Abstract Details

Thiamine deficiency can cause Wernicke-Korsakoff Syndrome (WKS), classically described by the triad of altered mental status, ataxia and ophthalmoplegia associated with residual amnestic and behavioral symptoms. Despite WKS being described in association with alcoholism, other causes are well described in the literature, such as gastrointestinal diseases and hyperemesis gravidarum.

A 28-year old woman, with a previous history of achalasia and hyperemesis gravidarum,  was admitted in the emergency department with a one week complaint of dizziness, binocular diplopia and nausea. On the neurologic examination she presented a mild degree of apathy, gait instability, symmetric hyperreflexia and horizontal nystagmus. The Magnetic Resonance Imaging (MRI) was unremarkable and she was discharged with oral prednisone for vestibular neuritis. One week later, she returned to the emergency department owing to persistence of the symptoms and behavioral changes. Her examination revealed involvement of the abducens nerve bilaterally, restricted extraocular motility to lateral gaze and vertical nystagmus. She appeared catatonic, presenting immobility, negativism, waxy flexibility, mutism and fixed gaze. Laboratory tests were normal and a second MRI was performed, demonstrating bilateral and symmetric increased signal in T2/FLAIR-weighted images involving the medial portion of the thalamus, mammillary bodies, periaqueductal area and posterior portion of the brainstem, with mild contrast enhancement. Due to the clinical and MRI findings, the history of achalasia and hyperemesis gravidarum, parenteral thiamine resposition was started. The patient presented significant clinical and radiological improvement, with reduction of the extension and intensity of the increased signal in the previously mentioned areas on brain MRI.

We described an atypical presentation of catatonia in a young patient with non-alcoholic thiamine deficiency. We emphasize that catatonia can occur in metabolic contexts and the clinical suspicion is necessary due to the irreversible impacts associated with late diagnosis.