Dr Kalpana received her MBBS from the National University of Singapore. She subsequently applied for Junior Residency in the field of Internal Medicine, and completed her post-graduate MRCP (M.Med) examinations in 2015. She is now a Senior Resident in the Department of General Medicine in a tertiary hospital in Singapore.
A Case Report: The Lady Who Forgot Her Pregnancy - Thiamine Deficiency In A Non-Alcoholic Patient
Dr Kalpana Vijakumar, Tan Tock Seng Hospital Singapore
Abstract: Thiamine deficiency leading to Wernicke’s Encephalopathy (WE) and progressing to Wernicke-Korsakoff Syndrome (WKS) is a continuum that has been well-studied in alcoholic patients. Besides alcoholism, other risk factors have been described that also lead to thiamine deficiency and WKS. Timely identification of WE are hindered because most patients do not fulfil classical diagnostic criteria. We aim to highlight the importance of a high clinical index of suspicion to reduce the burden of this reversible condition.
Case report: A young lady was urgently referred to Internal Medicine by her obstetrician for acute encephalopathy in the 18th week of gestation. 2 months prior, she had been hospitalised and treated for hyperemesis gravidarum. Her symptoms of daily vomiting and anorexia had recurred after discharge, but she did not seek further medical attention until they progressed to marked disorientation and memory loss. At presentation, she was noted to confabulate her history; in fact, she even denied being pregnant. Her family reported no fever, visual disturbances or imbalance. Of note, she had no significant alcohol intake or drug history.
On examination, she was afebrile and alert. There was significant anterograde and retrograde amnesia, but no oculomotor or cerebellar signs. She had no signs of meningism and other cognitive domains remained intact. Magnetic resonance brain imaging and initial biochemistry were unremarkable, and foetal monitoring was reassuring.
Based on her predisposition to dietary deficiencies from protracted vomiting, and presentation of altered mental status (AMS), we started treatment with high dose intravenous thiamine at 500mg thrice daily as for Wernicke’s encephalopathy. Subsequently her confusion and memory impairment resolved. She stopped vomiting, and her appetite improved. After a week, she was discharged with oral thiamine until delivery.
Discussion: This patient did not fulfil the classical triad of AMS, ophthalmoplegia and ataxia typically described in WE. However, she did have a predisposing factor of severe hyperemesis gravidarum. This led to prompt intervention and may have averted permanent neurological deficits in both mother and child.
In conclusion, a good understanding of all possible risk factors for WKS needs to be coupled with a high index of suspicion to diagnose and treat it effectively.