A 53-year-old woman presents to the emergency department appearing disheveled, diaphoretic, and anxious, with tremulous hands. Upon examination, she reports being homeless for the past two years and she denies drug use but admits to alcohol use. She thinks the current year is 2008 though it is 2022. She states that she has a history of a “liver issue.” She currently feels nauseous, agitated, and complains of headache that is diffuse. Vital signs have a HR 121, BP 146/82, RR 23, oxygen saturation is 98% on room air. During her evaluation in the ED, she falls on her way to the restroom landing on her buttock. It is noted that her gait is wide and slow. Her head is atraumatic after the fall, but noted to difficulty controlling her eye movements and her oral mucosa is dry.
What is the most likely diagnosis regarding this patient’s presentation?
A) Acute Stroke
B) Methamphetamine intoxication
C) Wernicke encephalopathy
D) Opioid overdose
E) Serotonin syndrome
C) Wernicke encephalopathy
This patient’s presentation is most concerning for Wernicke Encephalopathy (WE) with a medical history of alcohol use and possible liver disease. In a patient with poor nutrition caused by conditions such as chronic alcoholism and anorexia nervosa, Wernicke encephalopathy is a major concern caused by thiamine deficiency that can lead to severe neurological damages. WE is described by the triad of encephalopathy, oculomotor dysfunction, gait ataxia in an alcoholic patient. Patients usually present with a wide, slow, and unsteady gait. Large case series have found that the classic triad is only present in approximately 30% of patients. Looking for all features of the triad will lead to the condition being under-diagnosed or miss-diagnosed.
Key Learning Point
Ataxia usually presents a few days or weeks earlier. Do not look for all features of the triad to diagnose Wernicke Encephalopathy. The disease is difficult to confirm, thus, any patients with presentations concerning for possible Wernicke need to be administered thiamine immediately.
