patients with cancer have several risk factors for wernicke encephalopathy , including the use of chemotherapeutic agents , nutritional imbalance , performance of bypass surgery , and disease progression due to fast - growing tumor cells .
the classical symptoms of wernicke encephalopathy are global confusion , ataxia , and ophthalmoplegia , but only one third of patients present with all of these classical symptoms .
korsakoff syndrome , which is characterized by a chronic , striking loss of working memory , often follows or accompanies wernicke encephalopathy .
although wernicke encephalopathy can be resolved by rapid repletion of thiamine , korsakoff syndrome can not be resolved .
this is the first reported case of wernicke - korsakoff syndrome in a patient with primary peritoneal cancer .
a 76-year - old woman with primary peritoneal cancer and multiple lymph node metastases received 6 cycles of paclitaxel and carboplatin .
six months after her last chemotherapy cycle , she was admitted to the hospital because of sustained nausea and general weakness , which she had experienced for several months .
chest and abdominal - pelvic computed tomography scans showed that peritoneal metastasis and lymph node metastasis had progressed .
four days after admission , she developed disorientation and dizziness , which were followed by ataxia and diplopia .
her laboratory findings were as follows : white blood cell count 6.59  10/l , hemoglobin 12.0 g / dl , hematocrit 35.8% , blood platelet count 230  10/l , serum total protein 6.1 g / dl , albumin 3.3 g / dl , glucose 111 mg / dl , aspartate aminotransferase 21 iu , alanine aminotransferase 14 iu , blood urea nitrogen 9.0 mg / dl , creatinine 0.15 mg / dl , na 139 mm , k 4.6 mm , cl 107 mm , and ca 0.98 mg / dl .
magnetic resonance imaging ( mri ) of the brain showed hyperintensity in the mammillary body , medial aspects of both halves of the thalamus , cerebral aqueduct , tectal plate , and dorsal medulla on t2 fluid - attenuated inversion recovery ( flair ) images ( fig .
the patient 's serum thiamine level was 2.0 g / dl ( normal range 2.07.2 g / dl ) .
thiamine ( 100 mg ) was urgently administered intravenously , and ataxia and diplopia improved 2 days after thiamine injection .
fifteen days after the thiamine injection , she had recovered from her symptoms but displayed anterograde amnesia and disorientation with respect to time .
a follow - up mri scan of the brain showed improvement in the abnormal lesion ( fig .
the classic clinical triad of wernicke encephalopathy comprises nystagmus and ophthalmoplegia , changes in mental status , and ataxia .
predisposing factors for wernicke encephalopathy include a staple diet of polished rice , chronic alcohol abuse , chronic malnutrition , gastrointestinal surgical procedures , recurrent vomiting , chronic diarrhea , cancer , use of chemotherapeutic agents , systemic disease , magnesium depletion , the use of chemical compounds ( including drugs ) , and unbalanced nutrition .
thiamine is an important coenzyme in intermediated carbohydrate metabolism , lipid metabolism , the production of amino acids , and the production of glucose - derived neurotransmitters .
thiamine deficiency mainly results in changes to the macroscopic and microscopic findings of brain lesions .
notably , 100% of patients with wernicke encephalopathy show typical histopathological changes in the medial dorsal thalamic nucleus .
additionally , one third of patients show histopathological changes in the superior vermis of the cerebellum .
several reports have shown that some cases of thiamine deficiency are related to cancer [ 3 , 4 , 5 , 6 , 7 ] .
causes of thiamine deficiency in cancer patients include the use of thiamine by fast - growing neoplastic cells , poor dietary intake ( which is related to appetite and nausea ) , significant malabsorption , and the use of specific types of chemotherapeutic agents . in the present case ,
thiamine deficiency was probably related to fast - growing neoplastic cells and poor dietary intake .
the patient recovered completely from ophthalmoplegia after a few hours , from ataxia after a few days , and from mental changes after 23 weeks of thiamine replacement therapy .
however , irreversible brain damage or death occurs in approximately 20% of cases of wernicke encephalopathy , and the chronic irreversible form of the encephalopathy ( korsakoff syndrome ) is associated with a survival rate of approximately 85% . in the present case ,
however , she developed new symptoms of anterograde amnesia and disorientation with respect to time .
many reports have described cases of wernicke encephalopathy in patients with cancer , but korsakoff syndrome has not been reported in such patients . indeed , this is the first reported case of wernicke - korsakoff syndrome in a patient with primary peritoneal cancer .
in addition , it is difficult to diagnose wernicke encephalopathy if the patient has developed neurologic symptoms related to his or her cancer , because neurologic symptoms in patients with cancer can be related to many factors , such as electrolyte imbalance , cerebral metastasis , chemotherapeutic treatments , infection , and opioid overdose . to diagnose wernicke encephalopathy ,
wernicke encephalopathy is confirmed by measuring blood thiamine concentration or red blood cell transketolase activity . in our case ,
the blood thiamine level was 2.0 g / dl , which is the lower limit of normal .
an isocratic high - performance liquid chromatography method for thiamine , thiamine phosphate , and thiamine diphosphate in human erythrocytes is suitable for diagnosing wernicke encephalopathy , but this test was not available .
mri is a valuable tool for confirming a diagnosis of wernicke encephalopathy ; it has a high specificity of 93% and a sensitivity of 53% . in the present case ,
a follow - up mri scan showed improvement in the previously abnormal findings , but korsakoff syndrome remained .
primary peritoneal cancer is a rare cancer with a behavior that is very similar to epithelial ovarian cancer .
the development of wernicke encephalopathy has been reported in patients with gastrointestinal tract cancer , head and neck cancer , lung cancer , breast cancer , lymphoma , and leukemia ; however , wernicke - korsakoff syndrome has not been reported previously in patients with primary cancers [ 3 , 4 , 5 , 7 , 8 , 9 ] .
the case reported here involved wernicke - korsakoff syndrome in a patient with primary peritoneal cancer .
therefore , clinicians should consider wernicke encephalopathy in cancer patients with risk factors for this disease , such as nutritional imbalance due to long - term parenteral nutritional supply , use of chemotherapeutic agents , and fast - growing tumor cells .
clinicians should remember that wernicke encephalopathy occurs in patients with unbalanced nutrition , as well as in those with subacute or chronic disease that increases metabolism .
 wernicke encephalopathy is a disease that constitutes a medical emergency , but one that can be reversed with thiamine repletion if it is recognized early . 
 patients with cancer have a high risk of wernicke encephalopathy because of malnutrition , the use of chemotherapeutic agents , and disease progression . 
 korsakoff syndrome can follow or accompany wernicke encephalopathy . 
 although patients can recover from wernicke encephalopathy via rapid repletion of thiamine , few patients recover from korsakoff syndrome . here , the case of a 76-year - old female patient who had primary peritoneal cancer and developed wernicke - korsakoff syndrome as a result of prolonged nutritional imbalance and fast - growing tumor cells is reported . 
 the patient 's neurologic symptoms improved , but she did not recover from the psychiatric effects of the disease . 
Background
Case Presentation
Discussion