Wernicke's encephalopathy after total parenteral nutrition in patients with Crohn's disease

Abstract

Micronutrient deficiencies in Crohn's disease (CD) patients are not uncommon and usually result in a combination of reduced dietary intake, disease-related malabsorption, and a catabolic state. Decreased serum thiamine levels are often reported in patients with CD. Wernicke's encephalopathy (WE) is a severe form of thiamine deficiency that can cause serious neurologic complications. Although WE is known to occur frequently in alcoholics, a number of non-alcoholic causes have also been reported. Here, we report two cases of non-alcoholic WE that developed in two severely malnourished CD patients who were supported by prolonged total parenteral nutrition without thiamine supplementation. These patients complained of sudden-onset ophthalmopathy, cerebellar dysfunction, and confusion. Magnetic resonance imaging allowed definitive diagnosis for WE despite poor sensitivity. The intravenous administration of thiamine alleviated the symptoms of WE dramatically. We emphasize the importance of thiamine supplementation for malnourished patients even if they are not alcoholics, especially in those with CD.

Keywords: Crohn disease; Thiamine; Wernicke encephalopathy.

Fig. 1. Abdominal CT findings. (A) In the horizontal section, CD involvement of the ileocecal valve and terminal ileum is seen. (B) In the horizontal section, multisegmental small bowel wall thickening is found. (C) In the coronal view, a rim-enhancing low-density lesion in the right-side perianal area is seen. (D) In the coronal view, multifocal small bowel wall thickening is also noticed.

Fig. 2. Brain MRI findings. (A) In the horizontal section of a T2-weighed image (T2WI), a high signal intensity lesion is seen at both the right and left sides of the mammillary body. (B) In same scene of the T2WI, a high signal intensity lesion is present at both the right and left tectum. (C) In the horizontal section of the T2WI, the 4th ventricle floor showing a high signal intensity lesion. (D) At the medial thalamus, a high signal intensity lesion is noted.

Fig. 3. Abdominal CT findings. (A) In the horizontal view, a lobulated abscess with an enteromesenteric fistula is noticed. (B) In the horizontal view, a multilobulated abscess in pelvic cavity is seen. (C) In the coronal view, abscess formation in the pelvic cavity is noticed. (D) In the coronal view, tubular tract between the distal ileum and abscess is noticed.

Fig. 4. Brain MRI findings. (A) In the horizontal section of a T2-weighted image (T2WI), a high signal intensity lesion is observed at the inferior colliculus. (B) In the horizontal section of the T2WI, a high signal intensity lesion is seen at the pontomedullary junction.