A 47 year old woman presented to the emergency room with abdominal pain, decreased oral intake and vomiting. Her past medical history was significant for previous strokes due to a hypercoagulable state requiring anticoagulation, Graves disease, opioid use disorder, and chronic back pain. She had no history of alcohol abuse, diabetes, or diuretic use, and ate a balanced diet despite poor overall oral intake. Admission labs were notable for Na+ 107 mmol/L and a leukocytosis of 23.5 K/mL. She was admitted to the ICU. Her sodium was gradually corrected according to guidelines.
Neurology was consulted for encephalopathy. Initial examination was significant for diffuse weakness, lethargy and disorientation to place and date. There were no eye movement abnormalities. Toxic metabolic encephalopathy due to electrolyte imbalance and infection was presumed; Patient's metabolic picture improved with treatment, but confusion remained. An MRI of brain was performed, which showed FLAIR hyperintensities within the dorsal midbrain, bilateral medial thalami and mammillary bodies, consistent with Wernicke encephalopathy. IV thiamine repletion of 500 mg every 8 hours was initiated, along with niacin repletion. Thiamine level sent prior to repletion showed deficiency with a level of 46 nmol/L , with a lower limit of normal of 70 nmol/L per liter at our institution. Esophagoduodenogram demonstrated gastritis and duodenitis. She was discharged to inpatient rehabilitation with continued thiamine repletion.