Thiamine Deficiency Presenting as Intraventricular Hemorrhage

A 48-year-old man with hypertension, coronary artery disease, and obesity presented with a 6-week history of nausea, vomiting, decreased oral intake with 40-pound weight loss, and lethargy. Laboratory results were significant for low platelet count of 71 000 per mm3, slight elevation of prothrombin time/partial thromboplastin time and international normalized ratio acute kidney injury, and mild elevation of transaminases. Initial computed tomography of the head was unremarkable for acute intracranial findings (Figure [A]). Lumbar puncture revealed elevated opening pressure of 41 mm Hg but otherwise normal cerebrospinal fluid studies. After fluid repletion with D5 normal saline, there was a gradual decline in the patient’s mental status requiring endotracheal intubation for airway protection. Repeat computed tomography of the head 3 days after initial presentation showed bilateral thalamic hemorrhage with extension into the third ventricle (Figure [B]). Brain magnetic resonance imaging (MRI) showed increased T2 flair signal at the medial thalami (Figure [C]), peri-aqueductal region of midbrain, and the mammillary bodies (Figure [D]). Initial management included blood pressure control, platelet transfusion, fresh frozen plasma administration, and external ventricular drain placement. Digital subtraction angiography showed no evidence of underlying vascular anomaly. Computed tomography scan of the abdomen showed splenic enlargement and liver cirrhosis likely accounting for the elevated transaminases, mild coagulopathy, and low platelet level. The patient continued to be obtunded, requiring mechanical ventilation and vasopressors. Metabolic workup was notable for a thiamine level of 37 μg/dL (normal reference range: 78–185 μg/dL). Additional management included thiamine repletion and lactulose. Three days later, the patient was able to be weaned off vasopressor support and extubated after 5 days. His platelet count, coagulation studies, and transaminases normalized over time. His mental status and neurological function slowly improved during the course of his hospitalization. The patient was eventually discharged to rehab with short-term memory …