Chronic Severe Polyradiculoneuropathy with Ophthalmoplegia and Encephalopathy Due to Thiamine Deficiency in a Bariatric Surgery Patient (P7.088)

Background: Bariatric surgery predisposes to thiamine deficiency which manifests as Wernicke’s encephalopathy (WE) and axonal polyneuropathy (APN) that can be reversed with parenteral supplementation. Objective: Reporting simultaneous and irreversible manifestation of WE and APN in a patient with gastric bypass surgery. Case report: A 28 year old woman with hypothyroidism, partial gastrectomy for obesity presented with ascending bilateral leg weakness and paresthesias after a period of decreased oral intake. Within 2 months, she became wheelchair-bound with progressive arm weakness. Two weeks prior to her presentation to an outside hospital she developed diplopia, dysphagia, dysphonia and bowel incontincence. On admission, she had severe respiratory failure requiring intubation. Nerve conduction studies (NCS) showed severe sensorimotor polyradiculopathy with mixed demyelinating and axonal features. Cerebrospinal fluid analysis revealed albuminocytologic dissociation. She failed to respond to 5 days of IVIG given for possible chronic demyelinating inflammatory polyneuropathy (CIDP). Upon transfer to our hospital, her neurological examination revealed bilateral ptosis, restricted horizontal gaze, facial diplegia, and paretic tongue. She was diffusely areflexic and flaccid with 0/5 strength in all muscle groups except deltoid/biceps. Proprioception and vibration was absent in legs. Repeat NCS was consistent with severe diffuse sensorimotor axonal polyradiculoneuropathy. Brain MRI showed FLAIR hyperintensities in the periaqueductal gray matter, mammillary bodies, and medial thalami. With high dose parenteral thiamine she could be extubated, however did not have improved muscle strength. Her neurological examination was unchanged in 3 month follow-up. Conclusion: Our case represents a rare manifestation of thiamine deficiency mimicking chronic dysimmune polyradiculoneuropathy. Patients with history of bariatric surgery should be closely monitored for micronutrient deficiencies and prevention of neurological complications. Disclosure: Dr. Mehaffey has nothing to disclose. Dr. Herlopian has nothing to disclose. Dr. Gundogdu has nothing to disclose.