A 42 year old widow presents a one week history of progressive confusion unsteady gait. She works as a barmaid lives in poor social circumstances. On examination she malnourished disorientated. She nystagmus unable abduct either eye. The pupils are sluggish unequal. Ankle jerks are absent but upper limb reflexes are present. Shortly after her admission you are called ward as she become very drowsy collapsed on floor. Investigations on admission were as follows: Haemoglobin 11.4 g/dL MCV 99 fL White count 5.6 x 109/L Platelets 230 x 109/L Serum sodium 129 mmol/L Serum potassium 3.2 mmol/L Serum bilirubin 27 umol/L
25
Serum gamma GT 440 IU/L Serum alkaline phosphatase 180 IU/L Serum AST 90 IU/L Serum ALT 45 IU/L Serum albumin 33 g/L Prothrombin time 12 sec (Control 11.5 – 15.5 sec)
What was likely cause of her presentation drowsiness?
1 ) Hyponatraemia
2 ) Brain stem CVA
3 ) Central pontine myelinolysis
4 ) Liver failure
5 ) Wernicke‟s encephalopathy
Comments: This lady presents classic triad of WE (encephalopathy, gait ataxia occulomotor dysfunction). Lower limb neuropathy also a feature of WE. Her occupation, poor nutrition, social situation, results all suggest underlying alcoholism. The hyponatraemia mild unlikely cause symptoms CPM (related rapid correction of Na+) unlikely. A brainstem CVA unlikely due gradual onset over 2 weeks. Liver function appears well preserved (normal PT reasonable Albumin).