Abstract Details

Title Bilateral Hemorrhagic Disc Edema is not always Papilledema: An unusual presentation of Wernicke’s Encephalopathy

Topic Neuro-ophthalmology/Neuro-otology

Presentation(s) Neuro-ophthalmology/Neuro-otology Posters (7:00 AM-5:00 PM)

Poster/Presentation
Number 020

Background Thiamine is an essential cofactor of enzymes involved in glucose metabolism. The deficiency of this vitamin is classically associated with the triad of WE (acute confusional state, ataxia, and oculomotor dysfunction). However, in rare instances, ocular manifestations may go beyond motor dysfunction, with optic disc edema and retinal hemorrhages observed in about 4% and 2% of WE cases, respectively. This is potentially underestimated due to lack of recognition.

Objective To describe a case of Wernicke's encephalopathy (WE) with an unusual presentation of rapid bilateral vision loss, optic-disc edema, and peripapillary hemorrhages with rapid improvement of vision after thiamine supplementation.

Design/Methods Case report and literature search.

Results 45-year-old female with a history of gastric bypass 17-years ago presented to the ophthalmology clinic with 2-weeks of rapidly progressive, painless bilateral vision loss. Visual acuity was light perception bilaterally, and fundoscopy showed optic-disc edema with peripapillary hemorrhages bilaterally. She was sent to the emergency room for neurological evaluation. She had chronic diarrhea, intractable vomiting, and a 25-pound weight loss over the past month. Neurological examination was significant for mild disorientation, bilateral ocular abduction deficits, gaze-evoked nystagmus, absent ankle jerks, symmetric diminished sensation below the knees, and marked truncal ataxia. Magnetic resonance imaging of the brain revealed symmetric hyperintense signal in the bilateral medial thalami, periaqueductal gray matter, and mamillary bodies. The clinical and imaging findings were consistent with WE. She was treated with high dose parenteral thiamine with significant improvement in the visual acuity and ophthalmoplegia the next day and was back to baseline by day four. Serum thiamine level obtained prior to treatment resulted later and confirmed low level of 41 nmol/L (normal range 70-180 nmol/L).

Conclusions

WE is usually a reversible condition when promptly treated. A high index of suspicion is needed to diagnose WE, particularly when presentation is atypical such as in our case.

Authors/Disclosures
Salman Tarique, MD (University of Mississippi Medical Center) PRESENTER	Dr. Tarique has nothing to disclose.
Prashant Natteru, MBBS (Mayo Clinic Health System)	Dr. Natteru has nothing to disclose.
Zachary Goodwin, MD (University of Mississippi Medical Center)	Dr. Goodwin has nothing to disclose.
Juebin Huang, MD, PhD (University of Mississippi Medical Center)	Dr. Huang has nothing to disclose.
Manasa Gunturu, MD (University of MS Medical Center)	Dr. Gunturu has nothing to disclose.