A 55-year-old woman developed Wernicke encephalopathy (WE) during neoadjuvant FOLFOX therapy for rectal adenocarcinoma, highlighting diagnostic challenges and the role of thiamine deficiency in oncology patients, according to a case report and review published in Cureus.
The patient, treated with folinic acid, fluorouracil, and oxaliplatin, presented with intractable nausea, gait disturbance, and cognitive impairment. Despite normal contrast-enhanced MRI results, low serum thiamine levels and therapeutic response to intravenous thiamine confirmed the diagnosis. This case underscores the risk of WE in cancer patients, particularly those with malnutrition or metabolic stress from chemotherapy.
Case Details and Diagnostic Challenges
The 55-year-old Caucasian woman, undergoing neoadjuvant FOLFOX for stage III rectal adenocarcinoma, experienced progressive weight loss, fatigue, and neurological symptoms. She reported episodes of dizziness and diarrhea linked to chemotherapy cycles, with a 23% weight loss over six cycles. Physical examination revealed mild cognitive impairment and a wide-based gait, but no focal neurological deficits. Initial lab results included low serum thiamine levels, though MRI of the brain showed no acute abnormalities.
Wernicke Encephalopathy During Neoadjuvant Folinic Acid, Fluorouracil, and Oxaliplatin
Diagnosing WE in this context was complicated by atypical presentations. While the classic triad of altered mental status, oculomotor dysfunction, and gait ataxia is well-documented, only a minority of cases exhibit all three symptoms. The patient’s malnutrition, exacerbated by chemotherapy-induced mucositis and poor oral intake, likely contributed to thiamine deficiency. Cureus notes that cancer-related risk factors—such as increased metabolic demands and chemotherapy-induced thiamine dysfunction—raise the stakes for timely diagnosis.
Atypical Imaging Findings in Similar Cases
A 2024 case report from Radiology Case Reports describes a 60-year-old woman with depression who developed WE with atypical imaging findings. Her MRI showed abnormal signals in the thalamus, cerebral aqueduct, and cortex, alongside intracranial hemorrhage. Though distinct from the FOLFOX case, this highlights how WE can present variably, particularly in nonalcoholic populations. Radiology Case Reports emphasizes the need for clinicians to consider WE in depressed patients with altered consciousness, even when imaging does not align with typical patterns.
The contrast between these cases underscores the diagnostic complexity of WE. While the FOLFOX patient had normal MRI results, the depression case showed structural abnormalities. Both scenarios, however, point to thiamine deficiency as a critical, often overlooked factor. Cureus warns that delayed recognition of thiamine deficiency can lead to irreversible neurologic damage, particularly in vulnerable populations like cancer patients.
Wernicke encephalopathy with atypical imaging findings in a depressed
Treatment and Outcomes
Empiric high-dose intravenous thiamine was administered to the FOLFOX patient, leading to clinical improvement. However, the case report notes that thiamine deficiency often goes undetected in oncology settings, where symptoms may be attributed to the underlying cancer or chemotherapy side effects. Cureus recommends routine thiamine level monitoring for patients on FOLFOX, especially those with risk factors like malnutrition or prolonged gastrointestinal symptoms.
The 60-year-old depression case also received thiamine treatment, with MRI improvements noted after two weeks. However, persistent altered consciousness suggested ongoing metabolic or neurologic compromise. Radiology Case Reports stresses the importance of nutritional assessment in patients with prolonged depression, as malnutrition can exacerbate thiamine deficiency and complicate recovery.
Implications for Oncology Practice
FOLFOX – NCI
These cases highlight the need for heightened vigilance in cancer patients receiving FOLFOX. Thiamine deficiency is rare but potentially severe, and its symptoms can overlap with those of cancer or chemotherapy. Cureus advises clinicians to consider WE in patients with unexplained neurological symptoms, even if imaging appears normal. Early intervention with thiamine can prevent long-term disability.
For oncologists, this means integrating nutritional assessments into routine care. The National Cancer Institute (NCI) notes that FOLFOX is used to treat colorectal cancer, but its metabolic impacts require close monitoring. Patients with prolonged nausea, vomiting, or weight loss should be evaluated for thiamine deficiency, regardless of their alcohol use history.
The 55-year-old patient’s case was authored by Hiroyuki Tokue, Rei Ishikawa, Kiyohiro Oshima, Yusuke Sawada, Yuto Aramaki, Kei Kawano, Takumi Nihei, Kouta Isogai, Kohei Kawahara, Takayuki Yokota, Hiroyuki Yasui, Miho Ikeya, Tamaki Okabe, Azusa Tokue, and Yoshito Tsushima, affiliated with the Department of Diagnostic and Interventional Radiology and the Department of Emergency Medicine at Gunma University Hospital and Graduate School of Medicine in Japan. The 60-year-old depression case, published in Radiology Case Reports on February 13, 2024, with an eCollection date of May 2024, was also attributed to these authors.
The FOLFOX regimen, comprising leucovorin calcium (folinic acid), fluorouracil, and oxaliplatin, is approved by the Food and Drug Administration (FDA) to treat cancer or related conditions, according to the NCI Drug Dictionary. This combination is used to treat colorectal cancer and may be combined with other therapies. The NCI emphasizes that drug information is educational and not a substitute for medical advice, urging patients to consult healthcare professionals for personalized guidance.
Readers should note that while these cases highlight thiamine deficiency as a risk in oncology, they do not establish causation or recommend universal screening. Clinical decisions should be made in consultation with qualified professionals, as individual patient contexts vary widely.
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