Wernicke Encephalopathy
Case #187
A 55-year-old woman with a long history of alcoholism presented to the ED with alcohol intoxication.
She was admitted to the hospital.
After several days in the hospital, she was still confused despite resolution of her intoxication.
Various notes indicated dizziness, diplopia, unsteady gait, and that she was forgetful and vague during conversation.
Initially, these symptoms were easily explained by her alcohol intoxication.
However, when they persisted, the hospitalist (Dr. B) ordered thiamine 100mg PO qday (this occurred on day 12 of hospitalization).
2 days later, symptoms had not improved.
A neurologist was consulted.
He diagnosed Wernicke’s encephalopathy and Korsakoff syndrome.
An MRI was ordered.
It was read as a normal, but a neurology expert witness would later claim that she had bilateral signal changes in the hypothalamus on FLAIR sequences.
She improved somewhat but was ultimately discharged to a nursing home.
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The patient’s daughter was appointed as her guardian.
She filed a lawsuit against the hospital and 8 hospitalists who had cared for her.
The plaintiff’s expert witness wrote the following letter:
The plaintiff also hired a neurologist:
The plaintiff offered to settle the lawsuit for an oddly-specific amount:
After negotiations, a confidential settlement was reached.
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MedMalReviewer Analysis:
Differentiating Wernicke encephalopathy from alcohol intoxication can be challenging because they both can present with confusion, nystagmus and difficulty with ambulation. It’s understandable how this could be missed initially in the ED, but once a patient is sober on the floor and still has these symptoms, the diagnosis should be easier to make. Waiting 12 days to even consider Wernicke encephalopathy and begin treatment is suspicious.
Many hospitalized patients with alcohol intoxication or withdrawal are routinely given thiamine supplementation as a matter of protocol, even if there is no evidence of Wernicke encephalopathy. Admission order sets can make this easy to remember by making thiamine replacement a pre-selected order.
A brief Google search reveals the patient was a nurse who was put on probation by the state board multiple times for intoxication. I wonder if the defense considered raising the issue of contributory negligence by pointing out that her thiamine deficiency was caused by her own actions. This could be a risky move given that a jury might view this as victim-blaming.
I give it to every intox I admit, but otherwise no. is everyone putting IVs in their alcoholics who they plan on discharging?
Is there any substantial harm to thiamine repletion? I've always seen it given as a matter of course (in fact, as part of pre-printed order sets) for alcohol intoxication or withdrawal, and is started in emerge. This strikes me as a bad miss, both from the point of view of the doctors involved, and the system (assuming thiamine isn't part of PPOs).