Atypical Wernicke's syndrome sans encephalopathy with acute bilateral vision loss due to post-chiasmatic optic tract edema

A middle aged male presented with acute bilateral vision loss, 4 weeks after undergoing gastric bypass surgery for gastric carcinoma. He had normal sensorium, fundoscopy, normal pupillary reaction to light, but had mild opthalmoparesis and nystagmus with ataxia. Magnetic resonance imaging of the brain revealed post-chiasmatic optic tract edema along with other classical features of Wernicke''s syndrome. Thiamine supplementation leads to complete resolution of clinical as well as imaging findings. In appropriate clinical settings, a high index of suspicion and early treatment are essential for managing Wernicke''s syndrome even in patients with atypical clinical and imaging presentation.     

Neuromyelitis optica spectrum disorders may be misdiagnosed as Wernicke's encephalopathy

Purpose: To raise doctors’ attention to the differential diagnosis of neuromyelitis optica spectrum disorders (NMOSD) and Wernicke's encephalopathy (WE). Patients and methods: We extensively reviewed the medical records of 136 patients who had visited our hospital since 2008 and were suspected of having central nervous system demyelinating diseases. Four of those patients had somnolence, electrolyte imbalance and brain lesions around the third ventricle and were included in the study. We tested the serum of the four patients for the presence of aquaporin-4 (AQP4) M23 antibody. Results: All the four patients had positive AQP4 antibody in their serum. Two of the patients were misdiagnosed as WE before AQP4 antibody detection occurred. Conclusions: NMOSD and WE have similar brain lesion locations, histopathological changes and clinical manifestations. It is important to distinguish NMOSD from WE by detecting AQP4 antibody in serum or cerebral spinal fluid. Vitamin B1 should also be administered to the patients who have a history of thiamine deficiency.     

Correlation of magnetic resonance images with neuropathology in acute Wernicke's encephalopathy

We correlated serial brain MRIs with neuropathological findings in a 16-year-old female whose autopsy was consistent with Wernicke's encephalopathy (WE). Diffusion-weighted imaging, diffusion coefficients mapping and neuropathology findings were suggested vasogenic edema in the periaqueductal and peri-the-fourth ventricular areas. This is the first documented case report to make this direct comparison. The characteristic WE changes in the mammillary body was also correlated with the findings of MRI with contrast enhancement. Bilateral cortical lesions revealed by MRI were atypical and rare in WE and were not evidenced by pathological changes.     

Short stature as a possible etiological factor in anorexia nervosa

The 21st case of concurrence of anorexia nervosa (AN) and gonadal dysgenesis (GD) or Turners syndrome is presented together with two more cases of AN in girls of short stature, but with normal chromosomes. The concurrence of AN and GD in the Danish population over a 10 year period is found not to be beyond the expected frequency. The possibility of low stature as such as an etiologic factor in AN is presented on the background of three cases. The same hypothesis has been suggested previously, but we cannot support the view of short stature as a common condition in AN patients premorbidly.     

Assessment of ego state in anorexia nervosa and bulimia nervosa.

To clarify the effects of ego states on anorexia nervosa (AN) and bulimia nervosa (BN), the questionnaire of the Tokyo University Egogram (TEG) with critical parent, nurturing parent, adult, free child and adapted child scales was administered to 32 female AN patients aged 14 to 32 years (mean age 20 years) and 49 female BN patients aged 14 to 33 years (mean age 23 years). The scores on the critical parent and adapted child scales for AN were significantly lower than those for BN. A multiple logistic regression analysis including all of the TEG scales, age, duration of illness and education showed that the adapted child scale significantly discriminated between AN and BN. The adaptive ego state is suggested for differentiating between the two disorders.     

Pellagra: a rare complication of anorexia nervosa

Pellagra is a potentially fatal, nutritional disease with cutaneous, gastrointestinal, and neuropsychiatric manifestations. Because of the diversity of pellagra's signs and symptoms, diagnosis is difficult without an appropriate index of suspicion. A case of pellagra in a 14-year-old girl with anorexia nervosa is presented. Signs and symptoms of pellagra were resolved after niacin therapy and dietary treatment.     

Incidence of anorexia nervosa in Denmark.

From 1970 to 1989, 915 people were admitted for the first time to psychiatric institutions in Denmark and had as their main diagnosis an eating disorder, ICD-8 306.50-59. The incidence of these admissions increased from 0.42/100,000 population in 1970 to a maximum of 1.36/100,000 in 1988. During the time of our investigation, the number of discharges of patients with an eating disorder as the main diagnosis was constant from somatic hospitals, whereas discharges from psychiatric institutions increased.     

Anorexia nervosa in adolescent males: A review and case study

The clinical presentation of anorexia nervosa among males is quite rare. This paper examines the personality and developmental issues of anorexia nervosa in adolescent males through a comprehensive review of the literature and a case presentation. In addition, this paper will demonstrate the application of the empirical literature in the development of a conceptual model to identify critical diagnostic and psychotherapeutic issues within the assessment of a clinically rare case, a male adolescent with anorexia nervosa.     

Wernicke's encephalopathy in infancy

Summary Wernicke's encephalopathy documented by characteristic involvement of the mammillary bodies developed in a premature infant during parenteral nutrition. This case illustrates the need for thiamine supplementation in seriously ill patients with inadequate intake of the vitamin.     

奥氮平治疗神经性厌食症

目的:观察奥氮平治疗神经性厌食症的临床疗效。方法:10例神经性厌食症住院患者,给予奥氮平2.5～5mg/d治疗。于治疗前后测量体质量,比较治疗前后体质量变化。结果:出院时患者体质量平均增加(3.40±2.63)kg,体质量指数平均增加(1.30±0.99),有效率为50%。体质量变化与住院天数存在明显正相关(r=0.736,P=0.015)。结论:小剂量奥氮平治疗神经性厌食症具有一定疗效,耐受性好。     

Aldosterone responses to angiotensin II in anorexia nervosa.

Patients with anorexia nervosa (AN) tend to have renin-angiotensin-aldosterone (RAA) abnormalities caused by abnormal behaviors such as strict dieting, fasting, vigorous exercise, self-induced vomiting and abuse of laxatives and/or diuretics. Adrenal responsiveness to angiotensin II (A II) was studied in 13 AN patients before and after therapy and in 6 normal sex- and age-matched controls: adrenal responses to postural change (1 h of walking following 1 h in a supine position) and to exogenous A II injection (A II: 10 ng/kg/min intravenous infusion for 30 min). The 24-h urine sodium concentration was significantly lower in AN patients before therapy than after therapy. Plasma aldosterone secretory response to A II was significantly higher in AN patients before therapy in both postural change and exogenous A II injection tests compared with after therapy response and that of controls. On the other hand, there was no significant difference in adrenal response to postural change or to exogenous A II between AN patients after therapy and controls. In conclusion, increased A II sensitivity caused by chronic sodium deficiency in AN patients normalized over time as the patients recovered.     

Concurrence of turner's syndrome and anorexia nervosa.

The ninth known case of the concurrence of anorexia nervosa and Turner's syndrome is presented. The question whether the presence of Turner's syndrome represents a greater risk for a patient to develop anorexia nervosa is considered.     

Epidemiology of anorexia nervosa and bulimia nervosa in Bornholm County,Denmark, 1970–1989

In a retrospective study of anorexia nervosa and bulimia nervosa, potential cases were traced, studied, and diagnosed according to ICD-10. Forty-two cases were found in Bornholm County, comprising the island of Bornholm in Denmark, in a population of 47,000 from 1970 to 1989. Less than half of these cases (n= 16) were registered in Danish psychiatric case registers, and 35% (n= 14) could be found only by search in primary care. The incidence rates were stable during most of the study period, but a significant increase occurred during the last 5 years. The prevalence rates, determined by counting the number of cases in the population year by year, also increased during the late part of the study period. In 1989 the incidence rate of the high-risk group of females 10 to 24 years of age was 136 per 100,000 for anorexia nervosa and 45 per 100,000 for bulimia nervosa, and the prevalence rate was 222 per 100,000 for anorexia nervosa and 89 per 100,000 for bulimia nervosa.     

Prolactin responses in dexamethasone suppression test in patients with anorexia nervosa

In anorexia nervosa (AN), abnormalities are present in the hypothalamic-pituitary-adrenal axis, but the prolactin (PRL) response to dexamethasone suppression test (DST) has not yet been studied. In order to study the interrelationships between the various endocrine abnormalities, we investigated the responses of PRL and cortisol to DST (1 mg of dexamethasone at 2300) in AN patients. The subjects were 12 female inpatients with AN and 8 age- and sex-matched healthy controls. The percentage suppression and absolute change in PRL levels before and after dexamethasone administration were significantly different in the 2 groups. In the control group PRL levels suppressed to 36.5 +/- 3.7% of basal, while AN levels declined to 79.4 +/- 8.9% of basal. When the percentage suppression of PRL was compared between patients with and without cortisol suppression, the mean PRL level was 68.9 +/- 7.8% of the basal level for the cortisol-suppressed patients and 100.4 +/- 19.1% for the nonsuppressed patients. Hence in both groups, the percentage PRL suppression was significantly reduced compared with the control group, and indeed nonexistent in cortisol-nonsuppressed patients. The finding that there was less PRL suppression in the cortisol-suppressed patients than in the controls suggests that, in AN, there may be an abnormality in PRL secretion not related to the hypothalamic-pituitary-adrenal axis. Further work is needed to distinguish between the PRL response to stress and potential hypothalamic abnormality.     

Neuropathological study of the role of mast cells and histamine‐positive neurons in selective vulnerability of the thalamus and inferior colliculus in thiamine‐deficient encephalopathy

The purpose of the present study was to examine the role of histamine in the pathogenesis of experimental thiamine‐deficient encephalopathy. By studying sagittal serial sections the authors were able to examine the topographical relationship between histamine‐positive neurons and fibers, the number of mast cells, and localized lesions in the thalamus (TH) and inferior colliculus (IC). Adult rats were given a thiamine‐deficient diet and pyrithiamine was given intraperitoneally (30 µg/100 g bodyweight per day), and the distribution of vulnerable regions and petechial bleeding was histologically examined by reconstruction of the sagittal serial sections. The distribution of mast cells and histamine‐positive neurons and fibers was examined immunohistochemically in control rats, and compared between the vulnerable and non‐vulnerable regions of the TH and tectum. Changes in the aforementioned measures during the thiamine‐deficient state were also examined. The blood–brain barrier was examined using antibodies against rat endothelial barrier antigen (EBA) and albumin. The density of histamine‐positive fibers in the vulnerable regions of the TH and IC was very low and not different from the non‐vulnerable regions, and the number of mast cells was significantly higher in the lateral portion of the TH than the medial portion of the TH. The numbers of mast cells increased on days 7–10 after the start of the experiment, and significantly decreased on days 14–21. Histamine‐positive neurons and fibers in the TH and IC also had the same changes. Bleeding of the IC occurred exclusively around arteries, and perivenous bleeding was absent. Albumin exudation and suppression of EBA expression of capillaries were found in the spongy lesions of the TH and IC. The role of histamine in selective vulnerability of the TH and IC in experimental thiamine‐deficient encephalopathy was not supported. Findings in the present study suggest that the spongy change is a primary event, and vascular changes are secondary.     

Staging anorexia nervosa: conceptualizing illness severity

In recent years, there has been increasing attention to the conceptualization of anorexia nervosa (AN) and its diagnostic criteria. While varying levels of severity within the illness category of AN have long been appreciated, neither a precise definition of severity nor an empirical examination of severity in AN has been undertaken. The aim of this article is to review the current state of knowledge on illness severity and to propose a theoretical model for the definition and conceptualization of severity in AN. AN is associated with significant medical morbidity which is related to the 'severity' of presentation on such markers as body mass index, eating and purging behaviours. The development of a functional staging system, based on symptom severity, is indicated for reasons similar to those cited by the cancer lobby. Improving case management and making appropriate treatment recommendations have been the primary purpose of staging in other fields, and might also apply to AN. Such a standardized staging system could potentially ease communication between treatment settings, and increase the specificity and comparability of research findings in the field of AN.     

Taste reactivity deficit in anorexia nervosa

Aim: Anorexia nervosa is a complex psychiatric disorder posing a rapidly increasing burden on modern societies. Our purpose was to clarify perceptual‐motivational aspects of gustatory disturbances in the disease. Methods: A taste reactivity test, with the use of all five primary qualities in two concentrations, was performed in restrictive‐type anorexic patients, and their hedonic evaluations were compared to those of age‐matched healthy control subjects. Results: The patients gave significantly lower pleasantness scores for pleasant taste stimuli compared with controls. The differences were the greatest for the lower concentration sucrose, umami and sodium chloride. Ratings given for the aversive taste stimuli were similar in both experimental groups. Conclusion: Our findings contribute to a better understanding of complex symptoms of anorexia nervosa, and may also help to develop more effective cognitive‐behavioral therapies.     

Homocysteine plasma levels are elevated in females with anorexia nervosa

Summary. In the present pilot study significantly (T = 2.46, P = 0.018) higher levels of homocysteine were found in female anorectic patients (14.07, SD 7.3µmol/l; n = 18) when compared with bulimic patients (10.25, SD 2.82; n = 27) or healthy controls (8.10, SD 1.79; n = 25). Since homocysteine can induce neuronal cell death leading to brain atrophy in different diseases and since it has been linked to depressive disorders these findings may have important implications for understanding common symptoms in patients suffering from anorexia.Present address: Department of Psychiatry and Psychotherapy, University of Basel, Switzerland     

Salivary opiorphin levels in anorexia nervosa: A case–control study

Abstract

Objectives: Opiorphin is a physiological inhibitor of peptidases inactivating endogenous opioids displaying strong analgesic properties without undesirable side effects, antidepressant properties or hormonal dependency. It might therefore play an important role in patients with painful diseases related to neuro-hormonal dysregulation of the nervous system, affecting saliva secretion and composition such as anorexia nervosa (AN). The main objective aim of this study was to compare the level of opiorphin in saliva of patients with AN to matched subjects free of eating disorders.

Methods: A case–control clinical trial was conducted in 68 AN patients and 43 healthy matched control subjects. Depression symptoms were assessed with the self-scored questionnaire Beck Depression Inventory (BDI) and salivary samples were taken during the acute stage of AN (BMI <15?kg/m²) for measuring opiorphin. Opiorphin levels were measured with a quantitative assay using a commercial immunoenzymatic Elisa kit (cat no. EH1927, Wuchan, Hubei, China).

Results: No statistically significant difference was found in salivary opiorphin levels between the AN and control groups, (P?=?0.499, Mann–Whitney U-test). Positive correlations to duration of the disease, BDI and bodyweight in AN patients were evidenced.

Conclusions: Measurement of salivary opiorphin levels cannot be used as a marker of AN but may allow new perspectives in monitoring AN in its early stages.