🧠 Wernicke Encephalopathy: A Neurologic Emergency You Can’t Miss on the USMLE

Wernicke encephalopathy is a reversible but deadly neurological condition caused by thiamine (vitamin B1) deficiency—most commonly seen in alcoholics, but also in malnutrition, hyperemesis gravidarum, and bariatric surgery patients.

Because it's rapidly treatable and has a classic triad, it’s a favorite for USMLE-style questions across all steps.

🧬 The Classic Triad (USMLE Must-Know)

Symptom	Mechanism
Confusion	Brain energy metabolism disruption
Ophthalmoplegia	Cranial nerve dysfunction
Ataxia	Cerebellar damage (esp. vermis)

🧠 Tip: You don’t need all 3 signs for diagnosis—but if you see any in an at-risk patient, treat immediately.

⚠️ Risk Factors

• Chronic alcoholism

• Prolonged vomiting (e.g., hyperemesis gravidarum)

• Malnutrition / starvation

• After glucose administration without thiamine

• Bariatric surgery patients

🔥 USMLE Trick Question: Always give thiamine before glucose in malnourished or alcoholic patients to avoid precipitating Wernicke’s.

🧠 Pathophysiology Recap

Thiamine is a cofactor for several enzymes in carbohydrate metabolism:

• Pyruvate dehydrogenase

• α-Ketoglutarate dehydrogenase

• Transketolase (used in the pentose phosphate pathway)

Without thiamine, neurons can't generate enough ATP → neuronal injury, particularly in the mammillary bodies, thalamus, and cerebellum.

🔬 Imaging (High-Yield Clue)

• MRI may show increased signal in mammillary bodies or medial thalami

• Often a clinical diagnosis—don’t delay treatment for imaging

💉 Treatment: Time is Brain

Step	Action
1	Administer IV thiamine immediately
2	Then give glucose if needed
3	Supportive care and nutrition optimization

📚 USMLE Clinical Vignette Example

A 48-year-old homeless man presents with confusion, a wide-based gait, and horizontal nystagmus. His breath smells of alcohol. What’s the next best step?

✅ Answer: Immediate IV thiamine before any glucose or dextrose administration.

🖼 KOTC Visual Coming Up Next…

We’ll now generate a high-yield 1200x800 visual that summarizes Wernicke’s Triad, pathophysiology, and treatment. Perfect for review or using during your Anki sessions.

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