SHM Converge Scientific Abstract ePoster Gallery-An Elderly Zebra in Teenager's Clothing: Wernicke's Encephalopathy

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A 16-year-old boy with obesity presented with severe dehydration after a two-year history of episodic abdominal pain, nausea, and vomiting, with worsening symptoms for three months and a 70-pound weight loss. He also reported cannabis use and vaping. On admission he had dry mucous membranes, periumbilical tenderness, and horizontal nystagmus. Initial evaluation, including ophthalmology exam and brain MRI, was unrevealing, and the working differential focused on cannabis hyperemesis syndrome, cyclic vomiting, and vestibular disorders.<br /><br />Despite IV fluids and antiemetics, his vomiting continued. By hospital day 4 he developed vertical nystagmus, prompting concern for an ingestion-related cause. Over the next several days he worsened with confusion, slurred speech, visual hallucinations, urinary retention, and agitation. CT head and EEG were negative, and extensive infectious and autoimmune workup via lumbar puncture was also negative. A repeat MRI on hospital day 9 showed bilateral thalamic, mammillary body, and periaqueductal gray matter hyperintensities, consistent with Wernicke’s encephalopathy.<br /><br />He was started immediately on high-dose IV thiamine, with rapid improvement in mental status and resolution of hallucinations. His thiamine level later returned low. Ataxia persisted, requiring several weeks of inpatient rehabilitation, though by four months he had only mild residual nystagmus and otherwise recovered.<br /><br />This case emphasizes that Wernicke’s encephalopathy can occur in children and adolescents, including those with obesity, if malnutrition or prolonged poor intake is present. It highlights the importance of avoiding anchoring bias on cannabis use, recognizing that the classic triad of ataxia, encephalopathy, and oculomotor dysfunction may guide diagnosis, and treating empirically with thiamine early—especially before or alongside dextrose administration.

Asset Subtitle

Stephanie R. Moss

Meta Tag

Author List Stephanie R. Moss

Category Clinical Vignettes

Concept Wernicke Encephalopathy

Concept High-Dose Thiamine Replacement

Concept Ataxia

Concept Encephalopathy

Concept Thiamine

Distinguished Finalist

Presenter Organization The Cleveland Clinic Foundation

Presenting Author Stephanie R. Moss

Track Pediatric

Keywords

Wernicke encephalopathy

adolescent

obesity

thiamine deficiency

vomiting

nystagmus

malnutrition

cannabis hyperemesis syndrome

ataxia

MRI thalamic hyperintensities

Wernicke Encephalopathy

High-Dose Thiamine Replacement

Ataxia

Encephalopathy

Thiamine