400 - Putting the Pieces Together: The importance of a good history and physical exam when treating neurological conditions.

Case Diagnosis: Wernicke Encephalopathy and Thiamine Deficiency Peripheral Neuropathy

Case Description: A 40 y/o female with history of obesity s/p gastric sleeve presented with nausea and vomiting associated with lower extremity weakness. On exam patient was noted to have hyporeflexia, ataxia, and ophthalmoplegia. Initial brain/spine MRIs were normal and patient was diagnosed with Guillain Barre Syndrome (GBS) Miller Fisher Variant (MFV). Patient was treated with IV steroids and IVIG for suspected GBS MFV with minimal improvement. Hospital course was complicated by agitation, altered mentation and hallucinations leading to repeat MRIs which revealed abnormal enhancement in periaqueductal gray matter. Lumbar puncture revealed only elevated glucose with normal protein. Patient was then transferred to an inpatient rehabilitation facility (IRF) with a diagnosis of GBS-MFV. Upon chart review we discovered thiamine levels were significantly low, raising concern for accuracy of admission diagnosis. We diagnosed Wernicke Encephalopathy (WE) and Dry Beriberi. Patient was treated accordingly with improvement of neurological deficits and mental status.

Discussions: Clinical manifestations of thiamine deficiency, such as WE and dry beriberi, can present similar to MFV. WE and MFV share oculomotor dysfunction and ataxia as part of their classic diagnostic symptoms. Encephalopathy and limb weakness can be used to help distinguish between these two conditions. Encephalopathy is only seen in WE. Limb weakness has been found to only be present in ¼ of cases of MFV. Medical history is also important to consider as thiamine deficiency typically occurs in patients with bariatric surgery.

Conclusions: Due to similarity in the clinical presentation of these neurological conditions, an appropriate history and physical examination is critical for proper diagnosis, management and assessment of prognosis. Physiatrists, as critical thinkers, play an important role in the diagnosis, management and rehabilitation of these conditions.