Objective:

To describe a case of Wernicke encephalopathy with atypical MRI findings showing enhancement involving bilateral globi pallidi. 

Background:

Thiamine deficiency, commonly as a result of malnourishment associated with alcohol dependence, can cause Wernicke encephalopathy, a neuropsychiatric syndrome that presents with a triad of ophthalmoplegia, altered mental status, and ataxia. Brain MRI typically shows contrast enhancement of the thalamus and mammillary bodies.  

Design/Methods:

Case Study

Results:

In March 2022, a 55-year-old man with a history of alcohol dependence, hypertension, atrial fibrillation, kidney failure, sleep apnea, and obesity presented to our neurology clinic for initial evaluation and follow-up of a previous hospitalization in October 2021 for symptoms of Wernicke encephalopathy. Brain MRI obtained at his hospitalization showed edema and contrast enhancement with restricted diffusion involving the bilateral globi pallidi. He had been drinking 750 mL of bourbon every other day for about 10 years. He noted that his symptoms had improved with thiamine supplementation but still endorsed left unilateral gait instability. He denied carbon monoxide poisoning, exposure to insecticides/pesticides or other toxins. Lab results confirmed this and showed no evidence of exposure to toxins that are known to be associated with insults involving the globus pallidus.  His review of systems was positive for weakness and confusion. Physical examination was notable for some impairment of finger-to-nose test, difficulty in sustaining rapid alternating movements, and a broad-based but stable gait. We recommended that the patient continues thiamine supplementation and physical therapy.  

Conclusions:

Wernicke encephalopathy is associated with atrophic changes involving the mammillary bodies and thalamus, but current literature does not show evidence of changes involving the globus pallidus. The atypical involvement of the bilateral globi pallidi seen in this case demonstrates a need for further research into the role of globus pallidus in the pathogenesis of Wernicke encephalopathy.