To the Editor.—In his letter, Dr Marinella1 claims, "Thiamine should be administered prior
to a glucose load because cases of Wernicke encephalopathy have been reported
after glucose administration in thiamine-deficient patients." The reference
that supports this statement describes only 4 patients.2
The first was a 27-year-old woman with weight loss for more than 6 months,
gastrointestinal symptoms for 3 days, and the onset of dizziness and blurring
of her vision. She had tachycardia, confusion, ataxia, absent deep tendon
reflexes, and horizontal nystagmus. After treatment with 3 L of 5% dextrose
for more than 24 hours, her symptoms worsened. The second patient was a 79-year-old
woman with schizophrenia, anorexia, weight loss, horizontal nystagmus, absent
deep tendon reflexes, and a temperature of 33°C; the diagnosis was septicemia.
After 2 L of dextrose, she developed bilateral sixth nerve palsies, disorientation,
and coma. The third patient was a 45-year-old woman with end-stage renal failure
who began peritoneal dialysis and lost 6.3 kg in 6 months. Her peritoneal
dialysis fluid was switched to hypertonic glucose 48 hours prior to the development
of disorientation, nystagmus, and a sixth nerve palsy. The fourth patient,
a 36-year-old alcoholic man, developed renal failure secondary to rhabdomyolysis
and required hemodialysis. Five days after the initiation of a 20% dextrose
infusion he developed nystagmus, bilateral sixth nerve palsies, areflexia,
hypotension, and disorientation. All patients improved with thiamine administration.