A Veteran With Lesions, Alcohol Use, and Opioid Dependence

R. Hal Scofield, MD

Disclosures

October 27, 2021

Discussion

Multiple vitamin deficiencies are present in this patient. He has both thiamine and vitamin C deficiency (beriberi and scurvy).

With far lateral gaze, the patient's contralateral eye fails to fully adduct. Thus, he has an internuclear ophthalmoplegia. Lateral gaze is maintained by a neurologic connection between the third and sixth cranial nerves, which control the lateral and medical rectus muscles, respectively. This connection is secured by the medial longitudinal fasciculus.

Lesions in the medial longitudinal fasciculus ipsilateral to the eye that fails to adduct can produce this finding. The differential diagnosis includes brain stem stroke or tumor and multiple sclerosis. No tumor was seen on the CT scan of the brain. An ischemic stroke in the brain stem can cause internuclear ophthalmoplegia and, within the first few days, may not be visible on a CT scan. However, a single stroke or tumor would not result in bilaterally affected eyes. This finding does occur in patients with multiple sclerosis, but the onset of this disease is not common among older men.

Hepatic encephalopathy does not cause focal brain lesions, such as internuclear ophthalmoplegia, and is associated with liver dysfunction. Although the patient's AST/ALT ratio is consistent with alcohol use, no evidence suggests decreased liver function; the results of coagulation studies and the serum ammonia level are normal.

Given this patient's history of alcohol abuse and poor dietary intake, thiamine deficiency (beriberi) manifesting as Wernicke encephalopathy  is the most likely diagnosis. In fact, his red blood thiamine value, as determined by transketolase activity and returned a few days after presentation, was extremely low. Treatment with intravenous thiamine was initiated in the emergency department, and the abnormal eye movements and ataxia resolved within 24 hours.

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