Clinical suspicion for Non Alcoholic Wernicke’s Encephalopathy (NAWE) must guide early treatment to prevent significant neurologic morbidity. We examined 3 patients with NAWE who required management in a Neuro ICU. 

A 35 year old woman with depression and poor oral intake presented with subacute encephalopathy and visual hallucinations. Despite thiamine treatment, she remained comatose and ventilator dependent.

A 59 year old female with gastroparesis presented with 4 months of intractable vomiting followed by coma necessitating intubation. Family eventually withdrew care.

A 50 year old female with prior gastric bypass surgery and depression presented with 1.5 months of decreased oral intake and progressive encephalopathy. Her encephalopathy improved with thiamine, however she remains facility dependent.

MRI findings were consistent with thiamine deficiency: increased FLAIR signals or contrast enhancement in the medial thalami, frontoparietal cortex, or mammillary bodies. All 3 patients were adequately repleted with thiamine. 

Wernicke’s Encephalopathy is a neurological syndrome that requires emergent treatment to prevent death and neurologic morbidity. It typically presents with the classic triad of confusion, ophthalmoplegia and gait ataxia. However only 16% of patients have this classic triad. Frequently described in the setting of chronic alcohol abuse, diagnosis can be challenging in non-alcoholics, especially when the classic triad of symptoms is not present. As a result, this potentially fatal condition is still under-diagnosed. We present a cautionary tale of 3 patients with NAWE, none of whom had classic symptoms. These patients were diagnosed late in their disease course and despite treatment had no significant clinical improvement. Early thiamine supplementation can prevent significant neurologic injury. We urge clinicians to have a high index of suspicion in the appropriate clinical setting, as early diagnosis and intervention can be life saving. While MRI imaging can be a useful adjunct, time to image acquisition may lead to delayed treatment.