Rapid Review: Wernicke-Korsakoff Syndrome

This is a new type of post for First10EM. I frequently come across excellent papers that contain just a little too much information for the Articles of the Month reviews, but don’t really fit with the first 10 minutes resuscitation theme of the website. Up until now, I have simply not been sharing the information in these papers, but that seems like a bit of a waste. This is this trial of a new type of post – the rapid reviews – where I will briefly review the key points from a paper I read. Let me know what you think. If it needs to die, this can be the last post. If you like these, I will keep them coming.

Our topic: Wernicke-Korsakoff Syndrome (WKS)

The paper: Sharp CS, Wilson MP, Nordstrom K. Psychiatric Emergencies for Clinicians: Emergency Department Management of Wernicke-Korsakoff Syndrome. The Journal of emergency medicine. 51(4):401-404. 2016. PMID: 27553920

What is it?

A (primarily) neurologic disorder resulting from thiamine (vitamin b1) deficiency.

What are the symptoms?

The classic triad is mental status changes, ophthalmoplegia, and gait ataxia. However, only 20% of patients will have all three. According to the Caine criteria, you should make the diagnosis if a patient has 2 or more of:

  • Dietary deficiencies
  • Oculomotor abnormalities
  • Cerebellar dysfunction
  • An altered mental status or mild memory impairment

Who gets it?

The condition is probably underdiagnosed, as autopsy studies estimate the prevalence of WKS as 0.4-2.8%. In general, we think of this condition in chronic alcoholics with poor diets. However, there are many other conditions that predispose to WKS. For example, approximately 10% of AIDS patients have signs of WKS at autopsy. You should also consider the diagnosis in patients with hypermetabolic states (eg, hematologic malignancies) and hemodialysis patients.

How should we treat it?

You give thiamine. More than that, there is no evidence based answer. The traditional dose is 100mg PO daily. Some will give 500 mg IV TID for the first 3 days. Others 200 mg IV TID. Others give as much as 1500 mg daily. Really, just making the diagnosis and giving the thiamine is probably all that matters.

Weird Trivia: Although we normally think of WKS as being associated with chronic alcoholism, the first case ever described was actually in a 20 year old non-alcoholic woman. She developed pyloric stenosis after a failed suicide attempt by ingesting sulphuric acid and ultimately developed WKS due to severe malnutrition.

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

8 thoughts on “Rapid Review: Wernicke-Korsakoff Syndrome”

  1. Awesome format. I use the “Getting Things Done” rule that if something is going to take 2 minutes or less I force myself to do it right then. Nice to see informative posts that I don’t have to defer to the Land of Never Opened FOAM.

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  2. Nice post ! Recently reviewed Dutch protocol for prison GP’s – here in the Netherlands we give thiamine 250 IM, plus vitamin C and B complex orally for the first 3 days. There is a case to be made for injection therapy over oral administration : alcoholic gastritis limits oral uptake. Additionally there seems to be a point-of-no-return ( see Lancet Neurology few years back) – catch and treat before that and neurological symptoms will not be permanent. Better safe than sorry. As a jail/prison doc I see a lot of withdrawing alcoholics in ‘forced remission’. Although we immediately distribute oral thiamine we tend to see some WKS cases dispite adequate oral thiamine intake. Hadn’t seen one in over 6 months until last week : homeless, alcoholic, poor self-care, forced remission for a number of days, presented with gait ataxia and slurred speech, remarkable improvement in both speech and balance 3 h post thiamine injection. Catch them early ! kind regards, Tim Peeters MD MSc , prison GP

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    1. Thanks for the comment. I agree that injection therapy is probably preferred for patients with WKS. In the rapid review, I am just trying to capture the key points raised in an article, and these authors point out the lack of evidence to support choosing one modality over another, but we should always use our expertise to interpret the evidence. I think the main point I was trying to make there was that most of us are not working in settings were this is a common diagnosis, so the most important thing to do will be to recognize it and make the diagnosis. Once you have made the diagnosis, you can look up the treatment or ask an expert.

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      1. Totally agree, recognition is most important. I made a quick reference card w/ key symptoms and treatment for our docs. Unfortunately its in Dutch, otherwise I’d share. Found your website last night and am enjoying it

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