Thiamine is an essential vitamin that plays a vital role in energy metabolic pathways. Deficiency can lead to an array of symptoms, involving the neurological, cardiac, & gastrointestinal systems. Here we present a case reflecting the importance of recognizing & treating thiamine deficiency, especially in a young, malnourished female.

A 21-year-old female with anxiety & recent cholecystectomy presented with double vision, headache, & generalized weakness. She reportedly had multiple hospitalizations for recurrent nausea & vomiting secondary to cannabinoid hyperemesis syndrome. 2 months prior, she underwent cholecystectomy due to recurrent nausea & new-found gastroparesis, without clinical improvement. 7 days prior to presentation, developed double vision & headache. On presentation she was alert & oriented, however at rest noted to have exotropia & incomplete horizontal gaze movements; decreased hearing on the left, & hip flexor weakness. Initial MRI Brain w/wo contrast & spinal imaging was normal. On day 2, a change in mental status & hypotension required emergent intubation. EKG showed diffuse T-wave inversions, troponinemia, & generalized spike & wave discharges on EEG. Her initial echocardiogram revealed a depressed ejection fraction. She underwent a lumbar puncture without evidence of pleocytosis. Repeat MRI revealed T2 hyperintensities of the paramedian thalami, mammillary bodies, periaqueductal gray, & dorsal medulla.  Serum thiamine levels were undetectable & she was subsequently started on IV thiamine.  Over the next 48 hours, she had marked improvement in her mental status, respiratory status, cardiac function, & extraocular movements. Her hearing loss resolved at the time of extubation. She was discharged in stable condition with progressive improvement in her memory & cognitive function.

This case illustrates the potential for severe thiamine deficiency in the setting of cannaboid hyperemesis syndrome, demonstrating rapid progression of the disease with multitude of neurological symptoms may occur as well as development of wet beriberi. Increase use of cannabinoids raises critical importance to consider thiamine deficiency in all patients with a history of hyperemesis.