2026 ECNP Congress

EP01-1007

Delayed and inadequate thiamine treatment leading to korsakoff syndrome: a clinical and therapeutic pitfall

Gökçe Eren — B. Koparal · Gazi University Faculty of Medicine, Psychiatry, Ankara, Türkiye

2026 ECNP Congress

Background

Wernicke encephalopathy (WE) is an acute, life-threatening, and potentially reversible neuropsychiatric disorder caused by thiamine (vitamin B1) deficiency. While most commonly associated with chronic alcohol use disorder, it is also frequently observed in conditions involving malnutrition, malabsorption, and increased metabolic demand. If left untreated or managed with suboptimal doses, WE carries a high risk of progressing to Korsakoff syndrome (KS) which is a chronic, debilitating, and often irreversible amnestic condition characterized by anterograde and retrograde amnesia. A substantial proportion of untreated or suboptimally managed WE cases may progress to Korsakoff syndrome, with reported rates reaching up to 80%[1]. In this case report, we present the clinical course and management of a patient with Wernicke encephalopathy who progressed to Korsakoff syndrome as a result of delayed and insufficient thiamine treatment prior to admission, emphasizing the critical importance of timely and adequate thiamine replacement.

Case Presentation

A 50-year-old male with a 20-year history of chronic alcohol consumption presented with progressive neuropsychiatric symptoms, including global confusion, gait instability (ataxia), visual disturbances, and significant unintentional weight loss. These symptoms emerged following a period of increased alcohol intake and poor nutritional support.

Approximately 15 days prior to admission, the patient was found disoriented by his family and was hospitalized at an intensive care unit under suspicion of WE. He was treated with vitamin C and a very low-dose thiamine replacement (25 mg/day). Cranial MRI revealed no acute pathology.

Upon transfer to our inpatient psychiatry unit on the 20th day of the symptom onset, he had severe cognitive impairment, total disorientation, and prominent confabulations, clinically consistent with Korsakoff syndrome.

Clinical Course

Upon admission, high-dose parenteral thiamine (500 mg/day) was initiated for five days and continued with oral form for two weeks [2,3]. With treatment, partial clinical improvement was observed in gait and general physical condition. However, severe memory impairment and confabulation persisted, indicating incomplete neurological recovery and likely irreversible damage to memory-related neural circuits. No improvement was observed in the patient’s mental state during the 3-month follow-up.

Discussion

This case highlights the consequences of missing the therapeutic window due to inadequate thiamine dosing. Thiamine transport across the blood–brain barrier depends on active mechanisms that may be impaired in chronic alcohol use. In such cases, sufficient central nervous system levels can only be achieved through high-dose parenteral administration. Subtherapeutic doses fail to reach adequate brain concentrations, allowing continued neuronal injury, particularly in the mammillary bodies and thalamic nuclei[4]. Normal neuroimaging does not exclude WE, reinforcing its clinical nature and the need for immediate treatment. Substitution of thiamine with vitamin C further illustrates a gap between evidence-based guidelines and real-world clinical practice.

Conclusions

Delayed and insufficient thiamine treatment in WE may lead to preventable progression to Korsakoff syndrome. Increasing clinician awareness and adherence to evidence-based high-dose treatment protocols are essential to improve neurological outcomes and prevent irreversible cognitive impairment.

References

  1. Vasan S, Kumar A. Wernicke Encephalopathy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.
  2. Evren C. Alkol yoksunluk belirtileri ve alkol yoksunluk sendromu yönetimi. In: Evren C, editor. Alkol ve Madde Kullanım Bozuklukları Temel Kitabı. Ankara: Türkiye Psikiyatri Derneği Yayınları; 2017. p. 165-178.
  3. Thomson AD, Cook CC, Touquet R, Henry JA. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke’s encephalopathy. Alcohol Alcohol. 2002;37(6):513–521.
  4. Sechi G, Serra A. Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol. 2007;6(5):442–455. doi: 10.1016/S1474-4422(07)70104-7