Case Study presented by Gina Creutzburg and Cindy Myers CASE HISTORY A 60-year-old businessman with no history of alcoholism was referred to our hospital on July 8, 1997, because of the onset of an acute memory impairment 11 days earlier. The patient had undergone a partial gastrectomy and gastrojejunostomy in July 1995 for gastric adenocarcinoma and had been in good health thereafter. Two weeks before the onset of the patient's memory problems, he had an upper respiratory tract infection and poor appetite. A family physician had given him a single dose of vitamin B complex (containing 50 mg of thiamin hydrochloride) with fluid under the suspected diagnosis of mild undernourishment and dehydration.
On admission, the patient was alert but severely amnestic and disoriented. Some confabulations were noted. The results of the general physical examination were unremarcable. The patient's weight was 104 lb and his height was 5'2". A neurologic examination revealed truncal ataxia and hyporeflexia at the ankles. There was no evidence of oculomotor palsy, nystagmus, or sensory disturbance. He scored a 25 on the Mini-Mental State Examination. On the Wechsler Memory Scale-Revised, the patient scored less than 50 on the general memory index, 54 on the verbal memory index, 59 on the visual memory index, and less than 50 on the delayed recall index. He could not correctly recall events that had occurred up to 1 year before the onset of his condition. The patient's intellectual function was normal; he had a verbal IQ of 97 and a performance IQ of 108 on the Wechsler Adult Intelligence Scale-Revised. Serum levels of vitamin B,(163 nmol/L) and vitamin B12(12,912 pmol/L) were elevated because he had been administered a supplement prior of admission. Findings from a routine laboratory examination were unremarkable. Results from a lumbar puncture yielded normal cerebrospinal fluid findings. Findings from an electroencephalogram were also normal. Motor and sensory nerve conduction velocities were within normal ranges. Cranial magnetic resonance imaging scan findings were normal. There was no abnormal finding on a measurement of regional cerebral blood flow and oxygen metabolic ratio as determined by a positron emission tomographic scan and the oxygen 15-labeled gas inhalation steady state method. The patient was immediately treated with intravenous high-dose thiamin and then oral thiamin. All neurologic impairments improved to normal, and memory impairment became less severe. Two months later, the patient's scores were 63 on the general memory index of the Wechsler Memory Scale-Revised, 63 on the verbal memory index, 92 on the visual memory index, and less than 50 on the delayed recall index. His memories returned except for events that occurred during the several months prior to the onset of his condition.
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