Wernicke’s encephalopathy as a mimicker of a Brainstem Relapse in a Multiple Sclerosis Patient (P1.141)

OBJECTIVE: To present a case of Wernicke’s Encephalopathy (WE) after bariatric surgery in a multiple sclerosis (MS) patient. BACKGROUND: Thiamine deficiency follows after bariatric surgery in ~18[percnt] of cases. The triad of WE (ophthalmoplegia, ataxia and confusion) may not always present and may be misdiagnosed as a relapse in patients with MS. METHODS: Case Report. RESULTS: 40 year old woman with MS on Glatiramer Acetate developed vomiting and diarrhea 12 weeks after 80[percnt] gastrectomy. Initially diagnosed with viral gastroenteritis she presented with new-onset diplopia, vertigo and ataxia 4 weeks later. Neurologic exam revealed bilateral cranial nerve VI palsy, limited infraduction of the left eye, horizontal nystagmus, and ataxic gait. As she was compliant with vitamin supplementation, including oral thiamine, WE was considered less likely and she was treated with intravenous (IV) methylprednisolone for presumed MS flare. Brain MRI with contrast showed no new or enhancing lesions. Her condition after steroids worsened with vomiting and generalized weakness. In the emergency room at an outside hospital she received IV dextrose for presumed dehydration; but developed acute confusion. A repeated MRI demonstrated DWI, T2 and FLAIR hyperintensities in the bilateral medial thalami, but no abnormalities of the mammillary bodies. Thiamine level in serum was 35 (N 75-185). After 3 doses of 100 mg of IV thiamine her mental status and ophthalmoparesis resolved. At 3 weeks follow up, she had bilateral lower extremity weakness, loss of sensation to vibration/joint position, and ataxic gait. CONCLUSION: Wernicke’s encephalopathy may follow hyperemesis gravidarum, mal-absorptive conditions and after bariatric surgery even with vitamin supplementation. High index of suspicion for WE is required in patients with any of the above conditions and MS, as diplopia, ataxia and nystagmus are commonly observed in brainstem relapses. Proper diagnosis and early treatment with IV thiamine is essential to prevent irreversible neurologic injury. Disclosure: Dr. Antezana has nothing to disclose. Dr. Herbert has received personal compensation for activities with Biogen Idec, Teva, EDM Serono, and Bayer Pharmaceuticals as a consultant. Dr. Kister has nothing to disclose. Dr. Galetta has received personal compensation for activities with Biogen Idec, Genzyme, and Vaccinex.