What is the most likely preventative measure for the neurologic symptoms in a patient with a history of inflammatory bowel disease, recent Clostridium difficile infection, and current presentation of nearly complete ophthalmoplegia, mild ataxia, and increased signal in the paraventricular regions of the thalamus and hypothalamus on T2-weighted images, likely indicating Wernicke's encephalopathy?

From the Guidelines

The most likely intervention to have prevented this patient's neurologic symptoms is D) Oral vitamin B1 (thiamine) supplementation. This patient is presenting with Wernicke encephalopathy, characterized by confusion, ophthalmoplegia, and ataxia, with MRI findings showing increased signal in the paraventricular regions of the thalamus and hypothalamus. Wernicke encephalopathy results from thiamine deficiency, which is common in malnourished patients. This patient has risk factors including malnutrition (low BMI of 17 kg/m²), history of bowel resection affecting nutrient absorption, and recent diarrhea from C. difficile infection further depleting thiamine stores. Thiamine is essential for carbohydrate metabolism, and deficiency leads to neurological damage. Supplementation with thiamine, particularly before administering glucose (which can precipitate or worsen Wernicke encephalopathy in thiamine-deficient patients), would have prevented these neurological symptoms, as supported by guidelines that recommend thiamine supplementation for patients at risk of thiamine deficiency or with clinical suspicion of acute deficiency 1. The other options would not address the underlying thiamine deficiency causing this clinical presentation.

Key points to consider in this case include:

• The patient's malnourished state and history of bowel resection increase the risk of thiamine deficiency.
• Diarrhea from C. difficile infection can further deplete thiamine stores.
• Wernicke encephalopathy is a serious complication of thiamine deficiency that can be prevented with timely supplementation.
• Administration of glucose without thiamine supplementation can precipitate or worsen Wernicke encephalopathy in thiamine-deficient patients, as noted in guidelines for managing patients at risk of thiamine deficiency 1.
• Recent studies highlight the importance of thiamine prophylaxis in preventing Wernicke encephalopathy, especially in patients undergoing bariatric surgery or with other risk factors for thiamine deficiency 1.

From the FDA Drug Label

In the treatment of Wernicke-Korsakoff syndrome, thiamine hydrochloride has been administered IV in an initial dose of 100 mg, followed by IM doses of 50 to 100 mg daily until the patient is consuming a regular, balanced diet. Patients with marginal thiamine status to whom dextrose is being administered should receive 100 mg thiamine hydrochloride in each of the first few liters of IV fluid to avoid precipitating heart failure. The most likely option to have prevented this patient's neurologic symptoms is D) Oral vitamin B₁ (thiamine) supplementation or more specifically, intravenous thiamine supplementation, as the patient has symptoms consistent with Wernicke-Korsakoff syndrome, which is a complication of thiamine deficiency 2.

From the Research

Patient's Condition

The patient is a 62-year-old woman who has been hospitalized for treatment of pneumonia. She developed diarrhea secondary to antibiotic therapy, and stool cultures grew Clostridium difficile. She has a history of inflammatory bowel disease and has had difficulty maintaining her weight since undergoing bowel resection and hemicolectomy 7 years ago.

Neurologic Symptoms

The patient is confused and lethargic, and examination shows nearly complete ophthalmoplegia. She is able to move all extremities but has mild ataxia. An MRI of the brain shows an increased signal in the paraventricular regions of the thalamus and hypothalamus on T2-weighted images.

Possible Prevention of Neurologic Symptoms

Based on the studies, the most likely factor to have prevented this patient's neurologic symptoms is:

• Oral vitamin B1 (thiamine) supplementation 3, 4, 5, 6 The patient's symptoms, including confusion, ataxia, and ophthalmoplegia, are consistent with Wernicke's encephalopathy, a condition caused by thiamine deficiency. The studies suggest that thiamine supplementation can alleviate neurological symptoms, cognitive dysfunction, and brain imaging lesions associated with Wernicke's encephalopathy.

Key Findings

The studies highlight the importance of:

• Early diagnosis and treatment of Wernicke's encephalopathy to prevent permanent neurological morbidity and mortality 3, 4, 5, 6
• Thiamine supplementation as the primary treatment for Wernicke's encephalopathy 3, 4, 5, 6
• Consideration of patient-specific treatment and correction of other biochemical factors, such as magnesium and other B vitamin deficiencies 7