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Case Report: Wernicke-Korsakoff Syndrome
Doyle, R, OMS III. Podolski, J, D.O.
Department of Psychiatry, Eastern Connecticut Health Network, Manchester, Connecticut
Introduction: Wernicke-Korsakoff syndrome is a neurological manifestation of thiamine
deficiency often seen in chronic alcoholics. Wernicke’s encephalopathy (WE) is the first stage
of the disease, presenting with the classic triad of encephalopathy, ophthalmoplegia, and
ataxia. Korsakoff syndrome (KS) is a later stage of the same disease, characterized by
anterograde and retrograde amnesia, confabulation, impairments in attention and
concentration, and lack of insight or complete denial of illness. This case study highlights a
situation where a patient failed to disclose the extent of their alcohol abuse history.
Case: Our patient was a 59-year-old Caucasian man who presented for a scheduled vascular
surgery procedure; namely aortobifemoral bypass for aortic occlusive disease. There was
some indication pre-operatively that the patient had issues with alcohol abuse; however, there
was no documented history of alcohol dependence. Additionally, probably for a multitude of
reasons unknown to this writer, the patient and his family minimized his alcohol use. On
postoperative day two, the patient became confused, lethargic and underwent respiratory
failure requiring intubation. His surgeon quickly identified delirium, and suspecting WE ordered
IM and IV thiamine, along with initiating a Clinical Institute Withdrawal Assessment (CIWA)
with Lorazepam. At that point the patient’s wife disclosed to the treatment team that she
believed her husband was an alcoholic, and that he was frequently abusing alcohol just prior
to surgery. Neurologic and psychiatric consultations provided treatment recommendations for
his WE, however by postoperative day twenty-two he remained ataxic, irritable, unable to
follow simple instructions, disoriented to place and time, and appeared to be responding to
visual hallucinations. At that point Risperidone, an atypical antipsychotic, was added as a
standing dose to his medication regimen. Nursing staff was instructed to utilize atypical
antipsychotics in the place of benzodiazepines for acute agitation due to concerns that the
benzodiazepines were actually disinhibiting him rather than acting favorably towards
behavioral control. Subsequently, with the addition of a second atypical antipsychotic,
Quetiapine, his behavior improved, along with his sleep, appetite, and he was no longer
ataxic. However, he remained inattentive, exhibited profound impairments in retrograde
amnesia, and he began confabulating. At that point the suspected diagnosis of KS was made,
and by postoperative day forty-four, against medical advice, the patient was discharged to the
care of his wife despite recommendations for him to be placed in a rehab facility.
Discussion: Rapid assessment and treatment of thiamine deficiency is paramount in the
prevention of Korsakoff syndrome. This case not only demonstrates the clinical manifestations
of Wernicke-Korsakoff syndrome, but it also highlights several social and psychological factors
that complicated this particular clinical course. Specifically, this case illustrates the social
stigma related to substance abuse and mental health issues, as well as the pathologic
psychological codependency between the patient and his wife (e.g. wife’s enabling of the
patient’s alcoholism).