Wernicke's encephalopathy and central pontine myelinolysis in hyperemesis gravidarum
A 21-year-old woman with 16 weeks pregnancy was admitted because of progressive difficulty in walking for 3 weeks. She had a weight loss of 12 kg after conceiving due to hyperemesis gravidarum. Due to hyperemesis, she could only eat sweet red jelly. Also, she had been drinking domestic whisky since she was 16 years of age. She had no alcohol dependent symptoms and signs, and she quitted alcohol immediately after knowing about her pregnancy. On admission, she was lethargic, and responded slowly to verbal commands.\nVery prominent nystagmus was seen in the upbeat direction, and was prominent in all other directions. Limbs and truncal ataxia with ataxic gait were present. Mild proximal muscle weakness (grade 4/5) was noted. However, deep tendon reflexes were within the normal range. Thyroid function test was within the normal range, serum sodium was 135 mmol/L (normal range 135-145 mmol/L), potassium was 1.9 mmol/L (normal range 3.5-5.0 mmol/L), sodium bicarbonate was 31.5 mmol/L (normal range 21-32 mmol/L), phosphate was 3.2 mg/dL (normal range 2.5-4.9 mg/dL), and magnesium was 1.5 mg/dL (normal range 1.8-2.4 mg/dL). Magnetic resonance imaging (MRI) of the brain showed hypersignal intensity at the bilateral medial thalamus on diffusion weighted imaging (DWI), Fluid attenuated inversion recovery (FLAIR), and T2Weighted (T2W) series []. MRI of the brain also showed hypersignal intensity at central pons on the DWI, FLAIR, and T2W series []. Wernicke's encephalopathy with CPM was diagnosed. After three days of thiamine supplementation, her clinical features significantly improved. Hyperemesis gravidarum was managed by rehydration, corrected imbalance electrolytes (especially hypokalemia and hypomagnesemia), and antiemetic medications such as intravenous dimenhydranate. Last follow up at 2 months after discharge from the hospital demonstrated improvement in her conditions and normal findings, except for the presence ofmild vertical nystagmus. As she received antenatal care from another hospital, we did not have information about the pregnancy outcome.