A 56 years old female patient presented with a few weeks of persistent nausea, vomiting, watery diarrhea, generalized itching and unintentional weight loss. She denied alcohol intake. Labs showed mild hypercalcemia at 10.6 mg/dl. Abdominal examination was benign. Investigations revealed hypercalcemia with pancreatitis. Thyroiditis was also evident with positive thyroid stimulating antibodies. Her pancreatitis was managed conservatively and was presumed to be biliary origin, and a cholecystectomy was pursued. Methimazole at low dose was started after surgery. Persistent nausea and vomiting prompted Esophagogastroduodenoscopy (EGD) that was unremarkable. Physical exam showed an erythematous beefy tongue suggestive of glossitis. Vitamin B1 and B6 levels were low. Video fluoroscopy showed oropharyngeal dysphagia. Neurological exam showed diffuse ? weakness, decreased recent and remote memory with poor orientation. CT head was unremarkable. 24 hour electroencephalogram (EEG) was unyielding. Magnetic resonance imaging of the brain showed FLAIR hyperintensity at central pons and bilateral thalami. No disturbances of sodium level was evident. Her mental status continued to worsen rapidly within a few days and she became minimally responsive, hypothermic and hypotensive and as such she was intubated for airway protection. Cerebrospinal fluid analysis was unremarkable. Given the possibility of autoimmune encephalitis, she received empiric plasmapheresis and steroids. Lack of improvement prompted a consideration of thiamine replacement. Repeat MRI after a few days showed improving thalamic hyperintensities with improvement in mentation. Extensive workup was unyielding for malignancy, syphilis, human immunodeficiency virus (HIV), systemic lupus erythematosus (SLE), Sjogren syndrome, scleroderma, paraneoplastic and autoimmune encephalitis panels. Extubation was feasible after placement of tracheostomy and percutaneous endoscopic gastrostomy. Over the course of over one month, improvement was evident as she was able to speak with partial regain of muscle power with daily thiamine supplement.

This case serves to remind clinicians of the uncommon link between hyperthyroidism and non alcoholic Wernicke’s encephalopathy (WE). Intractable vomiting and poor oral intake can be the main presentation of hyperthyroidism. This, along with hypermetabolic state in hyperthyroidism, can induce rapid thiamine depletion. It also reminds us of atypical manifestations of WE.