Endocrine Abstracts

Introduction: Wernicke’s encephalopathy is a rare neurological disorder initially described in alcohol-dependent and malnourished patients. It is characterised by confusion, ataxia and nystagmus. It is caused by thiamine deficiency. We report the case of a patient with hyperemesis gravidarum and hashitoxicosis complicated by Wernicke’s encephalopathy

Observation: A 22 year old patient, 1G0P, without any particular pathological history, was admitted to the intensive care unit with incoercible vomiting that had been evolving for one and a half months during a pregnancy estimated at 12 weeks’ gestation, complicated by hydroelectrolytic disorders, in particular hypokalemia at 1.9 mmol/l and hyponatremia at 124 mmol/l. The clinical examination revealed confusion and dysarthria, the patient presented tachycardia at 128 bpm, normal blood pressure at 120/74 mmhg, no exophthalmos, her thyroid was palpable and not enlarged. The initial work-up showed liver cytolysis with ASAT and ALAT levels 4 times normal. Peripheral hyperthyroidism with TSHus < 0.005 µui/ml, T4l: 68 pmol/l. Cervical ultrasound showed a normal sized, homogeneous, normo-vascularized thyroid. Anti-TPO antibodies were positive, while anti-R-TSH antibodies were negative. Brain MRI confirmed the diagnosis of Wernicke’s encephalopathy. Treatment consisted of immediate thiamine administration, correction of fluid and electrolyte disorders, anti-emetic medication, and plasmapheresis for her hyperthyroidism. The clinical evolution was favourable with a normalisation of the ionogram and thyroid function tests.

Discussion: Wernicke’s encephalopathy is an acute condition caused by severe deficiency of thiamine, which is an essential cofactor in many biochemical pathways in the brain. The overall incidence rate of Wernicke’s encephalopathy is 0.04-0.13%. Hyperemesis gravidarum is an uncommon cause of Wernicke’s encephalopathy. Hyperthyroidism is a hypermetabolic state in which thiamine utilisation is increased. This condition may precipitate Wernicke’s encephalopathy in patients with reduced thiamine stores. Wernicke’s encephalopathy due to hyperemesis gravidarum and hyperthyroidism is rare and difficult to diagnose. Its gold standard treatment is urgent thiamine substitution, allowing resolution of symptoms within hours to days depending on the severity of the disease.

Conclusion: Wernicke’s encephalopathy is a potentially reversible disease if diagnosed and treated in time. Hyperthyroidism in patients with hyperemesis gravidarum may precipitate the onset of Wernicke’s encephalopathy.