title: Wernicke's encephalopathy in a malnourished surgical patient: a difficult diagnosis.
abstract: BACKGROUND
  Wernicke's encephalopathy is an acute neurological disorder resulting from thiamine deficiency mainly related to alcohol abuse. Severe thiamine deficiency is an emerging problem in non-alcoholic patients and it may develop in postoperative surgical patients with risk factors.
  
  
  METHODS
  We reported a case of a 46 years old woman who underwent, one year before, to cephalic duodenopancreatectomy complicated with prolonged recurrent vomiting. She underwent to a second surgical operation for intestinal sub-occlusion and postoperatively she developed septic shock and hemorrhagic Wernicke's disease. After ICU admission, because of neurological deterioration, she underwent CT scan and MRI that highlighted a strong suspicion for Wernicke's disease. We treated her with an initially wrong low dose of thiamine, then after MRI we increased the dosage with a neurological status improvement. Despite therapeutic efforts used to control septic shock and thrombocytopenia, she died on the 21st day after surgery because of massive cerebral bleeding and unresponsive cerebral edema.
  
  
  CONCLUSIONS
  Early detection of subclinical thiamine deficiency is a difficult task, as symptoms may be nonspecific. Wernicke's disease remains a clinical diagnosis because there are no specific diagnostic abnormalities revealed in cerebrospinal fluid, electroencephalogram or evoked potentials. About this, the best aid for a correct diagnosis is the clinical suspicion and clinicians should consider the disorder in any patients with unbalanced nutrition, increased metabolism or impaired food absorption. A hallmark of our case was the brain hemorrhage in the typical areas of the Wernicke's disease, maybe triggered by the thrombocytopenia secondary to sepsis. It might be a good clinical practice administer thiamine to all patients presenting with coma or stupor and risk factors related with thiamine deficiency. Any therapeutic delay may result in permanent neurological damage or death.
authors.affiliation: Cattedra di Anestesia e Rianimazione, Policlinico di Modena, Università di Modena e Reggio Emilia, Modena, Italy. stefanobusani7@gmail.com.
authors.forename: Stefano
authors.initials: S
authors.lastname: Busani
authors.forename: Cinzia
authors.initials: C
authors.lastname: Bonvecchio
authors.forename: Arianna
authors.initials: A
authors.lastname: Gaspari
authors.forename: Marcella
authors.initials: M
authors.lastname: Malagoli
authors.forename: Alessandra
authors.initials: A
authors.lastname: Todeschini
authors.forename: Nicola
authors.initials: N
authors.lastname: Cautero
authors.forename: Massimo
authors.initials: M
authors.lastname: Girardis
mesh_terms: D001929:Brain Edema / Q000209:etiology; D002543:Cerebral Hemorrhage / Q000209:etiology; D019587:Dietary Supplements; D013505:Digestive System Surgical Procedures / Q000009:adverse effects*; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D009752:Nutritional Status; D011237:Predictive Value of Tests; D012307:Risk Factors; D012772:Shock, Septic / Q000209:etiology; D013831:Thiamine / Q000627:therapeutic use; D013832:Thiamine Deficiency / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014899:Wernicke Encephalopathy / Q000175:diagnosis* / Q000209:etiology
chemical_list: D013831:Thiamine