Starvation-induced diplopia and weakness: a case of beriberi and Wernicke’s encephalopathy

A 56-year-old teetotaller man with hypertension and gout presented with a week duration of painless worsening diplopia on a background of loss of weight and appetite, generalised lethargy and weakness for 1 year. On examination, he was noted to be hypothermic and tachycardic with generalised muscle...

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Bibliographic Details
Published in:BMJ case reports 2019-01, Vol.12 (1), p.e227412
Main Authors: Tan, Timothy Xin Zhong, Lim, Kheng Choon, Chan Chung, Charles, Aung, Than
Format: Article
Language:English
Subjects:
Acidosis
Alcoholism
Anemia
Beriberi - complications
Beriberi - diagnosis
Case reports
Diagnosis, Differential
Diplopia - diagnosis
Diplopia - etiology
Hemoglobin
Humans
Iron
Magnetic Resonance Imaging - methods
Male
Middle Aged
Muscle Weakness - diagnosis
Muscle Weakness - etiology
Neuroimaging
Nutrition
Rare Disease
Rare Diseases
Rheumatism
Thiamine - administration & dosage
Thiamine - therapeutic use
Thiamine Deficiency - complications
Treatment Outcome
Vitamin B
Vitamin B Complex - administration & dosage
Vitamin B Complex - therapeutic use
Vitamin deficiency
Wernicke Encephalopathy - complications
Wernicke Encephalopathy - diagnostic imaging
Wernicke Encephalopathy - pathology
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Summary:A 56-year-old teetotaller man with hypertension and gout presented with a week duration of painless worsening diplopia on a background of loss of weight and appetite, generalised lethargy and weakness for 1 year. On examination, he was noted to be hypothermic and tachycardic with generalised muscle wasting. Proximal myopathy, lower limb fasciculations and areflexia, restricted bilateral eye abduction and nystagmus were observed. Blood investigations demonstrated compensated lactic acidosis, acute kidney injury and leucocytosis. A nerve conduction study showed severe length-dependent axonal sensorimotor polyneuropathy. This was a diagnostic dilemma until an MRI brain revealed symmetrical signal abnormality and enhancement in the periaqueductal area indicative of Wernicke’s encephalopathy, caused by thiamine deficiency from poor nutrition. Beriberi, also caused by thiamine deficiency, accounted for his tachycardia, polyneuropathy, areflexia, hypothermia and biochemical abnormalities. Both beriberi and Wernicke’s encephalopathy are medical emergencies, which were treated with intravenous thiamine to good effect.
ISSN:1757-790X
1757-790X
DOI:10.1136/bcr-2018-227412