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Journal of Clinical Oncology, Vol 22, No 19 (October 1), 2004: pp. 4020-4022 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.12.020
Medical Problems in Patients With MalignancyCASE 2. Wernicke's Encephalopathy: An Unusual Acute Neurologic Complication of Lymphoma and Its TherapyLineberger Comprehensive Cancer Center and Departments of Medicine and Radiology, The University of North Carolina School of Medicine, Chapel Hill, NC A 37-year-old woman presented with retroperitoneal adenopathy, bilateral ureteral obstruction, hydronephrosis, and marked lactic dehydrogenase elevation. A diffuse, large B-cell lymphoma was diagnosed by excisional biopsy. Her initial presentation was also remarkable for protracted, severe nausea that antedated chemotherapy administration. After percutaneous ureteral stenting and nephrostomy tube placement, the patient was treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) plus rituximab (R-CHOP) with a good response. Her ureteral obstruction resolved, and her lactic dehydrogenase level normalized after the first cycle of therapy. She continued to have significant nausea despite aggressive antiemetic therapy, but managed adequate oral intake to avoid dehydration and remain an outpatient. She lost 40 lbs (25% of total body weight) during her first two cycles of chemotherapy, though a portion of this weight-change was related to decreasing edema and tumor burden. Before her third cycle of R-CHOP, a family member found her obtunded with disconjugate gaze, and she was brought to the emergency department for evaluation. She was afebrile, her electrolytes and calcium were normal, and a lumbar puncture demonstrated no pleocytosis. Emergent magnetic resonance imaging of the brain was performed and demonstrated abnormal enhancement of the floor of the third ventricle and mammillary bodies (Figs 1A and C) —findings consistent with Wernicke's encephalopathy. The patient was treated with intravenous and then oral thiamine, with rapid resolution of her opthalmoplegia and radiographic improvement (Fig. 1B and D). Further questioning of family members revealed that the patient had a significant history of alcohol use, though the patient and family both stated that she had not used alcohol for 3 months before her diagnosis. The patient resumed R-CHOP after major improvement of her confusional state (1 week after thiamine replacement), though return to her baseline cognitive function required 2 additional months after thiamine replacement.
Wernicke's encephalopathy is a medical emergency.1 It is a result of thiamine deficiency. The triad of ophthalmoplegia, ataxia, and global confusion is found in only one-third of presenting patients. Untreated, it can be complicated by coma and death. Some patients do not recover completely, with residual neurologic sequelae that consist of a confabulatory state with impairment in recent memory and learning ("Korsakoff's syndrome"). Wernicke's encephalopathy can be precipitated by the administration of intravenous fluids containing glucose. Thiamine should be administered with fluids to any patient in which the diagnosis is suspected.1 Thiamine deficiency is now rare in the United States, and is predominantly associated with poor diet in the setting of chronic alcohol abuse. Nonalcoholic thiamine deficiency is predominantly associated with prolonged periods of malnourishment, such as in hyperemesis gravidarum or after gastric surgery.2-4 In this patient, the combination of nutritional deficiency related to prior alcohol use, poor dietary intake from her refractory nausea, and high-grade lymphoma, precipitated dramatic but reversible Wernicke's encephalopathy. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES 1. Reuler JB, Girard DE, Cooney TG: Current concepts: Wernicke's encephalopathy. N Engl J Med 312:1035-1039, 1985[Medline]
2. Abarbanel JM, Berginer VM, Osimani A, et al: Neurologic complications after gastric restriction surgery for morbid obesity. Neurology 37:196-200, 1987 3. Flannelly G, Turner MJ, Connolly R, et al: Persistent hyperemesis gravidarum complicated by Wernicke's encephalopathy. Ir J Med Sci 159:82, 1990[Medline] 4. Ogershok PR, Rahman A, Nestor S, et al: Wernicke encephalopathy in nonalcoholic patients. Am J Med Sci 323:107-111, 2002[Medline]
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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