A 60-year-old man is brought to the emergency department (ED) because of increasing confusion.* According to his roommate, the patient had not been eating well for about 3 weeks and was drinking less alcohol than usual. When the patient could no longer carry on a coherent conversation and was “acting like a baby,” the roommate took him to the ED.
Past medical history includes coronary artery disease, chronic obstructive pulmonary disease, and a gunshot wound to the left leg. The patient takes no medications, has no allergies, smokes a pack of cigarettes a day, drinks a pint of liquor a day, and smokes marijuana several times a week. He is single and unemployed.
Physical and neurological examination
The patient is cachectic and disheveled. He is afebrile. Blood pressure is 150/110 mm Hg; pulse, 110 beats/min; and respiration rate, 24 breaths/min. He answers questions but is disoriented to person, place, and time. He thinks he is in a restaurant.
He does not cooperate with the neurological examination. Horizontal nystagmus is present bilaterally in the direction of gaze. Otherwise, the results of cranial nerve, motor, reflex, and sensory examination are grossly normal.
Laboratory and imaging studies
A complete blood cell count, electrolyte levels, and metabolic and liver panels are normal. Alcohol level is undetectable. A thyroid panel and vitamin B12 level are normal. Rapid plasma reagin and HIV tests are negative. An urgent head CT scan is normal. An electroencephalogram reveals mild to moderate generalized slowing consistent with a toxic/metabolic encephalopathy.
The patient is given intravenous fluids, multivitamins including thiamine, and acyclovir for possible herpes simplex encephalitis. A lumbar puncture is traumatic and reveals 4 white blood cells, 2000 red blood cells, a protein level of 88 mg/dL, and a glucose level of 57 mg/dL. Gram staining and culture, cryptococcal antigen, and herpes polymerase chain reaction tests are negative. Acyclovir is discontinued.
MRI reveals increased signal in the periaqueductal gray matter (Figure 1) and bilateral thalami (Figure 2), which is suggestive of Wernicke encephalopathy. Thiamine, 100 mg/d, is continued throughout the patient’s hospital stay.
The patient becomes increasingly agitated on hospital day 2 and is treated for delirium tremens with benzodiazepines. He has three generalized tonic-clonic seizures, and phenytoin is started. The patient is unable to feed himself and receives parenteral nutrition. Eventually, he requires a percutaneous endoscopic gastrostomy feeding tube.
Over a period of several weeks, the patient’s level of consciousness slowly improves. After 3 weeks, he can participate in a conversation and follow simple commands but has poor attention and strays off topic. Because he is unable to care for himself, he is discharged to a nursing facility.
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