A Case Report of psychotic symptoms as clinical presentation of thiamine deficiency in an Alzheimer's disease patient

ZHOU Yi-ping; WEI Wen-shi

doi:10.3969/j.issn.2096-5516.2021.02.007

Chinese Journal of Alzheimer's Disease and Related Disorders >

2021 , Vol. 4 >Issue 2: 124 - 126

DOI: https://doi.org/10.3969/j.issn.2096-5516.2021.02.007

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A Case Report of psychotic symptoms as clinical presentation of thiamine deficiency in an Alzheimer's disease patient

ZHOU Yi-ping ,
WEI Wen-shi

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Huadong Hospital Affiliated to Fudan University, Department of Neurology, Center of Cogntive Disorder, Shanghai 200040, China

Received date: 2021-02-19

Revised date: 2021-03-15

Online published: 2021-06-25

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Abstract

The incidence of thiamine deficiency (TD) induced by non-alcoholic diseases is very low, which is often neglected clinically, resulting in Wernicke encephalopathy (WE) or Korsakoff syndrome caused by the delay in the treatment of this disease. Few cases have been reported the association between the exacerbation of the psychiatric symptoms of Alzheimer's disease (AD) patient and thiamine deficiency. An old man with AD visited our clinic because of acute deterioration in psychological symptoms of dementia (BPSD), with a decrease in food intake lasting more than 1 month, symptoms were improved significantly after thiamine administration. It is recommended that the treatment with TD can be started in any situation where thiamine deficiency is suspected. The potential benefits brought by it far outweigh the risks of no treatment. Meanwhile, it is recommended that therapeutic administration of thiamine be commenced in any case where thiamine deficiency is suspected, the potential benefits to a patient with possible thiamine deficiency far outweigh the risks of not treating.

Key words： thiamine; BPSD; wernicke encephalopathy; case report

Cite this article

ZHOU Yi-ping , WEI Wen-shi . A Case Report of psychotic symptoms as clinical presentation of thiamine deficiency in an Alzheimer's disease patient[J]. Chinese Journal of Alzheimer's Disease and Related Disorders, 2021 , 4(2) : 124 -126 . DOI: 10.3969/j.issn.2096-5516.2021.02.007

1 引言

维生素 B1 是水溶性B族维生素,其结构中有含硫的噻唑环与含氨基的嘧啶环而得名“硫胺素”^[1]。硫胺素辅助参与人体内多种酶系的能量代谢,但在人体内储量较少,需从饮食中获取,如动物内脏、猪肉、豆类等。当处于长期酗酒、营养不足等状态时,易继发硫胺素缺乏症（Thiamine deficiency, TD）^[2]。

韦尼克脑病（Wernicke encephalopathy, WE）是硫胺素缺乏引起的急性代谢异常性中枢神经系统疾病,最常见于慢性酒精中毒患者^[3]。尽管近年来有关于非酒精性硫胺素缺乏的报道,尤其是胃肠道肿瘤术后继发硫胺素缺乏的报道逐渐增多,但阿尔茨海默病患者的精神行为症状（BPSD）加重与硫胺素缺乏之间关联的报道极少。

本次介绍一患有阿尔茨海默病的82岁男性因精神行为症状（BPSD）的急剧恶化而来我院就诊。病史提示超过1月的食物摄入减少,在较大剂量硫胺素补充后症状得到明显改善。因此对于认知障碍患者尤其有进食减少,需怀疑硫胺素缺乏,其表现出BPSD的急性恶化可能与食物摄入减少相关。同时建议在怀疑硫胺素缺乏的任何情况下都可开始硫胺素的补充治疗,对可能存在硫胺素缺乏症的患者进行给药所带来的潜在收益远超不治疗的风险。

2 病例报告

临床资料：

患者,男,82岁,既往有阿尔茨海默病史3年,长期服用多奈哌齐片5mg,每晚一片。此次因“烦躁,日夜颠倒1周“而来我科就诊而收治入院。近一周患者记忆减退较前明显,同时有烦躁,不配合进食,伴有日夜颠倒。追问病史,患者居住于养老院,护理人员回忆患者有进食减少超过1月,有时一天只进食一两口。否认视幻觉,否认饮酒史及胃肠道手术史。

目前查体,神清,精神软,口齿清,易激惹,查体欠配合,颈软,时间空间定向力下降,即刻回忆、延迟回忆及计算力下降,四肢均有自主活动,腱反射（++）,巴氏征阴性,余查体欠配合。患者目前无法配合全套心理认知评估,谵妄分级量表（Delirium rating scale, DRS）总分20分/40分,严重程度得分16分/33分。我们追溯其3月前记忆门诊就诊评估记录,当时显示其MMSE22/30分;ADL 23/80分;NPI 0分;HIS2分;GDS7/30分。

患者初中文化,身高165cm,体重51kg,BMI指数18.7kg/m²。血压126/70mmHg,心律70bpm,体温36.7℃。

实验室检查：血常规：WBC 7.34 ×10⁹/L;HGB 110 g/L;PLT 451×10⁹/L;NEUT%: 65.83%;生化：ALB 29.1 g/L;K3.01 mmol/L;Na 134.5 mmol/L;CL 84 mmol/L;维生素B1 43.53 nmol/l(50-150);维生素B12 203pmol/l(138-652)等;余CRP;血沉;血氨;血气,甲状腺功能,HIV,梅毒;脑脊液检查常规生化等无殊。

辅助检查：头颅MRI：深部缺血灶,无急性病灶;脑电图α节律欠佳,未见痫样放电;心电图示正常,腹部B超：胆囊泥沙样结石。

诊疗过程：尽管患者既往有阿尔茨海默病史,但总体病情平稳,近1周内的精神症状加重考虑可能并非是AD的病情进展所致。患者1月余进食减少,而硫胺素如无额外补充,在体内的存储量3周左右即可耗竭。该患者符合Caine的WE诊断标准^[4]中的4条中两条,即眼部症状,小脑体征,轻度记忆障碍或精神症状,进食减少.现考虑诊断：阿尔茨海默病;硫胺素缺乏症。治疗方面：入院后对该患者予以肌肉注射维生素B1 100mg,一天两次,总用量2000mg,同时予以静脉补液及补钾治疗。患者2天后症状好转,情绪逐渐平稳。5天后可正常对答,配合认知评估。出院前认知评估 MMSE21/30分;DRS总分10分/40分,严重程度得分9分/33分。后患者出院继续口服维生素B1 20mg,一天三次;以及多奈哌齐片。患者1月后随访症状平稳。

3 讨论

硫胺素参与多种能量代谢,在人体内的储量较少,一般需从饮食中获取,硫胺素缺乏饮食或无硫胺素摄入情况下,体内硫胺素可在18天至6周内消耗殆尽^[5]。TD可进一步导致韦尼克脑病、科萨科夫综合征、周围神经病变等疾病。韦尼克脑病(WE)是硫胺素缺乏引起的急性代谢异常性中枢神经系统疾病,症状多样,且无特异性症状,实验室检测方法有限,其临床漏诊率很高。头颅核磁对诊断酒精性Wernicke脑病有一定价值^[6]。而非酒精性Wernicke脑病的MRI表现并不具有特异性,该病诊断目前仍主要基于临床表现。研究发现,尸检确诊的 Wernicke脑病患者中,酒精性 Wernicke脑病的生前临床诊断率为31.9%,而非酒精性 Wernicke脑病的诊断率仅为5.7%,而且相对发病轻的非死亡患者临床漏诊误诊率更高^[6,7]。而根据Caine等对尸解证实的WE诊断标准^[4]：进食减少;眼征;共济失调;精神症状4项中任意两项作为诊断依据,则诊断敏感性从23%增至85%^[5]。因此,在临床工作中, Caine WE诊断标准对早期识别和诊断TD引发的WE有更重要的实践意义,建议可在临床上应用。

硫胺素在阿尔茨海默病发病机理中发挥一定作用^[8]。有研究表明,阿尔茨海默病患者血浆中硫胺素水平偏低。在硫胺素缺乏的大鼠模型中,其受损大脑区域发现淀粉样蛋白前体沉积,造成β淀粉样蛋白堆积^[5]。而阿尔茨海默病疾病进程中易出现BPSD,多认为是疾病进展而忽略硫胺素缺乏症。目前关于阿尔茨海默病的BPSD与硫胺素缺乏相关报道尚少,推测TD可能导致BPSD发生及恶化,是未来进一步研究内容之一。

本病例中患者考虑诊断为TD的线索是护理人员提供病史,超过1个月食物摄入减少,而无额外营养素补充。另实验室检查提示维生素B1 43.53 nmol/l(50-150)水平偏低,但在目前临床检测中特异性并不高,可作为参考依据之一。据报道,大约50%的老年男性和39％的老年女性没有适当的硫胺素摄入量^[9]。而阿尔茨海默病患者易伴发进食障碍容易伴发TD,因此,不应忽视认知障碍患者进食减少时很容易发生TD的事实。照护家属及护理机构需对此类患者的进食量有一定监控,在日常饮食中也建议提供硫胺素强化饮食,如面包、谷物等。

关于治疗,TD的治疗通常在确诊之前就已开始^[5,10]。由于TD所致韦尼克脑病进展迅速,目前建议即使尚未做出明确诊断,怀疑硫胺素缺乏的任何情况下都应开始补充硫胺素的治疗^[10]。及早治疗该疾病可获得较好的治疗效果,而延误治疗后约有50%WE的预后欠佳,遗留有包括记忆力减退或Korsakoff综合征等后遗症^[11]。因酒精依赖而患WE的患者中,约80％会发展为Korsakoff综合征,约有40％的人可能因Wernicke-Korsakoff综合征而死亡^[11,12]。而非酒精相关的WE患者中,也只有约20％的患者能够完全康复,另20％的患者可能因其他并发症而死亡^[13]。而及早使用维生素B1的不良反应风险极低,据报道,静脉注射100万例中有4例发生过敏性休克,肌肉注射500万人中有1例发生过敏性休克^[10]。因此,对可能存在硫胺素缺乏症的患者进行给药所带来的潜在收益远超不治疗的风险^[5,10]。目前对于维生素B1的补充方法和剂量尚无定论。酒精相关的维生素B1缺乏需更多的补充剂量。欧洲神经病学学会联合会建议200 mg硫胺素每天,分3次静脉给药,直至临床状况稳定。也有专家建议硫胺素用法为每天3次,每次500mg,持续2~3天,后每天250mg,直到症状消失为止^[13]。同时治疗过程中应尽可能尽早恢复均衡饮食,保障摄入。

综上所述,随着阿尔茨海默病患者不断攀升,及早发现潜在的缺乏硫胺素的患者,及早治疗,有助于预防WE和Korsakoff综合征,改善患者预后。同时建议在怀疑硫胺素缺乏的任何情况下都可开始硫胺素的补充治疗,其所带来的潜在收益远超不治疗的风险。

References

Publishing order | Descend order by publishing year | Descend order by cited within

[1]	Sechi G, Serra A. Wernicke's encephalopathy: new clinical settings and recent advancesin diagnosis and management[J]. Lancet Neurol, 2007, 6(5): 442-455. DOI

[2]	Dinicolantonio JJ, Lavie CJ, Niazi AK, et al. Effects of thiamine on cardiac function in patients with systolic heart failure: systematic review and metaanalysis of randomized, double-blind, placebo-controlled trials[J]. Ochsner J, 2013, 13(4): 495-499.

[3]	Feng L, He W. Reduced thiamine is a predictor for cognitive impairment of cerebral infarction[J]. Brain and Behavior, 2020, 10: e01709.

[4]	Caine D, Halliday GM, Kril JJ, et al. Operational criteria for the classification of chronic alcoholics: identification of Wernicke's encephalopathy[J]. Neurol Neurosurg Psychiatry, 1997, 62: 51-60. DOI

[5]	Kohnke S, Meek CL. Don't seek, don't find: The diagnostic challenge of Wernicke's encephalopathy[J]. Ann Clin Biochem, 2021, 58(1): 38-46. DOI

[6]	Antel K, Singh N, Chisholm B, et al. Encephalopathy after persistent vomiting:thre cases of non - alcohol-related Wernicke's encephalopathy[J]. S Afr MedJ, 2015, 105(6): 442-443.

[7]	Nikolakaros G, Kurki T, Paju J, et al. Korsakofsyn- drome in non-alcoholic psychiatric patients.variable cognitive presentation and impairedfrontotemporal connectivity[J]. Front Psychiatry, 2018, 9: 204. DOI PMID

[8]	Quail Z, Carter MM. Management of cognitive decline in Alzheimer's disease using a non-pharmacological intervention program[J]. Medicine (Baltimore), 2020, 99(21):e20128. DOI

[9]	Thomson AD, Guerrini I, Marshall EJ, et al. Wernicke's encephalopathy: role of thiamine[J]. Pract Gastroenterol, 2009, 33: 20-31.

[10]	Thomson AD, Cook CC, Touquet R, et al. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke's encephalopathy in the accident and emergency department[J]. Alcohol Alcohol, 2002, 37(6):513-521 DOI

[11]	Scalzo SJ, Bowden SC, Ambrose ML, et al. Wernicke-Korsakoff syndromenot related to alcohol use: a systematic review[J]. Neurol Neurosurg Psychiatry, 2015, 86(12): 1362-1368.

[12]	Arts NJ, Walvoort SJ, Kessels RP, et al. Korsakoff's syndrome: a critical review[J]. Neuropsychiatr Dis Treat, 2017, 13: 2875-2890. DOI

[13]	Nishimoto A, Usery J, Winton JC, et al. High-dose parenteral thiamine in treatment of Wernicke's encepha lopathy: case series and review of the literature[J]. In Vivo, 2017, 31(1): 121-124. PMID

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