Concurrent Wernicke Encephalopathy and Posterior Reversible Encephalopathy Syndrome Following Gastric Sleeve Surgery

Wernicke encephalopathy-an uncommon and severe condition caused by thiamine deficiency-is most often associated with alcohol use but can occur in other settings of nutrient deficiency. Posterior reversible encephalopathy syndrome is an acute neurologic condition characterized by reversible subcortical vasogenic edema that is often associated with hypertension. We present the case of a patient with concurrent Wernicke encephalopathy and posterior reversible encephalopathy syndrome.

A 26-year-old female with a surgical history of laparoscopic sleeve gastrectomy performed 4 months prior presented with ataxia, confusion, bilateral blurred vision, and headache. Initial examination showed reduced visual acuity (20/200 in both eyes), ophthalmoplegia, high-frequency bilateral upbeat and mild horizontal nystagmus, bilateral optic disc swelling with disc hemorrhage, and intraretinal hemorrhages. She was found to have thiamine deficiency resulting in Wernicke encephalopathy, as well as bilateral frontal, parietal, and occipital T2 hyperintensities on magnetic resonance imaging consistent with posterior reversible encephalopathy syndrome. After treatment with pulse dose thiamine repletion and antihypertensives, the patient improved clinically, with increased visual acuity (20/30 in both eyes) and complete resolution of bilateral optic disc edema and intraretinal hemorrhages. However, upbeat nystagmus remained.

Neuro-ophthalmic signs may be early indicators of Wernicke encephalopathy and posterior reversible encephalopathy syndrome, underscoring the vital role of eye care providers in recognizing these conditions, particularly in patients who have undergone bariatric surgery. Without a high index of suspicion, Wernicke encephalopathy may be overlooked in these patients.