Magnetic resonance imaging changes in a head and neck cancer patient with wernicke encephalopathy and visual loss

A woman suffering from cancer presented with headache, confusion, and blurred and double vision with an unsteady gait. Magnetic resonance imaging and lumbar puncture were normal. Subsequently her visual loss and mental status worsened: examination then revealed moderate confusion; light perception vision bilaterally; upbeat nystagmus in primary gaze with gaze evoked vertical and horizontal nystagmus; and disc swelling with retinal haemorrhages. Repeat magnetic resonance imaging showed changes in her thalami, caudate, periaqueductal gray matter, and tectum. A serum thiamine level was measured and she was treated with thiamine replacement for Wernicke encephalopathy. She had near complete recovery of vision, mentation, and eye movements. Optical coherence tomography showed swelling of the retinal nerve layer, and visually evoked potential demonstrated delayed signals consistent with optic nerve demyelination. The case is the first to demonstrate rapid onset of imaging changes having a documented normal scan nine days previously.