A 53-year-old woman with history of psoriatic arthritis, latent syphilis, and chronic alcoholism presented with subacute bilateral painless vision decline, and lower extremity weakness with impaired ambulation. 

The neurological exam was pertinent for confabulation, bilateral decreased visual acuity limited to light perception, no ocular or fundus abnormalities, and significant allodynia in bilateral lower extremities. Initial workup revealed elevated ESR of 130 mm/hr, positive treponema pallidum antibody, and negative RPR. Lumbar puncture showed protein of 45 mg/dl (normal 15-45 mg/dL), and non-reactive CSF VDRL. Infectious, autoimmune, paraneoplastic, and demyelinating etiologies were ruled out. Brain MRI showed abnormal FLAIR signaling in bilateral mammillary bodies and around periaqueductal gray matter concerning WE. MRI of orbits showed enhancement surrounding optic nerve suggesting retrobulbar optic perineuritis. Electrodiagnostic testing demonstrated diffuse, axonal sensorimotor polyneuropathy. Due to concerns of WKS she was started on parenteral thiamine 500 mg daily for 3 days, followed by daily 100 mg with significant improvement in vision and allodynia. Unfortunately, thiamine level was tested after receiving the first therapeutic dose and was, therefore, normal. The patient was diagnosed with WKS and discharged to acute rehabilitation with daily thiamine supplementation.