Two Cases of Wernicke's Encephalopathy That Developed during Total Parenteral Nutrition in Colon Cancer Patients Treated with 5-Fluorouracil-based Chemotherapy

Kyung Pyo Cho; Jae Sung Lee; Ji Seok Seong; Yong Moon Woo; Young Jun Cho; Beom Jin Jeong; Jee Hoon Sohn; Su-Jung Kim

doi:10.4166/kjg.2014.64.3.158

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Cho, Lee, Seong, Woo, Cho, Jeong, Sohn, and Kim: Two Cases of Wernicke's Encephalopathy That Developed during Total Parenteral Nutrition in Colon Cancer Patients Treated with 5-Fluorouracil-based Chemotherapy

Case Report

Korean J Gastroenterol 2014;64(3):158-163.

Published online: 4 October 2014

DOI: https://doi.org/10.4166/kjg.2014.64.3.158

Two Cases of Wernicke's Encephalopathy That Developed during Total Parenteral Nutrition in Colon Cancer Patients Treated with 5-Fluorouracil-based Chemotherapy

Kyung Pyo Cho, Jae Sung Lee, Ji Seok Seong, Yong Moon Woo, Young Jun Cho, Beom Jin Jeong, Jee Hoon Sohn¹, Su-Jung Kim¹

Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, Korea

¹Division of Public Health Medical Service, Seoul National University Hospital, Seoul, Korea

Correspondence to: Su-Jung Kim, Division of Public Health Medical Service, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea. Tel: +82-2-2072-0055, Fax: +82-2-2072-0374, E-mail: annie8012@naver.com

Received 16 December 20131 March 2014 Accepted 3 March 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Wernicke's encephalopathy (WE) caused by thiamine deficiency is an acute neurological disorder. Clinically, the classic triad of WE consists of ophthalmoplegia, ataxia, and mental status changes. Thiamine deficiency is known to occur commonly in chronic alcoholic patients. Sometimes, it can occur in patients after gastrointestinal surgery and in those with malabsorption. In addition, patients undergoing renal dialysis, suffering from hyperemesis gravidarum, receiving total parenteral nutrition (TPN), and being treated with chemotherapeutic agents are also prone to develop thiamine deficiency. Herein, we report two cases of WE that developed following simultaneous 5-fluorouracil (5-FU) chemotherapy and TPN in colon cancer patients which was successfully treated with thiamine administration.

Keywords: Wernicke encephalopathy, Thiamine, Total parenteral nutrition, Fluorouracil, Colonic neoplasms

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Fig. 1.

Brain magnetic resonance images. T2 weighted images and fluid attenuated inversion recovery (FLAIR) images show (A) high signal intensity in both medial thalamus and (B) high signal intensity in mamillary body (arrows) and dorsal midbrain (arrow-heads).

Fig. 2.

Brain magnetic resonance images. T2 weighted images and fluid attenuated inversion recovery (FLAIR) images show (A) high signal intensity in anterior precentral gyrus, (B) high signal intensity in both medial thalamus, (C) high signal intensity in the walls of the third ventricle (arrow-heads), periaqueductal gray matter, and dorsal midbrain (arrows), and (D) high signal intensity in mamillary body.

Table 1.

Summary of the Reported Cases of Wernicke's Encephalopathy in Gastrointestinal Tract Cancer Patients in Korea

Authors	Age (yr)/sex	Type	Operation	Chemotherapy	Nutritional support	Neurologic symptoms	Thiamine concentration (ng/mL)	Image study	Thiamine treatment	Outcome
Jung et al.³	48/F	Gastric cancer	Inoperable	Paclitaxel/S-1	TPN	Ataxia, diplopia, nystagmus	Not done	MRI	Yes	Improved
Jung et al.³	58/F	Gastric cancer	Subtotal gastrectomy	FOLFOX-4	Oral	Ataxia, confusion, disorientation, gaze palsy, seizure	Not done	MRI	Yes	Not improved
Kweon et al.⁶	59/M	Gastric cancer	Gastrectomy	Unknown	Oral	Seizure, gaze palsy, nystagmus, ataxia	Unknown	MRI	Yes	Improved
Kim et al.⁷	65/M	Gastric cancer	Total gastrectomy	Unknown	TPN	Ataxia, disorientation, dizziness, nystagmus	7	MRI	Yes	Improved
Kim et al.⁷	71/F	Gastric cancer	Subtotal gastrectomy	Unknown	TPN	Confusion, disorientation, nystagmus	10	MRI	Yes	Improved
Park et al.⁸	42/F	Esophageal cancer and gastric cancer	Esophagectomy and total gastrectomy	Unknown	Oral	Disorientation, dizziness, nystagmus, ataxia	28.7	MRI	Yes	Improved
Lee et al.⁹	72/M	Colon cancer	LAR and partial colectomy	Unknown	Oral and TPN	Coma	Unknown	MRI	Yes	Partially improved
Jung et al.¹⁰	59/F	Gall bladder cancer	Total cholecystectomy	Capecitabine	Oral	Ataxia, dysarthria	Unknown	MRI	Yes	Improved
Present case	60/M	Colon cancer	LAR	FOLFOX	TPN	Ataxia, disorientation, nystagmus	Not done	MRI	Yes	Improved
Present case	35/M	Colon cancer	Total colectomy with ileorectal anastomosis and omentectomy	FOLFOX and bevacizumab	TPN	Stupor, nystagmus	Not done	MRI	Yes	Improved

M, male; F, female; TPN, total parenteral nutrition; LAR, low anterior resection.

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