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A CHALLENGING CASE: WERNICKE ENCEPAHALOPATHY AFTER GASTRIC SLEEVE SURGERY

Wernicke encephalopathy (WE) is a rare and often underdiagnosed complication of gastric bypass surgery. A 16-year-old girl was admitted to the emergency department with vomiting, visual loss and lower extremity weakness. Her symptoms lasted for two weeks, worsened and she became encephalopathic. She was mildly encephalopathic on admission. She had lower extremity weakness (muscle strength was 3/5 proximal, 2/5 distal) with absent deep tendon reflexes. On ophthalmologic examination, bilateral ophtalmoparesis and grade 3 optic disk edema were noted, and vision was finger counting level. Routine blood analysis and contrast-enhanced brain and whole spinal MRI were normal. Pulse methylprednisolon treatment started, but clinical signs and encephalopathy worsened at the third day. The patient was admitted to intensive care uniit with respiratory distress. During follow-up she was entubated. The new MRI revealed T2/FLAIR bilateral thalamic hyperintensity, and EMG showed acute symmetric mixed polyneuropathy. The patient’s new companion stated that she had sleeve gastrectomy surgery three months previously. The diagnosis was WE, intravenous thiamine 1500 mg/day was started. After the second day of treatment; consciousness and ophthalmoparesis improved dramatically and recovered completely on day 5. Thiamine therapy was tapered to maintance dose on the fifth day. However, a tracheostomy was performed one month later. On 5th month of treatment, her tracheostomy cannula was removed and now she is able to sit independently. There is a growing number of obesity and bariatic surgery. Encephalopathy, oculomotor dysfunction, gait ataxia are cardinal symptoms of WE. Rapid diagnosis and treatment with high dose thiamine is life saving.