Altered sensorium in a patient with chronic kidney disease: Unmasking the unusual

Abstract

Wernicke encephalopathy (WE) is an acute neuropsychiatric syndrome caused by thiamine deficiency, classically associated with chronic alcohol abuse. However, it is increasingly recognized in nonalcoholic settings. We report a 62-year-old male with chronic kidney disease on recent torsemide therapy who presented with acute confusion, ophthalmoplegia, and gait ataxia. Magnetic resonance imaging of the brain revealed symmetric T2/FLAIR hyperintensities in the medial thalami and periaqueductal region with mammillary body involvement, characteristic of WE. Whole-blood thiamine diphosphate levels were markedly reduced. The patient showed dramatic neurological improvement following high-dose intravenous thiamine therapy. This case highlights that chronic loop diuretic therapy may precipitate severe thiamine deficiency and WE even in nonalcoholic patients. Early recognition and prompt parenteral thiamine administration can result in complete neurological recovery. Routine thiamine supplementation should be considered in high-risk patients with cardiac or renal disease receiving prolonged diuretic therapy.