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Palliative treatment of thiamine-related encephalopathy (Wernicke's encephalopathy) in cancer: A case series and review of the literature

Published online by Cambridge University Press:  23 October 2014

Elie Isenberg-Grzeda Open the ORCID record for Elie Isenberg-Grzeda [Opens in a new window] ,
Alan John Hsu ,
Vaios Hatzoglou ,
Christian Nelso  and
William Breitbart
Elie Isenberg-Grzeda
Affiliation:
Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
Alan John Hsu
Affiliation:
VA San Diego Healthcare System, San Diego, California
Vaios Hatzoglou
Affiliation:
Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
Christian Nelso
Affiliation:
Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
William Breitbart*
Affiliation:
Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
*
Address correspondence and reprint requests to: Elie Isenberg-Grzeda, Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, New York 10022. E-Mail: [email protected]
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Abstract

Objective:

Thiamine-related encephalopathy (Wernicke's encephalopathy) is a neuropsychiatric syndrome caused by a vitamin B1 (thiamine) deficiency often associated with alcoholism. Cancer predisposes patients to thiamine deficiency unrelated to alcoholism, though many cases are missed clinically. The present report adds to the literature on thiamine as a palliative tool for thiamine-related encephalopathy (TRE) in cancer.

Method:

From a larger series of TRE in cancer, we report on three cases with terminal illness.

Results:

Case 1. A 61-year old woman with Hodgkin's lymphoma developed TRE over 13 days. Precipitants included a hypermetabolic state in the background of subacute thiamine deficiency. Diagnosis was supported by abnormal serum thiamine and positive MRI findings. Mental status improved within 36 hours of initiating thiamine 500 mg IV t.i.d. Case 2. A 68-year-old man with colon cancer metastatic to liver and bone developed TRE precipitated by C. difficile–related diarrhea superimposed on 3 months of low appetite and weight loss. Diagnosis was supported by abnormal serum thiamine, and thiamine 500 mg IV t.i.d. was initiated. Improvements in mental status began within 36 hours. Case 3. An 80-year-old man with squamous cell carcinoma developed TRE precipitated by systemic infection in the context of three weeks of dysphagia. Antibiotic treatment did not reverse his cognitive symptoms, and a diagnosis of TRE was made based on operationalized criteria. Thiamine 100 mg IV daily did not reverse his symptoms. On his 30th day of admission, thiamine was increased to 500 mg IV t.i.d., resulting in a rapid reversal of altered mental status.

Significance of Results:

This report adds to the list of cancer types in which TRE/Wernicke's encephalopathy has been reported. It supports the use of higher doses of thiamine than are typically recommended in North America. Improvement following treatment allowed patients to engage with family and treatment teams prior to death.

Keywords

CancerThiamineWernicke's encephalopathyThiamine-related encephalopathyDelirium
Type
Original Articles
Information
Palliative & Supportive Care , Volume 13 , Issue 5 , October 2015 , pp. 1241 - 1249
Copyright
Copyright © Cambridge University Press 2014 

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References

REFERENCES

Antunez, E., Estruch, R., Cardenal, C., et al. (1998). Usefulness of CT and MR imaging in the diagnosis of acute Wernicke's encephalopathy. AJR. American Journal of Roentgenology, 171(4), 1131–1137.Google Scholar
Arana-Guajardo, A.C., Camara-Lemarroy, C.R., Rendon-Ramirez, E.J., et al. (2012). Wernicke encephalopathy presenting in a patient with severe acute pancreatitis. Journal of the Pancreas, 13(1), 104–107.Google Scholar
Boldorini, R., Vago, L., Lechi, A., et al. (1992). Wernicke's encephalopathy: Occurrence and pathological aspects in a series of 400 AIDS patients. Acta Bio-Medica de l'Ateneo Parmense, 63(1–2), 43–49.Google Scholar
Bonucchi, J., Hassan, I., Policeni, B., et al. (2008). Thyrotoxicosis-associated Wernicke's encephalopathy. Journal of General Internal Medicine, 23(1), 106–109.Google Scholar
Caine, D., Halliday, G.M., Kril, J.J., et al. (1997). Operational criteria for the classification of chronic alcoholics: Identification of Wernicke's encephalopathy. Journal of NeurologyNeurosurgery, & Psychiatry, 62(1), 51–60.Google Scholar
de Reuck, J., Sieben, G., De Coster, W., et al. (1981). Prospective neuropathologic study on the occurrence of Wernicke's encephalopathy in patients with tumours of the lymphoid–hemopoietic systems. Acta Neuropathologica Supplementum, 7, 356–358.Google Scholar
Donnino, M.W., Vega, J., Miller, J., et al. (2007). Myths and misconceptions of Wernicke's encephalopathy: What every emergency physician should know. Annals of Emergency Medicine, 50(6), 715–721.CrossRefGoogle ScholarPubMed
Galvin, R., Brathen, G., Ivashynka, A., et al. (2010). EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. European Journal of Neurology, 17(12), 1408–1418.Google Scholar
Hahn, J.S., Berquist, W., Alcorn, D.M., et al. (1998). Wernicke encephalopathy and beriberi during total parenteral nutrition attributable to multivitamin infusion shortage. Pediatrics, 101(1), E10.Google Scholar
Immadisetty, V., Cant, T., Thyarappa, P., et al. (2009). Biomarkers for detecting thiamine deficiency: Improving confidence and taking a comprehensive history are also important. Alcohol and Alcoholism, 44(6), 634.CrossRefGoogle ScholarPubMed
Isenberg-Grzeda, E., Kutner, H.E. & Nicolson, S.E. (2012). Wernicke–Korsakoff syndrome: Under-recognized and under-treated. Psychosomatics, 53(6), 507–516.Google Scholar
Isenberg-Grzeda, E., Chabon, B. & Nicolson, S.E. (2014). Prescribing thiamine to inpatients with alcohol use disorders: How well are we doing? Journal of Addiction Medicine, 8(1), 1–5.Google Scholar
Kleinert-Altamirano, A.P. & Juarez-Jimenez, H. (2014). Wernicke's encephalopathy and Caine criteria: Report of six cases. Revista Médica del Instituto Mexicano del Seguro Social, 52(1), 104–107.Google Scholar
Kuo, S.H., Debnam, J.M., Fuller, G.N., et al. (2009). Wernicke's encephalopathy: An underrecognized and reversible cause of confusional state in cancer patients. Oncology, 76(1), 10–18.Google Scholar
Lishman, W.A. (1981). Cerebral disorder in alcoholism: Syndromes of impairment. Brain, 104(Pt. 1), 1–20.Google Scholar
Lu'o'ng, K.V. & Nguyen, L.T. (2013). The role of thiamine in cancer: Possible genetic and cellular signaling mechanisms. Cancer Genomics & Proteomics, 10(4), 169–185.Google Scholar
Macleod, A.D. (2000). Wernicke's encephalopathy and terminal cancer: Case report. Palliative Medicine, 14(3), 217–218.Google Scholar
Onishi, H., Kawanishi, C., Onose, M., et al. (2004). Successful treatment of Wernicke encephalopathy in terminally ill cancer patients: Report of three cases and review of the literature. Supportive Care in Cancer, 12(8), 604–608.Google Scholar
Palacios-Marques, A., Delgado-Garcia, S., Martin-Bayon, T., et al. (2012). Wernicke's encephalopathy induced by hyperemesis gravidarum. BMJ Case Reports, doi: 10.1136/bcr-2012-006216.Google Scholar
Sechi, G. & Serra, A. (2007). Wernicke's encephalopathy: New clinical settings and recent advances in diagnosis and management. The Lancet Neurology, 6(5), 442–455.CrossRefGoogle ScholarPubMed
Singh, S. & Kumar, A. (2007). Wernicke encephalopathy after obesity surgery: A systematic review. Neurology, 68(11), 807–811.Google Scholar
Thomson, A.D., Cook, C.C., Touquet, R., et al. (2002). The Royal College of Physicians report on alcohol: Guidelines for managing Wernicke's encephalopathy in the accident and emergency department. Alcohol and Alcoholism, 37(6), 513–521.CrossRefGoogle ScholarPubMed
Thomson, A.D., Cook, C.C., Guerrini, I., et al. (2008 a). Wernicke's encephalopathy revisited: Translation of the case history section of the original manuscript by Carl Wernicke, “Lehrbuch der Gehirnkrankheiten für Aerzte und Studirende” (1881), with a commentary. Alcohol and Alcoholism, 43(2), 174–179.Google Scholar
Thomson, A.D., Cook, C.C., Guerrini, I., et al. (2008 b). Wernicke's encephalopathy: “Plus ca change, plus c'est la meme chose.” Alcohol and Alcoholism, 43(2), 180–186.Google Scholar
Thomson, A.D., Marshall, E.J. & Guerrini, I. (2010). Biomarkers for detecting thiamine deficiency: Improving confidence and taking a comprehensive history are also important. Alcohol and Alcoholism, 45(2), 213.Google Scholar
Yae, S., Okuno, S., Onishi, H., et al. (2005). Development of Wernicke encephalopathy in a terminally ill cancer patient consuming an adequate diet: A case report and review of the literature. Palliative & Supportive Care, 3(4), 333–335.Google Scholar
Zuccoli, G., Pipitone, N. & Santa Cruz, D. (2008). Metronidazole-induced and Wernicke encephalopathy: Two different entities sharing the same metabolic pathway? AJNR. American Journal of Neuroradiology, 29(9), E84; author reply E85.Google Scholar