(031) A Dangerous Obsession: An Adolescent with Wernicke Encephalopathy

‎Background/Significance: Wernicke Encephalopathy (WE) is a well-known neurological complication of ‎malnutrition that is most commonly associated with alcohol use disorder. In pediatric patients, WE is rare, and typically ‎associated with chronic illness. We present a case of Wernicke Encephalopathy in a previously healthy 17-year-old with ‎severe obsessive compulsive disorder. ‎

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Case: GC is a 17 year old female who presented with diplopia, gait instability, and horizontal gaze nystagmus ‎following a 9 month period of restricted eating and a 90 pound weight loss. For approximately 1 year, she avoided ‎leaving her home due to fears of contracting a respiratory illness and dying. She endorsed intense fear of ‎contamination of all foods by nut allergens, despite no personal history of anaphylaxis. Her fear of nut allergen then ‎expanded to a fear of anaphylaxis to any new foods. For 6 weeks prior to presentation, she had avoided all foods, ‎drinking only water. Fundoscopic examination revealed retinal hemorrhage and bilateral papilledema. MRI of the head ‎showed punctate T2 hyperintensities in bilateral cerebral hemispheres, medial thalami, and periaqueductal gray, ‎consistent with Wernicke Encephalopathy. Thiamine, Vitamin D, albumin, magnesium, and phosphorus were all low. ‎GC was admitted to a pediatric hospitalist medicine service, and was diagnosed with obsessive compulsive disorder ‎after psychiatric evaluation. During hospitalization, escitalopram was initiated, and symptoms improved after exposure ‎to novel foods in a monitored setting. ‎

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Discussion: Anorexia nervosa has also been infrequently described as a causative etiology of WE (Oudman, ‎‎2018), and there is literature to suggest that there is underdiagnosis and late recognition of WE in patients with ‎schizophrenia (Oudman, 2021). Adolescent females are at highest risk of being diagnosed with anorexia nervosa ‎‎(Neale, 2020), and thus there may be more anchoring by providers to diagnose a patient such as ours with an eating ‎disorder. Case reports have described Wernicke Encephalopathy in patients with chronic illness and comorbid OCD ‎‎(Sahu, 2020). However, this case, to our knowledge is unique in that it involves a previously healthy adolescent. The ‎severity of this presentation highlights the specific mental health challenges that children and families have faced both ‎during and immediately following the COVID-19 pandemic and subsequent isolation. Our case also highlights the ‎importance of thorough evaluation for psychiatric comorbidities or alternative diagnoses in cases of suspected eating ‎disorder.‎

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References: ‎
Oudman, E., Wijnia, J. W., Oey, M. J., van Dam, M. J., & Postma, A. (2021). Wernicke Encephalopathy in ‎schizophrenia: a systematic review. International journal of psychiatry in clinical practice, 25(3), 233–237. ‎https://doi.org/10.1080/13651501.2020.1819333‎
Oudman, E., Wijnia, J. W., Oey, M. J., van Dam, M. J., & Postma, A. (2018). Preventing Wernicke's ‎encephalopathy in anorexia nervosa: A systematic review. Psychiatry and clinical neurosciences, 72(10), 774–‎‎779. https://doi.org/10.1111/pcn.12735‎
Neale, J., & Hudson, L. D. (2020). Anorexia nervosa in adolescents. British journal of hospital medicine ‎‎(London, England: 2005), 81(6), 1–8. https://doi.org/10.12968/hmed.2020.0099‎
Sahu, M., Beal, M., Chism, K., & Becker, M. A. (2020). Wernicke-Korsakoff Syndrome in a Patient With Celiac ‎Disease and Obsessive-Compulsive Disorder: A Case Report. Psychosomatics, 61(4), 375–378. ‎https://doi.org/10.1016/j.psym.2019.09.007‎