Case Report:
A 22 year old lady, presented with a history of blurring of vision since 6 days. The visual blurring was acute in onset and progressive over 3 days. She was 28 weeks pregnant and had a history of vomiting since 3 months. Clinical examination revealed that, although conscious, she was confused and not oriented to time, place or person. Her bilateral corrected visual acuity was 6/9 bilaterally. There was a bilateral sixth nerve palsy. She was able to stand with minimal support and had stance/ gait ataxia. Further, there were bilateral cerebellar signs on examination.
Fundoscopy revealed bilateral disc edema with retinal hemorrhages (Figure 1: A and B). Her Blood investigations revealed a sodium of 128 meq/ l, potassium of 2.9 meq / l and urine ketone bodies were positive. An echocardiogram done revealed normal cardiac function. A nerve conduction study of all 4 limbs was done, which was normal.
MRI brain done showed flair hyperintensities in bilateral medial thalami, periaqueductal grey matter and mamillary bodies (figure 2). Visual fields showed severe constriction bilaterally (Figure 3 A and B: Right and Left eyes respectively). Thus, a diagnosis of Wernicke’s encephalopathy was made.
The patient was treated with Thiamine parenterally, 500 mg iv on the first day followed by 100 mg intravenously thrice a day for 7 days. Her vision improved dramatically with treatment. The bilateral sixth nerve palsy and cerebellar signs also resolved in 1 week. She was continued on oral thiamine 100 mg twice daily for a month.
The disc edema resolved completely in 1 month (Figure 1 C and D) and visual fields improved too (Figure 3 C and D, Right and Left eyes respectively)