Suffering from Wernicke Korsakoff Syndrome - Essay Example

CASE PATHOPHYSIOLOGY The Patient is suffering from Wernicke Korsakoff Syndrome. It is a neurological or brain disorder. It is prevalent in alcoholics. It occurs due to thiamine deficiency. Thiamine is also known as vitamin B1. Vitamin B1 deficiency can result due to alcoholism, decreased dietary intake of vitamin B1 and people suffering from malabsorption of food which may occur for example after obesity surgery. Wernicke Korsakoff Syndrome is actually a combination of Wernicke’s encephalopathy and Korsakoff syndrome. In Wernicke’s encephalopathy the thalamus and hypothalamus of the brain are damaged. Korsakoff syndrome results from damage of the memory related brain areas (Dudgale, 2010). Therefore Wernicke’s encephalopathy can be called the acute phase and Korsakoff syndrome the chronic phase. Vitamin B1 is responsible for producing energy for the brain by metabolizing glucose. An impairment of this function due to any reason such as thiamine deficiency leads to decreased oxygen supply to the brain especially the thalamus and mammillary bodies and hence causes the brain damage. Mammillary bodies are part of the hypothalamus. There are neuronal connections between the hippocampus and the mammillary bodies. Then the neuronal connections extend from the mammillary bodies to the thalamus and then to the cortex of the brain. Memories are formed in the hippocampus and then stored in the cortex through this route. This is how damage to these areas of the brain in Wernicke Korsakoff syndrome leads to memory loss particularly anterograde amnesia. This means that memories of the distant past are remembered and available, while new memories cannot be formed, thereby leading to immediate forgetting of the recent events. The patient remembers events of the past before the illness but not after he started suffering from Wernicke Korsakoff syndrome (Barry, 2006). Without treatment Wernicke’s Korsakoff syndrome keeps on getting worse and can be life threatening. Its treatment is symptomatic and thus involves controlling the symptoms. In addition thymine is also given. Alcohol consumption maybe stopped. In addition to this drugs like donepezil and rivastigmine are also prescribed. These drugs are used in Alzheimer’s disease, but have been found to work effectively in Wernicke Korsakoff syndrome patients too. Antidepressants which increase levels of serotonin in the brain have been found to be very useful too. In order to prevent Wernicke Korsakoff syndrome, a person should control his drinking problem if he is a heavy drinker. He can reduce the drinking and just drink in moderation. Quitting drinking is the best thing to do in this case. But if a person cannot quit drinking then he should take thiamine supplements and consume a good diet. This will reduce the risk of Wernicke Korsakoff syndrome considerably but not eliminate it completely. Symptoms Symptoms of acute phase or Wernicke’s symptoms: 1. Loss of muscle co-ordination There will be loss of muscle co-ordination due to damage to the brain. This may include tremors of limbs especially leg tremors. 2. Confusion The patient will appear to be confused. This may mislead a person to think that the patient has severe alcohol intoxication. However these effects are present even after the alcohol intoxication wears off. This is an important differentiating point. 3. Abnormal Eye Movements There will be abnormal eye movements in the patient. An explanation for this is that in Wernicke’s encephalopathy the regions of the brain making connections with the nerves controlling the eye muscles maybe damaged. 4. Eye lid drooping Eye lid drooping may also result due to brain and nerve damage controlling the eye muscles. 5. Double vision Double vision may also result as a result of Wernicke’s encephalopathy. Symptoms of chronic phase or Korsakoff syndrome are all memory related and these include the following: 1. Loss of memory In a patient with Korsakoff syndrome there is loss of memory after the illness. This is because the patient suffers from anterograde amnesia. Retrograde amnesia which is the loss of memory of distant past is very rare in these patients. But the anterograde amnesia can be very severe. 2. Inability to form new memories In Korsakoff syndrome the patient suffers from inability to form new memories. This is due to the brain damage to the mammillary bodies and the thalamus, which are involved in the memory storage pathway. Hence new memory cannot be stored in the brain cortex and the patient suffers from anterograde amnesia. 3. Hallucination The patient may also hallucinate. He may see or hear things that aren’t actually there and respond to them. 4. Confabulation This is a term used for making up stories. As the patients of Korsakoff syndrome suffer from anterograde amnesia, this together with confusion leads to them making up stories, especially to the questions they cannot find answers to. This includes questions from their present situation. They tend to confuse their past of which they have memory of with their present (Kopelman MD 1995). In addition to the above symptoms the following may also be observed in Wernicke Korsakoff syndrome: 1. Impairment of fine motor functions There is an impairment of fine motor functions. This means that hand or finger movements maybe diminished. 2. Sense of smell In patients suffering from Wernicke Korsakoff syndrome, the sense of smell may also be affected. 3. Alcohol withdrawal symptoms There may also be symptoms of alcohol withdrawal. These may include anxiety or nervousness, depression, difficulty thinking clearly, fatigue, irritability or easy excitability, jumpiness or shakiness, nightmares, rapid emotional changes, clammy skin, enlarged (dilated) pupils, headache, insomnia (sleeping difficulty), loss of appetite, nausea and vomiting, pallor, rapid heart rate, sweating, tremor of the hands or other body parts, agitation, delirium tremens -- a state of severe confusion and visual hallucinations, fever and seizures (Merrill, 2010). PATIENT ASSESSMENT There are three signs which are checked by doctors in a patient in order to diagnose him with Wernicke’s encephalopathy. These are: mental confusion, ataxia and eye movement disorders. If these three signs are present then the patient is surely that of Wernicke’s encephalopathy (Solange 2001). In order for the diagnosis of Korsakoff syndrome, the sign which is checked for is anterograde amnesia. This is the primary sign for Korsakoff syndrome. This is checked along with a history of chronic alcoholism or heavy drinking over a long period. In addition to these investigations the following is a complete examination which is performed: 1. Eye movements These will be abnormal. 2. Reflexes Reflexes will be decreased or abnormal. 3. Heart rate Heart rate will be fast or rapid. 4. Body temperature Body temperature will be low. 5. Muscle weakness There will be loss of tissue mass and atrophy. 6. Blood pressure The blood pressure will be low. 7. In co-ordination The gait or walk will be slow and there will be muscle Inco-ordination. 8. Serum vitamin B1 levels The serum vitamin B1 levels are checked for thiamine deficiency and hence also a confirmation for Wernicke’s Korsakoff syndrome. 9. Serum albumin Serum albumin levels are checked to see the level of general nutrition. Whether there is malnutrition involved or not. 10. Transketolase activity in red blood cells This is an enzyme in red blood cells, whose activity is reduced in people suffering from thiamine deficiency. 11. AIDS, Cancers, heart failure and thyrotoxicosis may also lead to thymine or vitamin B1 deficiency. Jack Freeling’s Case Following were the observations present in Jack Freeling on examination: 12. Heart rate – 96 and irregular Normal heart rate is around 72 beats per minute for an average person. Here the heart rate is increased and has gone up to 96 beats per minute. This happens in Wernicke’s syndrome. 13. Blood Pressure – 210/105 The normal blood pressure is 120/90. But here both the systolic and the diastolic pressure appear to be raised considerably. 14. Respiratory rate – 14 with snoring Normal respiratory rate is 14-18 breaths per minute. Therefore the respiratory rate seems to be normal but does not correspond with the high blood pressure and the high heart rate and is inconsistent with that. As the heart rate and blood pressure have increased, the respiratory rate should have been higher too. 15. Capillary refill - < 2 seconds Capillary refill is a test performed to check the blood supply to the tissues and also to check dehydration. In this test pressure is applied on the nail bed and then left. The time is noted for the blood to get back there. This is indicated by the nail bed becoming pink again instead of white. This also helps to check for hypothermia, shock and peripheral vascular disease. The normal value for capillary refill is 2 or less than 2 seconds. In this case the capillary refill value is normal. 16. GCS (Glasgow coma scale) ‐ 12 (E4:V3:M5) In Glasgow coma scale a patient is rated out of 15. A reading of less than 3 suggests vegetative state, in the range of 3-8 suggests severe disability, and 9-12 suggests mild disability. In this case where there is mild disability means that there is loss of consciousness greater than 30 minutes, physical or cognitive impairments which may or may not resolve and benefit from rehabilitation. The scale may not be useful for brain injury victims with special conditions that limit his or her ability to respond (Glasgow coma scale 2009). 17. Pupils – L4 slow/R3+ This suggests that the eye movements are not normal. These abnormal eye movements are also a sign of Wernicke’s syndrome. This maybe a result of damage of the brain areas making connections with the nerves supplying the muscles of the eye. The nerve supplying the pupils may also be damaged. 18. Skin – warm, flushed and mildly sweaty The peripheral blood flow of the patient has increased, leading to warm and flushed skin. This has also enhanced the process of sweating, and the patient is mildly sweaty. 19. ECG – AF The electrocardiogram of the patient is not normal and shows atrial fibrillation. 20. BGL – 8.1 The blood glucose level of the patient is 8.1. It is the amount of glucose in the blood of the patient. The normal value is from 4-8. Therefore the blood glucose level of the patient is normal. DIFFERENTIAL DIAGNOSIS ‘It is the process of weighing the probability of one disease versus that of other diseases possibly accounting for a patients illness’ (Definition of differential diagnosis 2002). Alzheimer’s disease In Alzheimer’s disease there is also loss of memory. ‘Alzheimers disease (AD) is a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception.’ (Crystal 2009). In Alzheimer’s disease in addition to loss of memory the patient may often experience confusion, loss of judgment, and difficulty finding words, finishing thoughts, or following directions. The patient may also become agitated and irritable. In some people the sense of vision, smell and taste can also be affected. All these symptoms are very similar to that of Wernicke Korsakoff syndrome. Therefore careful examination must be done to differentiate a patient of Alzheimer’s disease from that of Korsakoff syndrome. Wernicke Korsakoff syndrome In Wernicke Korsakoff syndrome there is memory loss just like in Alzheimer’s disease. The patient also experiences confusion and vision problems. All these things are quite similar to Alzheimer’s disease. This may mislead the doctor to the wrong diagnosis. But there are a few symptoms that can be used to separate the two. In Wernicke Korsakoff syndrome there will be abnormal eye movements. The reflexes of the body will be decreased or abnormal. Heart rate is generally increased or rapid in a patient of Wernicke Korsakoff syndrome. There is muscle weakness and the gait or walk is slow. Inco-ordination is a major complaint. The patient suffers from muscle Inco-ordination. Hand or finger movements may also be diminished, and is known as impairment of fine motor functions(C Toth 2001) The sense of smell of the patient may also be affected. There may also be alcohol withdrawal symptoms. Serum vitamin B1 levels will be low too. Transketolase activity in the red blood cells will also be reduced due to thiamine deficiency. The most important factor in the differentiation of the two diseases is the history of the patient. Alzheimer’s disease occurs in very old patients usually after the age of 70 years and is a slowly progressing disease. Wernicke Korsakoff syndrome is basically composed of 2 phases. The acute phase is the Wernicke’s encephalopathy, while the chronic phase is the Korsakoff syndrome. Most importantly, a patient of Wernicke Korsakoff syndrome usually has a history of alcoholism and/or malnutrition. This really helps in the diagnosis of the patient (Sechi and Serra 2007). Hence, a patient presenting with these symptoms can be diagnosed properly and correctly and treatment given accordingly. PREHOSPITAL INTERVENTIONS Prehospital interventions are the measures taken by the doctors or the paramedical staff before the patient gets to the hospital. Initially the patient’s medical and psychiatric condition is assessed. In an alcoholic patient the airway, breathing and circulation is stabilized. Then short acting benzodiazepines can be given for seizures. And lastly the electrolyte imbalances are corrected. This may include acidosis. In addition to this nutritional supplements may also be given orally. If the nutritional supplements are not taken orally then they may be given through the IV route. Intravenous fluids may also be administered if required (Domino FJ 2006). In a patient of Wernicke Korsakoff syndrome, he is instantly administered a dose of thiamine. Thiamine is either injected in the patient or given by mouth. In case of injection the thiamine is administered in a vein or a muscle. This is very helpful and helps to improve many symptoms. Confusion or delirium is improved. The difficulties that the patient was experiencing with vision and eye movement are also improved and abnormal eye movements can be controlled. The lack of muscle co-ordination is another symptom of Wernicke Korsakoff syndrome which is also improved a lot by the administration of thiamine. Then another symptom that needs to be treated instantly is atrial fibrillation. Atrial fibrillation can be treated with different drugs including digitalis, diltiazem, verapamil and ß-adrenergic blockers. All these are very effective drugs in the management of atrial fibrillation. All these things or measures should be enough to save the life of the patient. These measures are taken before the patient gets to the hospital. One more thing that is done is that the patient is evaluated on the Glasgow coma scale. It is a scale in which points are given out of 15. The more points the patient scores, the better it is. Points are distributed depending on various parameters and responses by the patient. A score of less than 3 is alarming and indicates vegetative state. A score of 3-8 is also alarming and is an indication of severe disability. While a score of 9-12 is an indication of mild disability. Attempt should be made to improve the Glasgow coma scale reading of the patient. All the steps taken above are aimed at improving the condition of the patient. These measures also lead to improvement of the Glasgow coma scale reading of the patient. Mentioned above were the pre hospital interventions that should be taken in a patient of apparent alcohol intoxication and of Wernicke Korsakoff syndrome. Reference List Accetta, SG, Abeche, AM, Buchabqui, JA, Hammes, L, Pratti, R, Afler, T & Capp E 2001, Memory loss and ataxia after hyperemesis gravidarum: a case of Wernicke–Korsakoff syndrome, Elsevier. Barry, D 2001, Wernicke Korsakoff syndrome, viewed 2 October 2010, C Toth & C Voll 2001, Wernickes Encephalopathy Following Gastroplasty for Morbid Obesity. The Canadian Journal of Neurological Sciences, CJNS. Crystal, H (2010) Alzheimer’s disease, viewed 2 October 2010, Definition of differential diagnosis 2002, viewed 2 October 2010, Domino FJ 2006, management of Wernicke kosakoff syndrome, Five minute clinical consult, Lippincott Williams and Wilkins. Dudgale, DC 2010, Wernicke Korsakoff syndrome, viewed 2 October 2010, Glasgow coma scale 2009, viewed 2 October 2010, Kopelman MD 1995, The Korsakoff Syndrome, The British journal of psychiatry, London, The Royal College of Psychiatrists. Merrill, DB 2010, Alcohol withdrawal, viewed 2 October 2010, Sechi GP, Serra A 2007, Wernickes encephalopathy: new clinical settings and recent advances in diagnosis and management, The Lancet Neurology, vol. 6, no. 5. Italy. Elsevier Read More