IMAGES IN FORENSICS The pathological features of Wernicke encephalopathy Kelly Olds • Neil E. I. Langlois • Peter Blumbergs • Roger W. Byard Accepted: 9 January 2014 Ó Springer Science+Business Media New York 2014 Case report A 47-year-old man with a history of alcoholic liver disease was found dead at his home address on the floor, lying face down. He had been unwell for 2 months prior to death and had complained of abdominal pain. He also had a diagnosis of prolonged QT interval. At autopsy there was no evidence of liver failure although the liver was fatty and fibrotic. There was a congenital anomaly of the coronary arteries with the cir- cumflex coronary artery arising from the right sinus of Valsalva with significant narrowing of the ostium. There was no evidence of trauma and toxicological screening of blood was unremarkable. Biochemical analysis of vitreous humor revealed elevated sodium (144 mmol/L) and creat- inine (217 lmol/L) levels in keeping with terminal dehy- dration and renal failure, with a normal b-hydroxy butyrate (thus excluding alcoholic ketoacidosis). Although the brain appeared externally unremarkable with no vermal atrophy of the cerebellum, sectioning of the mammillary bodies demonstrated symmetrical hemorrhage highly suggestive of Wernicke encephalopathy (Figs. 1, 2). Focal hemorrhagic areas were also noted within the walls of the third ventricle. Microscopically the mammillary bodies displayed recent microhemorrhages and prominent microvascular proliferation with endothelial swelling typical of Wernicke encephalopathy (Fig. 3). The mammillothalamic tracts and the walls of third ventricle also contained microhemor- rhages. There was patchy microvacuolation of the neuropil with unremarkable neurons, fibrous astrocytes, and occa- sional perivascular macrophages containing hemosiderin, indicative of more chronic disease. Mild extravasation of erythrocytes and prominent congested vessels were noted within medullary dorsal motor vagal nuclei. Death was attributed to natural causes, most likely involving a combination of cardiac and alcohol-related disease. The striking finding was of clinically unsuspected Wernicke encephalopathy. Discussion Wernicke encephalopathy is a neurological disorder resulting from thiamine (vitamin B-1) deficiency [1]. Although in Western countries it occurs predominantly in alcoholics, related to poor dietary intake and impaired utilization, it can also be caused by a variety of other conditions that interfere with normal thiamine metabolism. These include starvation, bariatric surgery, hyperemesis gravidarum, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and in infants given thiamine-deficient formulas [1, 2]. The clinical prevalence of Wernicke encephalopathy is uncertain as autopsy studies indicate that the condition is likely under-diagnosed during life [3]. Delay in diagnosis may result from nonspecific symptoms that resemble intoxication. The symptoms, severity, and the regions of the brain that are affected are also variable due to a K. Olds Á N. E. I. Langlois Á R. W. Byard School of Medical Sciences, The University of Adelaide, Frome Road, Adelaide, SA 5005, Australia N. E. I. Langlois Á P. Blumbergs Á R. W. Byard Forensic Science SA, Adelaide, SA 5005, Australia R. W. Byard (&) Discipline of Anatomy and Pathology, Level 3 Medical School North Building, The University of Adelaide, Frome Road, Adelaide, SA 5005, Australia e-mail: roger.byard@sa.gov.au 123 Forensic Sci Med Pathol DOI 10.1007/s12024-014-9535-x