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Starvation-induced diplopia and weakness: a case of beriberi and Wernicke’s encephalopathy
  1. Timothy Xin Zhong Tan1,
  2. Kheng Choon Lim2,
  3. Charles Chan Chung3 and
  4. Than Aung3
  1. 1 Department of Emergency Medicine, Singapore General Hospital, Singapore
  2. 2 Department of Radiology, Singapore General Hospital, Singapore
  3. 3 Department of Internal Medicine, Singapore General Hospital, Singapore
  1. Correspondence to Timothy Xin Zhong Tan, timothy.tbj13{at}


A 56-year-old teetotaller man with hypertension and gout presented with a week duration of painless worsening diplopia on a background of loss of weight and appetite, generalised lethargy and weakness for 1 year. On examination, he was noted to be hypothermic and tachycardic with generalised muscle wasting. Proximal myopathy, lower limb fasciculations and areflexia, restricted bilateral eye abduction and nystagmus were observed. Blood investigations demonstrated compensated lactic acidosis, acute kidney injury and leucocytosis. A nerve conduction study showed severe length-dependent axonal sensorimotor polyneuropathy. This was a diagnostic dilemma until an MRI brain revealed symmetrical signal abnormality and enhancement in the periaqueductal area indicative of Wernicke’s encephalopathy, caused by thiamine deficiency from poor nutrition. Beriberi, also caused by thiamine deficiency, accounted for his tachycardia, polyneuropathy, areflexia, hypothermia and biochemical abnormalities. Both beriberi and Wernicke’s encephalopathy are medical emergencies, which were treated with intravenous thiamine to good effect.

  • movement disorders (other than parkinsons)
  • neuroimaging
  • malnutrition
  • radiology

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  • Contributors The corresponding author TXZT followed up with the patient, had full access to all data and information used in this case report, and drafted the initial manuscript and subsequent edition. TXZT therefore takes responsibility for the integrity of the submission and its contents. KCL reported the initial imaging findings and selected the radiological images which were eventually selected for use in this article. KCL also reviewed the article and provided necessary feedback and comments. CCC and TA were involved in the direct care of the patient, and gave recommendations and edits which contributed to the final draft. TA provided overall direction and oversaw the entire study.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.