Alcohol Induced Neurocognitive Impairment (Wernicke - Korsakoff): A Hidden Syndrome
Clinical Medicine Research
Volume 4, Issue 2-1, April 2015, Pages: 15-23
Received: Dec. 23, 2014;
Accepted: Dec. 28, 2014;
Published: Feb. 8, 2015
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Prabhoo Dayal, National Drug Dependence Treatment Centre (WHO Collaborating centre), All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi-110029, India
Ankur Sachdeva, National Drug Dependence Treatment Centre (WHO Collaborating centre), All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi-110029, India
Mina Chandra, Department of Psychiatry and Drug De-addiction, Post Graduate Institute of Medical Education & and Research (PGIMER) and Dr Ram Manohar Lohia Hospital, New Delhi-110001, India
Kishore Hindustani, Department of Psychiatry, VMMC and Safdarjang Hospital, New Delhi, India
Kuljeet Singh Anand, Department of Neurology, Post Graduate Institute of Medical Education & and Research (PGIMER) and Dr Ram Manohar Lohia Hospital, New Delhi-110001, India
Wernicke’s encephalopathy (WE) is an acute neuro-psychiatric syndrome due to inadequate supply of thiamine (vitamin B1) to the brain which leads to significant morbidity and mortality. Although alcohol use is the most common predisposing factor but Wernicke’s encephalopathy can occur in any patient with nutritional deficiency conditions such as hyperemesis gravidarum, hemodialysis, malignancy, use of total parenteral nutrition without adequate thiamine, and abdominal surgery. In a developing country, there are more chances of thiamine deficiency, because of poor intake of nutrients in routine diet due to economic reasons and local customs and cultural practices concerning the processing and cooking of rice and other foodstuffs. The national household survey of drug use in India (2004) found prevalence of alcohol use in about 21.4% of male population between 18-40 age group. Most of the emergency physicians and general practitioners are not well sensitized about neuropsychiatric disorders in patients with alcohol use disorders. Such patients are still under diagnosed. Till date, no such studies are available about treatment of wernicke-korsakoff syndrome in Indian population. Educating clinicians, specially emergency physicians about evaluation and treatment of Wernicke-Korsakoff syndrome is as important as to educate people to eat well balanced, mixed diet containing thiamine rich food as most of these patients receive emergency treatment but are frequently unrecognized. If undiagnosed or inadequately treated, it is likely to proceed to Korsakoff syndrome. Therefore best treatment for Wernicke-Korsakoff syndrome is prompt diagnosis and adequate treatment.
Kuljeet Singh Anand,
Alcohol Induced Neurocognitive Impairment (Wernicke - Korsakoff): A Hidden Syndrome, Clinical Medicine Research. Special Issue: Recent Research in Dementia.
Vol. 4, No. 2-1,
2015, pp. 15-23.
Campbell ACP, Russel WR. Wernicke's encephalopathy: the clinical features and their probable relationship to vitamin B deficiency. Q J Med 1941; 10: 41-64.
Ihara M, Ito T, Yanagihara C, et al. Wernicke’s encephalopathy associated with hemodialysis: report of two cases and review of the literature. Clin Neurol Neurosurg. 1999; 101:118-121.
Wagener H, Weir J. Ocular lesions associated with postoperative and gestational nutritional deficiency. Am J Ophthalmol. 1937; 20:253-59.
Toth C, Voll C. Wernicke’s encephalopathy following gastroplasty for morbid obesity. Can J Neurol Sci. 2001; 28:89-92.
Michowitz Y, Copel L, Shiloach E, et al. Non-alcoholic Wernicke’s encephalopathy: unusual clinical findings. Eur J Intern Med.2005; 16:443-44.
Munir A, Hussain SA, Sondhi D, et al. Wernicke’s encephalopathy in a non-alcoholic man: case report and brief review. Mt SinaiJ Med. 2001; 68:216-18.
Chiossi G, Neri I, Cavazzuti M, et al. Hyperemesis gravidarum complicated by Wernicke encephalopathy: background, case report, and review of the literature. Obstet Gynecol Surv. 2006; 61:255-68.
Harper C. The incidence of Wernicke’s encephalopathy in Australia—a neuropathological study of 131 cases. J Neurol Neurosurg Psychiatry. 1983; 46:593-98.
Harper C. Wernicke’s encephalopathy: a more common disease than realised. A neuropathological study of 51 cases. J Neurol Neurosurg Psychiatry. 1979; 42:226-31.
Bleggi-Torres LF, de Medeiros BC, Werner B, et al. Neuropathological findings after bone marrow transplantation: anautopsy study of 180 cases. Bone Marrow Transplant. 2000; 25:301-07.
Torvik A. Wernicke’s encephalopathy—prevalence and clinical spectrum. Alcohol Alcohol Suppl. 1991; 1:381-84.
Boldorini R, Vago L, Lechi A, et al. Wernicke’s encephalopathy:occurrence and pathological aspects in a series of 400 AIDS patients. Acta Biomed Ateneo Parmense. 1992; 63:43-49.
Harper CG, Giles M, Finlay-Jones R. Clinical signs in the Wernicke-Korsakoff complex: a retrospective analysis of 131 cases diagnosed at necropsy. J Neurol Neurosurg Psychiatry 1986; 49: 341-45.
Lana-Peixoto MA, Dos Santos EC, Pittella JE. Coma and death in unrecognized Wernicke’s encephalopathy. An autopsy study. Arq Neuropsiquiatr. 1992; 50:329-33.
Vasconcelos MM, Silva KP, Vidal G, et al. Early diagnosis of pediatric Wernicke's encephalopathy. Pediatr Neurol 1999; 20: 289-94.
Torvik A, Lindboe CF, Rogde S. Brain lesions in alcoholics. A neuropathological study with clinical correlations. J Neurol Sci.1982; 56:233-48.
Harper CG, Sheedy DL, Lara AI, et al. Prevalence of Wernicke-Korsakoff syndrome in Australia: has thiamine fortification made a difference? Med J Aust. 1998; 168:542-45.
Naidoo DP, Bramdev A, Cooper K. Autopsy prevalence of Wernicke’s encephalopathy in alcohol-related disease. S Afr Med J. 1996; 86:1110-12.
Victor M, Adams RD, Collins GH. The Wernicke-Korsakoff Syndrome and Related Neurologic Disorders Due to Alcoholism and Malnutrition. 2nd ed. Philadelphia, PA: FA Davis; 1989.
Victor M. The Wernicke-Korsakoff syndrome. In: Vinken PJ, Bruyn GW, eds. Handbook of clinical neurology, vol 28, part II. Amsterdam: North-Holland Publishing Company, 1976: 243-70.
Victor M, Adams RD, Collins GH. The Wernicke-Korsakoff syndrome: a clinical and pathological study of 245 patients, 82 with post-mortem examinations. Contemp Neurol Ser 1971; 7: 1-206.
Blass JP, Gibson GE. Abnormality of a thiamine requiring enzyme in patients with Wernicke-Korsakoff Syndrome. N Engl J Med 1977; 297: 1367-70.
Harper C, Fornes P, Duyckaerts C, et al. An international perspective on the prevalence of the Wernicke-Korsakoff syndrome. Metab Brain Dis 1995; 10: 17-24.
Thomson AD, Marshall EJ. The natural history and pathophysiology of Wernicke's encephalopathy and Korsakoff's psychosis. Alcohol Alcohol 2006; 41: 151-58.
Guerrini I, Thomson AD, Cook CC, et al. Direct genomic PCR sequencing of the high affinity thiamine transporter (SLC19A2) gene identifies three genetic variants in Wernicke Korsakoff syndrome (WKS) AmJ Med Genet B Neuropsychiatr Genet. 2005; 137:17–19.
Guerrini I, Thomson AD, Gurling HM. Molecular genetics of alcohol related brain damage. Alcohol and Alcoholism. 2009; 44:166–70.
Singleton CK, Martin PR. Molecular mechanisms of thiamine utilization. Curr Mol Med 2001; 1: 197-207.
Thomson AD. The absorption of sulphur-labelled thiamine hydrochloride in control subjects and in patients with intestinal malabsorption. Clinical Science 1966; 31(2): 167–79.
Thomson AD, Baker H, Leevy CM. Patterns of 35S-thiamine hydrochloride absorption in the malnourished alcoholic. Journal of Laboratory and Clinical Medicine 1970; 76(1): 34–45.
Thomson AD, Jeyasingham M, Pratt OE, et al. Nutrition and alcoholic encephalopathies. ActaMedicaScandinavica. Supplementum. 1987; 717: 55–65.
Thomson AD. Mechanisms of vitamin deficiency in chronic alcohol misusers and the development of the Wernicke-Korsakoff Syndrome. Alcohol and Alcoholism. 2000; 35(1):2–7.
Thomson AD, Marshall EJ. The treatment of patients at risk of developing Wernicke's encephalopathy in the community. Alcohol and Alcoholism. 2006; 41:159–67.
Harper C, Dixon G, Sheedy D, et al. Neuropathological alterations in alcoholic brains. Studies arising from the New South Wales Tissue Resource Centre. Prog Neuropsychopharmacol Biol Psychiatry. 2003; 27:951–61.
Thomson AD, Cook CCH, Touquet R, et al. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke’s encephalopathy in the Accident and Emergency Department. Alcohol and Alcoholism. 2002;37:513–21.
Zieve I. Influence of magnesium deficiency on the utilization of thiamine. Ann NY Acad Sci 1969; 162: 732-43.
Traviesa DC. Magnesium deficiency: a possible cause of thiamine refractoriness in Wernicke-Korsakoff encephalopathy. J Neurol Neurosurg Psychiatry 1974; 37: 959-62.
Sauberlich HE, Herman YF, Stevens CO, Herman RH. Thiamine requirement of the adult human. Am J Clin Nutr 1979; 32: 2237-48.
Davis RE, Icke GC. Clinical chemistry of thiamine. Adv Clin Chem 1983; 17: 93-140.
Thomson AD, Cook CCH, Touquet R,et al. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke's encephalopathy in the accident and emergency department. Alcohol Alcohol Suppl 2002; 37: 513-21.
Tanphaichitr V. Thiamin. In: Shils ME, Olson JA, Shike M, Ross AC, eds. Modern Nutrition in Health and Disease. Baltimore MD: Williams and Wilkins, 1999: 381-89.
Leevy CM. Thiamin deficiency and alcoholism. Ann N Y Acad Sci 1982; 378: 316-26.
Schenker S, Henderson GI, Hoyumpa AM, et al. Hepatic and Wernicke's encephalopathies: current concepts of pathogenesis. Am J Clin Nutr 1980; 33: 2719-26.
Manzo L, Locatelli C, Candura SM, et al. Nutrition and alcohol neurotoxicity. Neurotoxicology 1994; 15: 555-65.
Iwata H. Possible role of thiamine in the nervous system. Trends Pharmacol Sci 1982; 4: 171-73.
McCandless DW, Schenker S, Cook M. Encephalopathy of thiamine deficiency: studies of intracerebral mechanisms. J Clin Invest 1968; 47: 2268-80.
Butterworth RF. Cerebral thiamine-dependent enzyme changes in experimental Wernicke's encephalopathy. Metab Brain Dis 1986; 1: 165-75.
Hazell AS, Pannunzio P, Rama Rao KV, et al. Thiamine deficiency results in downregulation of the GLAST glutamate transporter in cultured astrocytes. Glia 2003; 43: 175-84.
Collins GH. Glial cell changes in the brain stem of thiamine-deficient rats. Am J Pathol 1967; 50: 791- 814.
Robertson DM, Wasan SM, Skinner DB. Ultrastructural features of early brain stem lesions of thiamine-deficient rats. Am J Pathol 1968; 52: 1081-97.
Hakim AM, Pappius HM. Sequence of metabolic, clinical, and histological events in experimental thiamine deficiency. Ann Neurol 1983; 13: 365-75.
Hazell AS, Todd KG, Butterworth RF. Mechanisms of neuronal cell death in Wernicke's encephalopathy. Metab Brain Dis 1998; 13: 97-122.
Navarro D, Zwingmann C, Hazell AS, et al. Brain lactate synthesis in thiamine deficiency: a re-evaluation using 1H-13C nuclear magnetic spectroscopy. J Neurosci Res 2005; 79: 33-41.
Matsushima K, MacManus JP, Hakim AM. Apoptosis is restricted to the thalamus in thiamine-deficient rats. Neuroreport 1997; 8: 867-70.
Desjardins P, Butterworth RF. Role of mitochondrial dysfunction and oxidative stress in the pathogenesis of selective neuronal loss in Wernicke's encephalopathy. Mol Neurobiol 2005; 31: 17-25.
Chan F, Butterworth RF, Hazell AS. Primary cultures of rat astrocytes respond to thiamine deficiency-induced swelling by downregulating aquaporin-4 levels. Neurosci Lett 2004; 366: 231-34.
Jung YC, Chanraud S, Sullivan EV. Neuroimaging of Wernicke's encephalopathy and Korsakoff's syndrome. Neuropsychol Rev. 2012; 22(2):170-80.
Brust JCM. Ethanol and cognition: indirect effects, neurotoxicity and neuroprotection: a review. International Journal of Environmental Research Public Health. 2010; 7:1540–57.
Wood B. Thiamin status in Australia. World Review of Nutrition and Dietetics. 1985; 46:148–218.
Victor M, Adams RD (1985). The alcoholic dementias. In P. J. Vinken, G. W. Bruyn, & H. L. Klawans (Eds.), Handbook of clinical neurology (Vol 46, pp. 335–353). Amsterdam: Elsevier.
Reuler JB, Girard DE, Cooney TG. Current concepts. Wernicke’s encephalopathy. N Engl J Med. 1985; 312:1035-39.
De Keyser J, Deleu D, Solheid C, et al. Coma as presenting manifestation of Wernicke’s encephalopathy. J Emerg Med.1985; 3:361-63.
Kearsley JH, Musso AF. Hypothermia and coma in the Wernicke-Korsakoff syndrome. Med J Aust. 1980; 2:504-06.
Donnan GA, Seeman E. Coma and hypothermia in Wernicke’s encephalopathy. Aust N Z J Med. 1980; 10:438-39.
Ackerman WJ. Stupor, bradycardia, hypotension and hypothermia. A presentation of Wernicke’s encephalopathy with rapid response. West J Med 1974; 121:428-9.
Fried RT, Levy M, Leibowitz AB, et al. Wernicke’s encephalopathy in the intensive care patient. Crit Care Med. 1990; 18:779-80.
Thomson AD, Guerrini I, Marshall JE. Wernicke's encephalopathy: role of thiamine. Practical Gastroenterology. 2009; 33(6):21-30.
Caine D, Halliday GM, Kril JJ, et al. Operational criteria for the classification of chronic alcoholics: identification of Wernicke’s encephalopathy. J Neurol Neurosurg Psychiatry. 1997; 62:51-60.
Antunez E, Estruch R, Cardenal C, et al. Usefulness of CT andMR imaging in the diagnosis of acute Wernicke’s encephalopathy. AJR Am J Roentgenol. 1998; 171:1131-37.
Hack JB, Hoffman RS. Thiamine before glucose to prevent Wernicke encephalopathy: examining the conventional wisdom. JAMA. 1998; 279:583-84.
Watson AJ, Walker JF, Tomkin GH, et al. Acute Wernicke’s encephalopathy precipitated by glucose loading. Ir J Med Sci.1981; 150:301-03.
Zimitat C, Nixon PF. Glucose loading precipitates acute encephalopathy in thiamin-deficient rats. Metab Brain Dis. 1999; 14:1-20.
Zimitat C, Nixon PF. Glucose induced IEG expression in the thiamin-deficient rat brain. Brain Res. 2001; 892:218-27.
Weidauer S, Nichtweiss M, Lanfermann H, et al. Wernicke's encephalopathy: MR findings and clinical presentation. Eur Radiol 2003; 13: 1001-09.
Brechtelsbauer DL, Urbach H, Sommer T, et al. Cytomegalovirus encephalitis and primary cerebral lymphoma mimicking Wernicke's encephalopathy. Neuroradiology 1997; 39: 19-22.
Zurkirchen MA, Misteli M, Conen D. Reversible neurological complications in chronic alcohol abuse with hypophosphatemia. Scweiz Med Wochenschr 1994; 124: 1807-12.
Squier MV, Thompson J, Rajgopalan B. Case report: neuropathology of methyl bromate intoxication. Neuropathol Appl Neurobiol 1992; 6: 579-84.
Greenwood J, Love ER, Pratt OE. Carrier mediated transport of thiamine across the blood–brain Barrier. Proceedings of the Physiological Society, Journal of Physiology. 1980; 310:23.
Rindi G, Patrini C, Comincioli V, et al. Thiamine content and turnover rates of some rat nervous regions, using labeled thiamine as a tracer. Brain Research. 1980; 81:369–80.
Rolland S, Truswell AS. Wernicke-Korsakoff syndrome in Sydney hospitals after 6 years of thiamine enrichment of bread. Public Health Nutr 1998; 1: 117-22.
Pratt OE, Jeyasingham M, Shaw GK, et al. Transketolase variant enzymes and brain damage. Alcohol and Alcoholism. 1985; 20:223–32.
Heap LC, Pratt OE, Ward RJ, et al. Individual susceptibility to Wernicke–Korsakoff syndrome and alcoholism induced cognitive deficit: impaired thiamine utilization found in alcoholics and alcohol abusers. Psychiatric Genetics. 2002; 12:217–24.
Nakada T, Knight RT. Alcohol and the central nervous system. The Medical Clinics of North America. 1984; 68:121–31.
Wood B, Currie J, Breen K. Wernicke’s encephalopathy in a metropolitan hospital: a prospective study of the incidence, characteristics and outcome. Medical Journal of Australia 1986; 144: 12–16.
Lingford-Hughes AR, Welch S, Nutt DJ. Evidence based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. J Psychopharmacology. 2004; 18:293–335.
Galvin R, Brathen G, Ivashynka A, et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke Encephalopathy. European Journal of Neurology. 2010; 17:1408–18.
NICE (2011). Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Clinical Guideline 115. London: NICE.
Cook CCH, Hallwood PM, Thomson AD. B-vitamin deficiency and neuro-psychiatric syndromes in alcohol misuse. Alcohol Alcohol Suppl 1998; 33: 317-36.
Cook CC. Prevention and treatment of Wernicke-Korsakoff Syndrome. Alcohol Alcohol Suppl 2000; 35: 19-20.
Bligh JG, Madden JS. Managing alcohol dependence. Practitioner 1983; 227: 82-85.
Wrenn KD, Murphy F, zidovudine Slovis CM. A toxicity study of parenteral thiamine hydrochloride. Ann Emerg Med 1989; 18: 867-70.
Wrenn KD, Slovis CM. Is intravenous thiamine safe?. Am J Emerg Med 1992; 10: 165.
Leitner ZA. Untoward effects of vitamin B. Lancet 1943; 2: 474-75.
Stein W, Morgenstern M. Sensitization to thiamine hydrochloride: report of a case. Ann Int Med 1994; 70: 826-28.