Abstract Details

A 28-year-old woman, 45 days after childbirth, with recurrent vomiting during pregnancy and medical past of esophagectomy and partial gastrectomy due to idiopathic achalasia, presented in the emergency care unit with subacute onset of diplopia, horizontal nystagmus and vertigo. Her brain MRI was unremarkable. She was evaluated by otorhinolaryngology team and was discharged with diagnosis of vestibular neuritis and treatment with oral prednisone. After one week she returns with behavioral changes. Her examination revealed restricted extraocular motility to lateral gaze, vertical nystagmus, and  she quickly became catatonic. Laboratory tests were initially normal. New brain MRI showed increased signal involving the mammillary bodies, periaqueductal area, and periventricular region of the third ventricle in fluid-attenuated inversion recovery (FLAIR) sequence (Figure 1). A clinical suspicion of thiamine deficiency was made and parenteral thiamine was administered and resulted in significant clinical improvement.

Although the classic neurologic manifestation of thiamine deficiency is Wernicke encephalopathy triad, patients may not fulfill the classic triad of ocular dysmotility, gait ataxia, and mental status changes in early presentations of this disease. While MRI is the imaging modality of choice, it may not necessarily be abnormal and can change over the course of disease. The classic signs of catatonia, which are part of a broad psychopathology, may be found in neurologic metabolic disorders. While thiamine deficiency has often been described in the setting of alcohol use, it can occur in patients with many conditions, as history of gastric surgery and recurrent vomiting during pregnancy.