV-related neurocognitive disorders and has implications for disease management.
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17
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Vora B, Green EAE, Khuri N, Ballgren F, Sirota M, Giacomini KM. Drug-nutrient interactions: discovering prescription drug inhibitors of the thiamine transporter ThTR-2 (SLC19A3). Am J Clin Nutr 2020; 111:110-121. [PMID: 31764942 PMCID: PMC6944527 DOI: 10.1093/ajcn/nqz255] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/11/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Transporter-mediated drug-nutrient interactions have the potential to cause serious adverse events. However, unlike drug-drug interactions, these drug-nutrient interactions receive little attention during drug development. The clinical importance of drug-nutrient interactions was highlighted when a phase III clinical trial was terminated due to severe adverse events resulting from potent inhibition of thiamine transporter 2 (ThTR-2; SLC19A3). OBJECTIVE In this study, we tested the hypothesis that therapeutic drugs inhibit the intestinal thiamine transporter ThTR-2, which may lead to thiamine deficiency. METHODS For this exploration, we took a multifaceted approach, starting with a high-throughput in vitro primary screen to identify inhibitors, building in silico models to characterize inhibitors, and leveraging real-world data from electronic health records to begin to understand the clinical relevance of these inhibitors. RESULTS Our high-throughput screen of 1360 compounds, including many clinically used drugs, identified 146 potential inhibitors at 200 μM. Inhibition kinetics were determined for 28 drugs with half-maximal inhibitory concentration (IC50) values ranging from 1.03 μM to >1 mM. Several oral drugs, including metformin, were predicted to have intestinal concentrations that may result in ThTR-2-mediated drug-nutrient interactions. Complementary analysis using electronic health records suggested that thiamine laboratory values are reduced in individuals receiving prescription drugs found to significantly inhibit ThTR-2, particularly in vulnerable populations (e.g., individuals with alcoholism). CONCLUSIONS Our comprehensive analysis of prescription drugs suggests that several marketed drugs inhibit ThTR-2, which may contribute to thiamine deficiency, especially in at-risk populations.
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Affiliation(s)
- Bianca Vora
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Elizabeth A E Green
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Natalia Khuri
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Frida Ballgren
- Department of Pharmaceutical Biosciences, Faculty of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Marina Sirota
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen M Giacomini
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
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18
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Theodoreson MD, Zykaite A, Haley M, Meena S. Case of non-alcoholic Wernicke's encephalopathy. BMJ Case Rep 2019; 12:12/11/e230763. [PMID: 31732541 DOI: 10.1136/bcr-2019-230763] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A 61-year-old obese man presented with 8-week history of nausea and occasional vomiting. He reported poor appetite and unintentional weight loss of more than 20 kg of his body mass. A week after admission, he developed double vision and unsteady gait. Neurological examination revealed isolated sixth cranial nerve palsy on the left side with horizontal nystagmus that progressed to bilateral lateral gaze palsy with normal vertical gaze. Brain MR revealed T2/fluid attenuation inversion recovery (FLAIR) high signal in mammillary bodies, tectum of the midbrain and the periaqueductal grey matter. He was diagnosed with Wernicke's encephalopathy (WE). WE is a medical emergency that carries high mortality yet can be often under-diagnosed in the non-alcoholic patient. Varied presentation and absence of alcohol dependence lowers the degree of suspicion and this was true in this case. The patient was given intravenous thiamine and made a rapid and dramatic recovery.
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Affiliation(s)
| | - Ausrine Zykaite
- General Medicine, Weston Area Health NHS Trust, Weston-super-Mare, UK
| | - Michael Haley
- General Medicine, Weston Area Health NHS Trust, Weston-super-Mare, UK
| | - Saroj Meena
- Radiology, Weston Area Health NHS Trust, Weston-super-Mare, UK
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19
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Abstract
Half a million bariatric procedures are performed annually worldwide. Our aim was to review the signs and symptoms of Wernicke's encephalopathy (WE) after bariatric surgery. We included 118 WE cases. Descriptions involved gastric bypass (52%), but also newer procedures like the gastric sleeve. Bariatric WE patients were younger (median = 33 years) than those in a recent meta-analysis of medical procedures (mean = 39.5 years), and often presented with vomiting (87.3%), ataxia (84.7%), altered mental status (76.3%), and eye movement disorder (73.7%). Younger age seemed to protect against mental alterations and higher BMI against eye movement disorders. The WE treatment was often insufficient, specifically ignoring low parenteral thiamine levels (77.2%). In case of suspicion, thiamine levels should be tested and treated adequately with parenteral thiamine supplementation.
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Affiliation(s)
- Erik Oudman
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands.
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands.
| | - Jan W Wijnia
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
| | - Mirjam van Dam
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
| | - Laser Ulas Biter
- Department of Bariatric Surgery, Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Albert Postma
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
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20
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Xu XY, Ding HG, Li WG, Jia JD, Wei L, Duan ZP, Liu YL, Ling-Hu EQ, Zhuang H, Hepatology CSO, Association CM. Chinese guidelines on management of hepatic encephalopathy in cirrhosis. World J Gastroenterol 2019; 25:5403-5422. [PMID: 31576089 PMCID: PMC6767982 DOI: 10.3748/wjg.v25.i36.5403] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/07/2019] [Accepted: 08/24/2019] [Indexed: 02/06/2023] Open
Abstract
The Chinese Society of Hepatology developed the current guidelines on the management of hepatic encephalopathy in cirrhosis based on the published evidence and the panelists' consensus. The guidelines provided recommendations for the diagnosis and management of hepatic encephalopathy (HE) including minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy, emphasizing the importance on screening MHE in patients with end-stage liver diseases. The guidelines emphasized that early identification and timely treatment are the key to improve the prognosis of HE. The principles of treatment include prompt removal of the cause, recovery of acute neuropsychiatric abnormalities to baseline status, primary prevention, and secondary prevention as soon as possible.
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Affiliation(s)
- Xiao-Yuan Xu
- Department of Infectious Diseases, Peking University First Hospital, Beijing 100034, China
| | - Hui-Guo Ding
- Hepatology and Digestion Center, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Wen-Gang Li
- Department of Liver Oncology, Cancer Radiation Therapy Center, Fifth Medical Center, PLA General Hospital, Beijing 100039, China
| | - Ji-Dong Jia
- Hepatology Center, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lai Wei
- Hepatobiliary and Pancreatic Department, Beijing Tsinghua Changgeng Hospital, Beijing 102218, China
| | - Zhong-Ping Duan
- Artificial Liver Center, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Yu-Lan Liu
- Department of Gastroenterology, Peking University People's Hospital, Beijing 100044, China
| | - En-Qiang Ling-Hu
- Department of Gastroenterology, First Medical Center, PLA General Hospital, Beijing 100853, China
| | - Hui Zhuang
- Department of Pathogenic Biology, Peking University Health Science Center, Beijing 100191, China
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21
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Yin H, Xu Q, Cao Y, Qi Y, Yu T, Lu W. Nonalcoholic Wernicke's encephalopathy: a retrospective study of 17 cases. J Int Med Res 2019; 47:4886-4894. [PMID: 31502510 PMCID: PMC6833415 DOI: 10.1177/0300060519870951] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective Nonalcoholic Wernicke’s encephalopathy (WE) is a devastating
neuropsychiatric syndrome caused by thiamine deficiency.
Although many case reports on WE have been published, more
studies are required to guide the diagnosis and treatment of
nonalcoholic WE. Methods We retrospectively studied patients who were diagnosed with WE in
our hospital. Data on demographics, possible causes,
phenomenology, and diagnostic and treatment delays were
abstracted from medical records by chart reviews. Results Seventeen patients were diagnosed with nonalcoholic WE.
Nonalcoholic WE had many causes, such as gastrointestinal
surgery, gastrointestinal tract diseases, vomiting, and
psychiatric diseases. Most patients presented with abnormal
mental symptoms, including those in a coma. Conclusion In summary, we recommend using operational criteria to diagnose and
treat nonalcoholic WE as early as possible to avoid misdiagnosis
and treatment delays. Nonalcoholic WE remains a clinical
diagnosis, and certain examinations are helpful for this
diagnosis, such as measuring serum thiamine concentrations. We
should focus on patients who present with abnormal mental
symptoms, even those in a coma, and administer parenteral
thiamine before any carbohydrate to reduce the high frequency of
residual morbidity.
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Affiliation(s)
- Hongzhen Yin
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Qiancheng Xu
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Yingya Cao
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Yupeng Qi
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Tao Yu
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Weihua Lu
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
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A Late Onset of Wernicke-Korsakoff Encephalopathy After Biliopancreatic Diversion: a Case Report. Obes Surg 2019; 29:2309-2311. [PMID: 31044351 DOI: 10.1007/s11695-019-03894-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Wai JM, Aloezos C, Mowrey WB, Baron SW, Cregin R, Forman HL. Using clinical decision support through the electronic medical record to increase prescribing of high-dose parenteral thiamine in hospitalized patients with alcohol use disorder. J Subst Abuse Treat 2019; 99:117-123. [PMID: 30797383 DOI: 10.1016/j.jsat.2019.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/20/2019] [Accepted: 01/23/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with alcohol use disorder (AUD) are at an increased risk of developing Wernicke's encephalopathy (WE), a devastating and difficult diagnosis caused by thiamine deficiency. Even as AUD is present in up to 25% of hospitalized patients on medical floors, appropriate thiamine supplementation in the hospital setting remains inadequate. These patients are particularly susceptible to thiamine deficiency and subsequent WE due to both their alcohol use and active medical illnesses. The electronic medical record (EMR) has become ubiquitous in health care systems and can be used as a tool to improve the care of hospitalized patients. METHODS As a quality improvement initiative, we implemented a medication order panel in the EMR with autopopulated orders for thiamine dosing to increase the appropriate use of high-dose parenteral thiamine (HPT) for hospitalized patients with AUD. We conducted a retrospective cohort study of all inpatients with AUD who received an Addiction Psychiatry Consult Service consult three months before and after the EMR change. We compared the proportion of patients receiving HPT prior to consultation (primary outcome) and the length of stay (secondary outcome) between the historical control group and the EMR intervention group. RESULTS Patients in the EMR intervention group were significantly more likely to receive HPT than the historical control group (20.2% vs. 2.7%, p < 0.0001). This difference remained statistically significant when adjusted for potential confounders (OR: 9.89, 95% CI: [2.77, 35.34], p = 0.0004). There was a trend towards statistical significance that the intervention group had a higher likelihood of being prescribed any thiamine (76.6% vs. 64.6%, p = 0.06) and had a shorter length of stay (median (IQR): 3.8 (2.4, 7.0) vs. 4.6 (2.9, 7.8) days, p = 0.06). CONCLUSION These results indicate that providing autopopulated thiamine order panels for patients with AUD can be an effective method for specialty services to increase appropriate care practices without additional education or training for providers. Further research should consider the clinical outcomes of increasing HPT for patients with AUD.
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Affiliation(s)
- Jonathan M Wai
- Department of Psychiatry, Columbia University, 1051 Riverside Drive, Unit 66, Office 3705, New York, NY 10032, USA; Division on Substance Use Disorders, New York State Psychiatric Institute, Unit 66, Office 3705, New York, NY 10032, USA; Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Christopher Aloezos
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA; Department of Psychiatry, NYU School of Medicine, One Park Avenue, New York, NY 10016, USA
| | - Wenzhu B Mowrey
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - Sarah W Baron
- Department of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Regina Cregin
- Department of Pharmacy, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Howard L Forman
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
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Non-alcoholic Wernicke encephalopathy presenting as bilateral hearing loss: a case report. J Neurol 2019; 266:1027-1030. [PMID: 30729314 DOI: 10.1007/s00415-019-09220-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 01/27/2019] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
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Nikolakaros G, Kurki T, Myllymäki A, Ilonen T. A patient with Korsakoff syndrome of psychiatric and alcoholic etiology presenting as DSM-5 mild neurocognitive disorder. Neuropsychiatr Dis Treat 2019; 15:1311-1320. [PMID: 31190835 PMCID: PMC6535456 DOI: 10.2147/ndt.s203513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/04/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Wernicke's encephalopathy (WE) and Korsakoff syndrome (KS) are underdiagnosed. The DSM-5 has raised the diagnostic threshold by including KS in the major neurocognitive disorders, which requires that the patient needs help in everyday activities. Methods: We report clinical, neuropsychological, and radiological findings from a patient who developed Wernicke-Korsakoff syndrome as a result of alcohol use and weight loss due to major depression. We assess the diagnosis in the context of the scientific literature on KS and according to the DSM-IV and the DSM-5. Results: The patient developed ataxia during a period of weight loss, thus fulfilling current diagnostic criteria of WE. WE was not diagnosed, but the patient partially improved after parenteral thiamine treatment. However, memory problems became evident, and KS was considered. In neuropsychological examination, the Logical Memory test and the Word List test were abnormal, but the Verbal Pair Associates test was normal (Wechsler Memory Scale-III). There were intrusions in the memory testing. The Wisconsin Card Sorting Test was broadly impaired, but the other test of executive functions (difference between Trail Making B and Trail Making A tests) was normal. There was atrophy of the mammillary bodies, the thalamus, the cerebellum, and in the basal ganglia but not in the frontal lobes. Diffusion tensor imaging showed damage in several tracts, including the uncinate fasciculi, the cinguli, the fornix, and the corona radiata. The patient remained independent in everyday activities. The patient can be diagnosed with KS according to the DSM-IV. According to the DSM-5, the patient has major neurocognitive disorders. Conclusions: Extensive memory testing is essential in the assessment of KS. Patients with a history of WE and typical clinical, neuropsychological, and radiological KS findings may be independent in everyday activities. Strict use of the DSM-5 may worsen the problem of Wernicke-Korsakoff syndrome underdiagnosis by excluding clear KS cases that do not have very severe functional impairment.
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Affiliation(s)
- Georgios Nikolakaros
- Satakunta Hospital District, Psychiatric Care Division, General Psychiatry Outpatient Clinic, Pori, Finland.,HUS Medical Imaging Center, Department of Clinical Neurophysiology, Helsinki University Hospital, Helsinki, Finland
| | - Timo Kurki
- Terveystalo Pulssi Medical Center, Turku, Finland.,Department of Radiology, University of Turku, Turku, Finland
| | - Arttu Myllymäki
- Satakunta Hospital District, Psychiatric Care Division, General Psychiatry Outpatient Clinic, Pori, Finland
| | - Tuula Ilonen
- Department of Psychiatry, University of Turku, Turku, Finland
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26
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Profound Hypokalaemia Resulting in Maternal Cardiac Arrest: A Catastrophic Complication of Hyperemesis Gravidarum? Case Rep Obstet Gynecol 2018; 2018:4687587. [PMID: 30151287 PMCID: PMC6087565 DOI: 10.1155/2018/4687587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 07/08/2018] [Indexed: 11/18/2022] Open
Abstract
We present a case of a 39-year-old G8P6 Pacific Islander woman who at 15+5 weeks' gestation had an out-of-hospital cardiac arrest secondary to profound hypokalaemia which was associated with severe hyperemesis gravidarum (HG). Her clinical course after arrest was complicated by a second 5-minute cardiac arrest in the Intensive Care Unit (ICU) (pre-arrest potassium 1.8), anuric renal failure requiring dialysis, ischaemic hepatitis, and encephalopathy and unfortunately fetal demise and a spontaneous miscarriage on day 2 of admission. Despite these complications, she was discharged home 4 weeks later with a full recovery. Following a plethora of inpatient and outpatient investigations, the cause of her cardiac arrest was determined to be profound hypokalaemia. The hypokalaemia was presumed second to a perfect storm of HG with subsequent nutritional deficiencies causing electrolyte wasting, extracellular fluid (ECF) volume reduction, and activation of the renin-angiotensin-aldosterone axis (RAAS). This combined with the physiological changes that promote potassium wasting in pregnancy including volume expansion, increased renal blood flow, increased glomerular filtration rate, and increase in cortisol contributed to the patient having a profoundly low total body potassium level. This diagnosis is further strengthened by the fact that her pre- and post-pregnancy potassium levels were within normal limits in the absence of supplementary potassium. This case highlights the potentially life-threatening electrolyte imbalances that can occur with HG and the importance of recognising the disease, comprehensive electrolyte monitoring, and aggressive management in pregnancy.
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Bielewicz J, Szczepańska-Szerej A, Ogórek M, Dropko P, Wojtal K, Rejdak K. Wernicke-Korsakoff syndrome as a rare phenotype of sporadic Creutzfeldt-Jakob disease. Prion 2018; 12:143-146. [PMID: 29380664 DOI: 10.1080/19336896.2018.1433988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
We reported the case of a patient with Wernicke-Korsakoff syndrome (WKs) as an early clinical manifestation of sporadic Creutzfeld-Jakob disease (sCJD). The 66-year-old female complained of dizziness and imbalance which mostly occurred while walking. A neurological examination revealed a triad of symptoms characteristic for WKs such as gaze paresis, ataxia of limbs and trunk as well as memory disturbances with confabulations. The disturbances increased during the course of the disease, which led to the death of the patient four months after the appearance of the signs. The patient was finally diagnosed with sCJD disease. The most useful ancillary examination results supporting sCJD diagnosis were brain diffusion DWI MRI (diffusion weighted magnetic resonance imaging) and the presence of 14-3-3 protein in CSF (cerebrospinal fluid). Since that manifestation of sCJD is very unique other causes should be taken into consideration while making a final diagnosis.
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Affiliation(s)
- Joanna Bielewicz
- a Department of Neurology , Medical University of Lublin , Lublin , Poland
| | | | - Magdalena Ogórek
- a Department of Neurology , Medical University of Lublin , Lublin , Poland
| | - Piotr Dropko
- a Department of Neurology , Medical University of Lublin , Lublin , Poland
| | - Katarzyna Wojtal
- b Department of Interventional Radiology and Neuroradiology , Medical University of Lublin , Lublin , Poland
| | - Konrad Rejdak
- a Department of Neurology , Medical University of Lublin , Lublin , Poland
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a practical clinical approach to confusion in the patient with cancer. Confusion in the cancer population has a broader differential diagnosis than in the general medical population. The clinician must consider the usual differential diagnoses as well as causes unique to the cancer patient including direct complications from the cancer and indirect complications related to cancer treatment. RECENT FINDINGS In the recent age of precision medicine, the oncologist now utilizes the genomic profile of both the patient and the tumor to provide advanced biologic therapies including targeted anticancer drugs, antiangiogenic agents, and immunotherapy. Such advances carry with them an emerging pattern of neurotoxicity which, although less well described in the literature, is now an important consideration to the clinical approach to confusion in cancer patients. SUMMARY Confusion is the most common neurologic complication in cancer and is associated with significant morbidity, mortality, and prolonged hospital stays resulting in increased healthcare costs. Early recognition and treatment of delirium is essential to improve clinical outcomes.
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Nikolakaros G, Kurki T, Paju J, Papageorgiou SG, Vataja R, Ilonen T. Korsakoff Syndrome in Non-alcoholic Psychiatric Patients. Variable Cognitive Presentation and Impaired Frontotemporal Connectivity. Front Psychiatry 2018; 9:204. [PMID: 29910747 PMCID: PMC5992887 DOI: 10.3389/fpsyt.2018.00204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/02/2018] [Indexed: 12/14/2022] Open
Abstract
Background: Non-alcoholic Wernicke's encephalopathy and Korsakoff syndrome are greatly underdiagnosed. There are very few reported cases of neuropsychologically documented non-alcoholic Korsakoff syndrome, and diffusion tensor imaging (DTI) data are scarce. Methods: We report clinical characteristics and neuropsychological as well as radiological findings from three psychiatric patients (one woman and two men) with a history of probable undiagnosed non-alcoholic Wernicke's encephalopathy and subsequent chronic memory problems. Results: All patients had abnormal neuropsychological test results, predominantly in memory. Thus, the neuropsychological findings were compatible with Korsakoff syndrome. However, the neuropsychological findings were not uniform. The impairment of delayed verbal memory of the first patient was evident only when the results of the memory tests were compared to her general cognitive level. In addition, the logical memory test and the verbal working memory test were abnormal, but the word list memory test was normal. The second patient had impaired attention and psychomotor speed in addition to impaired memory. In the third patient, the word list memory test was abnormal, but the logical memory test was normal. All patients had intrusions in the neuropsychological examination. Executive functions were preserved, except for planning and foresight, which were impaired in two patients. Conventional MRI examination was normal. DTI showed reduced fractional anisotropy values in the uncinate fasciculus in two patients, and in the corpus callosum and in the subgenual cingulum in one patient. Conclusions: Non-alcoholic Korsakoff syndrome can have diverse neuropsychological findings. This may partly explain its marked underdiagnosis. Therefore, a strong index of suspicion is needed. The presence of intrusions in the neuropsychological examination supports the diagnosis. Damage in frontotemporal white matter tracts, particularly in the uncinate fasciculus, may be a feature of non-alcoholic Korsakoff syndrome in psychiatric patients.
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Affiliation(s)
- Georgios Nikolakaros
- "Specialists in Psychiatry" Medical Center, Turku, Finland.,Satakunta Hospital District, Psychiatric Care Division, General Psychiatry Outpatient Clinic, Pori, Finland.,Turku University Central Hospital, Salo Psychiatry Outpatient Clinic, Salo, Finland
| | - Timo Kurki
- Terveystalo Pulssi Medical Center, Turku, Finland.,Department of Radiology, University of Turku, Turku, Finland
| | - Janina Paju
- Department of Psychiatry, University of Turku, Turku, Finland
| | - Sokratis G Papageorgiou
- Cognitive Disorders/Dementia Unit, 2nd University Department of Neurology, Medical School, National and Kapodistrian University of Athens, University General Hospital "ATTIKON", Athens, Greece
| | - Risto Vataja
- Division of Neuropsychiatry, Helsinki University Hospital, Helsinki, Finland
| | - Tuula Ilonen
- Department of Psychiatry, University of Turku, Turku, Finland
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30
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Abstract
In this review, we present a survey on Korsakoff's syndrome (KS), a residual syndrome in patients who suffered from a Wernicke encephalopathy (WE) that is predominantly characterized by global amnesia, and in more severe cases also by cognitive and behavioral dysfunction. We describe the history of KS and its definition, its epidemiology, and the lack of consensus criteria for its diagnosis. The cognitive and behavioral symptoms of KS, which include anterograde and retrograde amnesia, executive dysfunction, confabulation, apathy, as well as affective and social-cognitive impairments, are discussed. Moreover, recent insights into the underlying neurocognitive mechanisms of these symptoms are presented. In addition, the evidence so far on the etiology of KS is examined, highlighting the role of thiamine and alcohol and discussing the continuity hypothesis. Furthermore, the neuropathology of KS is reviewed, focusing on abnormalities in the diencephalon, including the mammillary bodies and thalamic nuclei. Pharmacological treatment options and nonpharmacological interventions, such as those based on cognitive rehabilitation, are discussed. Our review shows that thiamine deficiency (TD) is a crucial factor in the etiology of KS. Although alcohol abuse is by far the most important context in which TD occurs, there is no convincing evidence for an essential contribution of ethanol neurotoxicity (EN) to the development of WE or to the progression of WE to KS. Future research on the postmortem histopathological analysis of brain tissues of KS patients is crucial for the advancement of our knowledge of KS, especially for associating its symptoms with lesions in various thalamic nuclei. A necessary requirement for the advancement of studies on KS is the broad acceptance of a comprehensive definition and definite diagnostic criteria. Therefore, in this review, we propose such a definition of KS and draft outlines for prospective diagnostic criteria.
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Affiliation(s)
- Nicolaas Jm Arts
- Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, Venray.,Neuropsychiatry Center Thalamus, Institution for Integrated Mental Health Care Pro Persona, Wolfheze
| | - Serge Jw Walvoort
- Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, Venray
| | - Roy Pc Kessels
- Centre of Excellence for Korsakoff and Alcohol-Related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, Venray.,Department of Neuropsychology and Rehabilitation Psychology, Donders Institute for Brain, Cognition and Behaviour, Radboud University.,Department of Medical Psychology, Radboud University Medical Center, Nijmegen, the Netherlands
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31
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Jayaprakash B, Rao KN, Patil N, Bhattacharjee D, Maden M, Rau NR. Wernicke's Encephalopathy - 'Pushing the Envelope' of Patient's Profile: A Case Report. Ann Neurosci 2016; 23:188-193. [PMID: 27721589 DOI: 10.1159/000449186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 05/13/2016] [Indexed: 11/19/2022] Open
Abstract
Wernicke's encephalopathy (WE), an acute neuropsychiatric condition, is caused by thiamine deficiency. Traditionally, it has been associated with patients with a background of alcoholism. However, in the past few decades, with increasing trends in the incidence of WE among patients without a history of alcohol consumption, a pressing need was felt to examine the existing guidelines for the management of WE and its sequelae. The need for a revision was felt as the guidelines for the management of WE were developed around the premise that this affliction is observed mainly among alcoholics. In light of the opportunity presented to us by one of our patients who did not 'fit the bill' of a traditional case of WE, we decided to compare and contrast the management of WE among patients with and without a background of alcoholism. After analyzing the available data on WE among alcoholics and non-alcoholics, we concluded that a high degree of suspicion should be kept in mind if any of the classical features are observed, with a special emphasis on eliciting the underlying causes through a detailed history. Furthermore, thiamine supplementation at a lower dose of 100-200 mg should be initiated first, followed by laboratory and radiological investigations.
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Affiliation(s)
- B Jayaprakash
- Department of Medicine, Kasturba Medical College, Manipal Campus, Manipal University, Mangalore, Karnataka, India
| | - Karthik N Rao
- Department of Medicine, Kasturba Medical College, Manipal Campus, Manipal University, Mangalore, Karnataka, India
| | - Navin Patil
- Department of Pharmacology, Kasturba Medical College, Manipal Campus, Manipal University, Mangalore, Karnataka, India
| | - Dipanjan Bhattacharjee
- Department of Pharmacology, Kasturba Medical College, Manipal Campus, Manipal University, Mangalore, Karnataka, India
| | - Mohit Maden
- Department of Pharmacology, Kasturba Medical College, Manipal Campus, Manipal University, Mangalore, Karnataka, India
| | - N R Rau
- Department of Medicine, Yenepoya Medical College, Mangalore, Karnataka, India
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Lerner RK, Pessach I, Rubinstein M, Paret G. Lactic Acidosis as Presenting Symptom of Thiamine Deficiency in Children with Hematologic Malignancy. J Pediatr Intensive Care 2016; 6:132-135. [PMID: 31073437 DOI: 10.1055/s-0036-1587325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/30/2016] [Indexed: 10/21/2022] Open
Abstract
Thiamine is an essential component of cellular metabolism and its deficiency results in potentially life-threatening events and profound lactic acidosis through anaerobic metabolism. Acute decompensation in thiamine-deficient patients may manifest as neurologic or cardiovascular changes, with severe lactic acidosis as the presenting symptom. We describe two hematological pediatric patients with thiamine deficiency and hemodynamic instability who improved following thiamine supplements. Thiamine levels were inversely proportional to lactic acidosis; specifically, lower thiamine levels were related to higher lactate levels. We recommend that children with hematological malignancies admitted to a pediatric intensive care unit with low blood pressure and lactic acidosis should be considered for thiamine-level screening and receive supplementation accordingly.
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Affiliation(s)
- Reut Kassif Lerner
- Department of Pediatrics, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to Tel Aviv University, Ramat Gan, Israel
| | - Itay Pessach
- Pediatric Intensive Care Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to Tel Aviv University, Ramat Gan, Israel
| | - Marina Rubinstein
- Pediatric Intensive Care Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to Tel Aviv University, Ramat Gan, Israel
| | - Gideon Paret
- Pediatric Intensive Care Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to Tel Aviv University, Ramat Gan, Israel
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33
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Isenberg-Grzeda E, Shen MJ, Alici Y, Wills J, Nelson C, Breitbart W. High rate of thiamine deficiency among inpatients with cancer referred for psychiatric consultation: results of a single site prevalence study. Psychooncology 2016; 26:1384-1389. [PMID: 27228202 DOI: 10.1002/pon.4155] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 03/03/2016] [Accepted: 04/17/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Thiamine deficiency (TD) is increasingly recognized in medically ill patients. The prevalence of TD among cancer patients is unknown. This study aims to characterize the prevalence of TD among inpatients with cancer. METHODS Retrospective chart review of patients admitted to a large cancer center who were referred for psychiatric consultation and whose serum thiamine concentration was measured. Patients with alcohol use were excluded. RESULTS Among 217 patients with various cancer types, TD was found in 55.3%. Risk factors included fluorouracil-based chemotherapy, significant weight loss, and undergoing active cancer treatment. Almost all patients were normal weight, overweight, or obese, and few had concomitant vitamin B12 or folate deficiency. A total of 17.5% were receiving multivitamin supplementation. Nearly half (49.8%) did not receive empiric treatment with thiamine and among those who did, treatment delay occurred in the majority of cases (59.6%). Measurement of serum thiamine concentration preceded psychiatric consultation in only 10.6% of cases. CONCLUSIONS Our findings suggest that TD is highly prevalent among inpatients with cancer, even among normal and overweight individuals, in the absence of other vitamin deficiencies, and while receiving multivitamin supplements. Several potential risk factors were identified, including active cancer treatment. Evaluation of TD was most commonly not initiated by oncologists. Failure to treat and treatment delay were common. Given these findings, oncologists must be vigilant about detecting TD among inpatients with cancer. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Elie Isenberg-Grzeda
- Department of Psychiatry, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | | | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan Wills
- Department of Information Systems, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Nelson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Mitoma H, Manto M. The physiological basis of therapies for cerebellar ataxias. Ther Adv Neurol Disord 2016; 9:396-413. [PMID: 27582895 DOI: 10.1177/1756285616648940] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cerebellar ataxias represent a group of heterogeneous disorders impacting on activities of daily living and quality of life. Various therapies have been proposed to improve symptoms in cerebellar ataxias. This review examines the physiological background of the various treatments currently administered worldwide. We analyze the mechanisms of action of drugs with a focus on aminopyridines and other antiataxic medications, of noninvasive cerebellar stimulation, and of motor rehabilitation. Considering the cerebellum as a controller, we propose the novel concept of 'restorable stage'. Because of its unique anatomical architecture and its diffuse connectivity in particular with the cerebral cortex, keeping in mind the anatomophysiology of the cerebellar circuitry is a necessary step to understand the rationale of therapies of cerebellar ataxias and develop novel therapeutic tools.
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Affiliation(s)
- Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, 6-7-1 Nishi-shinjyuku, Shinjyuku-ku, Tokyo, 160-0023, Japan
| | - Mario Manto
- Unité d'Etude du Mouvement (UEM), FNRS, Neurologie ULB-Erasme, Brussels, Belgium Université de Mons, Mons, Belgium
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35
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Sánchez-García M, Vera-Montes de Oca A, Tomoiu I, Delgado-Casado J. Consecuencia del abuso de alcohol. Semergen 2016; 42:199-202. [DOI: 10.1016/j.semerg.2015.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 03/19/2015] [Accepted: 03/23/2015] [Indexed: 11/16/2022]
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Sechi G, Sechi E, Fois C, Kumar N. Advances in clinical determinants and neurological manifestations of B vitamin deficiency in adults. Nutr Rev 2016; 74:281-300. [PMID: 27034475 DOI: 10.1093/nutrit/nuv107] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
B vitamin deficiency is a leading cause of neurological impairment and disability throughout the world. Multiple B vitamin deficiencies often coexist, and thus an understanding of the complex relationships between the different biochemical pathways regulated in the brain by these vitamins may facilitate prompter diagnosis and improved treatment. Particular populations at risk for multiple B vitamin deficiencies include the elderly, people with alcoholism, patients with heart failure, patients with recent obesity surgery, and vegetarians/vegans. Recently, new clinical settings that predispose individuals to B vitamin deficiency have been highlighted. Moreover, other data indicate a possible pathogenetic role of subclinical chronic B vitamin deficiency in neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, and amyotrophic lateral sclerosis. In light of these findings, this review examines the clinical manifestations of B vitamin deficiency and the effect of B vitamin deficiency on the adult nervous system. The interrelationships of multiple B vitamin deficiencies are emphasized, along with the clinical phenotypes related to B vitamin deficiencies. Recent advances in the clinical determinants and diagnostic clues of B vitamin deficiency, as well as the suggested therapies for B vitamin disorders, are described.
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Affiliation(s)
- GianPietro Sechi
- G.P. Sechi, E. Sechi, and C. Fois are with the Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy. N. Kumar is with the Mayo Clinic, Rochester, Minnesota, USA.
| | - Elia Sechi
- G.P. Sechi, E. Sechi, and C. Fois are with the Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy. N. Kumar is with the Mayo Clinic, Rochester, Minnesota, USA
| | - Chiara Fois
- G.P. Sechi, E. Sechi, and C. Fois are with the Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy. N. Kumar is with the Mayo Clinic, Rochester, Minnesota, USA
| | - Neeraj Kumar
- G.P. Sechi, E. Sechi, and C. Fois are with the Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy. N. Kumar is with the Mayo Clinic, Rochester, Minnesota, USA
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Wernicke's Encephalopathy, Wet Beriberi, and Polyneuropathy in a Patient with Folate and Thiamine Deficiency Related to Gastric Phytobezoar. Case Rep Neurol Med 2015; 2015:624807. [PMID: 26697247 PMCID: PMC4677180 DOI: 10.1155/2015/624807] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 10/20/2015] [Indexed: 01/23/2023] Open
Abstract
Background. Wernicke's encephalopathy (WE) is an acute neurological disorder resulting from thiamine deficiency. It is mainly related to alcohol abuse but it can be associated with other conditions such as gastrointestinal disorders. This vitamin deficiency can also present with cardiovascular symptoms, called “wet beriberi.” Association with folate deficit worsens the clinical picture. Subject. A 70-year-old man with gastric phytobezoar presented with gait instability, dyspnoea, chest pain associated with right heart failure and pericarditis, and folate deficiency. Furosemide was administered and cardiac symptoms improved but he soon developed vertiginous syndrome, nystagmus, diplopia, dysmetria, and sensitive and motor deficit in all four limbs with areflexia. Results. A cerebral magnetic resonance imaging (MRI) showed typical findings of WE. He was immediately treated with thiamine. Neurological symptoms improved in a few days and abnormal signals disappeared in a follow-up MRI two weeks later. Conclusion. Patients with malabsorption due to gastrointestinal disorders have an increased risk of thiamine deficiency, and folate deficiency can make this vitamin malabsorption worse. An established deficiency mainly shows neurological symptoms, WE, or rarely cardiovascular symptoms, wet beriberi. Early vitamin treatment in symptomatic patients improves prognosis. We recommend administration of prophylactic multivitamins supplements in patients at risk as routine clinical practice.
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Nonalcoholic Thiamine-Related Encephalopathy (Wernicke-Korsakoff Syndrome) Among Inpatients With Cancer: A Series of 18 Cases. PSYCHOSOMATICS 2015; 57:71-81. [PMID: 26791514 DOI: 10.1016/j.psym.2015.10.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Wernicke-Korsakoff Syndrome (WKS) is a neuropsychiatric syndrome caused by thiamine deficiency. Cancer predisposes to thiamine deficiency through various mechanisms. Although many case reports exist on nonalcoholic WKS in cancer, larger qualitative studies are lacking. METHOD Retrospective study of patients admitted to a cancer hospital and diagnosed with WKS during routine care on a psychiatric consultation service. Only patients with at least 1 additional supporting feature (magnetic resonance imaging findings, low serum thiamine concentrations, or response to treatment) were included. Data pertaining to demographics, risk factors, phenomenology, and outcomes were abstracted from medical records by chart review. RESULTS In all, 18 patients were included. All patients developed WKS during cancer treatment. Hematologic malignancy, gastrointestinal tract tumors, low oral intake, and weight loss were common risk factors. All patients presented with cognitive dysfunction, most commonly impaired alertness, attention, and short-term memory. All were diagnosed by operational criteria proposed by Caine et al., 1997 (where 2 of the following are required: nutritional deficiency, ocular signs, cerebellar signs, and either altered mental status or mild memory impairment). Few exhibited Wernicke's classic triad. Diagnostic and treatment delay were common. Only 3 patients recovered fully. CONCLUSION Nonalcoholic WKS can occur during cancer treatment and manifests clinically as delirium. Diagnosis should be made using operational criteria, not Wernicke's triad. Most patients were not underweight and had normal serum concentration of vitamin B12 and folate. A variety of mechanisms might predispose to thiamine deficiency and WKS in cancer. Given the high frequency of residual morbidity, studies should focus on decreasing diagnostic and treatment delay.
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