Undiagnosed Wernicke’s encephalopathy. A case report on hyperactive delirium

Introduction
Wernicke-Korsakoff syndrome can present with persistent altered mental status, delirium and agitation. The cause of Wernicke’s encephalopathy (WE) is primary loss of thiamine in the mammillary bodies of the limbic area of the brain. WE can be seen in nearly 3% of the general population and studies show preva­lence ranging from 13 to 60% in patients with alcohol abuse. Furthermore, it is often clinically under-recognised and thiamine treatment tends to be underutilised in at-risk patients.

Case description
We present a male in his 70s with a past medical history significant for alcohol use disorder who was admitted to hospital for acute metabolic encephalopathy and dizziness. At the physical exam, the patient was noted as having slurred speech, poor short- and long-term memory and horizontal nystagmus with fixed and frequent upward gaze. Hospital treatment was complicated by repeated aggression despite a negative neurological and medical check-up. WE was diagnosed after several days of hospitalisation. The patient improved slowly after multiple weeks of parenteral thiamine supplementation.

Commentary
WE is a medical emergency and if left untreated or treated inappropriately, may result in a life-threatening and irreversible neurological damage and function impairment. While parenteral thiamine is the treatment mainstay for WE, there is little consensus on best dosage, duration or route. The following case report summarises the literature on best treatment for WE. Additional research needs to be conducted on biases leading to misdiagnosis of WE and best treatment regimens for thiamine supplementation.