Title : Seizure As The Main Manifestation of Non Alcoholic Wernicke’s Encephalopathy but Without Cortical Involvement
This is a case report of a 45 years old female patient with a past medical history of depression and poor oral intake presented for a single episode of unwitnessed seizure and 3 days of unsteady gait and vertigo. Then she had two episodes of seizure focal and then generalized tonic. Physical exam was remarkable for lethargy, bilateral gaze induced horizontal nystagmus with rotational component and change in direction. MRI brain with contrast showed non enhancing bilateral symmetrical FLAIR hyperintensities in medial thalami and tectum. Vitamin B1 level was found to be low. Lumbar puncture was unyielding. She was loaded with high dose thiamine replacement. After a few days, a neurological exam revealed improvement with unilateral nystagmus with less lethargy. Valproate that was started initially was eventually discontinued during follow-up after resolution of neurological deficits. Interestingly, a baseline echocardiography showed heart failure with reduced ejection fraction at 40% with clinical euvolemia. It was believed to be secondary to Beri Beri.
This case serves to remind us that seizure can be the main manifestation of Wernicke’s encephalopathy (WE) even without cortical involvement. It also shows that early thiamine replacement can result in significant neurological improvement. We believe this is a good case to report as seizure as initially presentation of WE was reported only in 4 cases in English literature. In this case report, we aim to review what the English literature has to answer the questions of differences between alcoholic and non alcoholic WE, risk factors of non alcoholic WE, typical and atypical MRI findings, and prevalence of seizure and cortical lesion in WE.
What will the audience learn from the presentation ?
- Seizure is a rare but possible initial presentation of WE
- Differences between alcoholic and non alcoholic WE
- Risk factors for non alcoholic WE
- Typical and atypical MRI findings in WE