A 68-year-old man was hospitalized on March 4, 1998 for disturbances in consciousness. In 1995, he had received proximal subtotal
gastrectomy and reconstructive surgery of the jejunal interposition for
gastric cancer. Thereafter he had been taking enough food without the habit of taking liquor. In October 1997, his short term memory was becoming gradually worse. On February 12, 1998, he suffered from
numbness in the feet, and then
dysphagia,
unsteady gait, and
diplopia developed gradually. On February 26, brain MRI showed no abnormalities. On March 3, he had a
fever of 38.5 degrees C and his consciousness became unclear. Neurological examination revealed semi-
coma, total
ophthalmoplegia, and absence of doll's eye movement. Deep tendon reflexes were absent. The serum
thiamine level was 9 ng/ml (normal range: 20-50). Brain MRI demonstrated symmetrical high intensity lesions in the periaqueductal area of the midbrain, dorsomedial nuclei of bilateral thalami, and vestibular nuclei. About 30 seconds after
intravenous infusion of
thiamine, his consciousness improved dramatically, but returned to semi-
coma after about two minutes.
Wernicke-Korsakoff syndrome usually occurs acutely. In the present case, however, the disease showed slow onset, chronic progression, and then rapid worsening after
fever. Reconstructive surgery of the jejunal interposition might have caused the slow onset of
Wernicke-Korsakoff syndrome, and
fever might have facilitated the rapid progression of the disease. An immediate high concentration of
thiamine modifies the kinetics of
acetylcholine receptor ion channels, thereby maintaining wakefulness, and the level of consciousness may change dramatically.