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25 Cards in this Set

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...: a combination of psychic and autonomic hyperactivity, occurring usually after 3 to 5 days of alcohol abstinence (can occur as late as 14 days later)
-Overall, only 5 to 6% of individuals develop this condition
-30 to 40% of individuals who have withdrawal seizures and do not receive medical treatment will go on to develop this
-These individuals are agitated, confused, hallucinating (visual, auditory), febrile, tachycardic, hypertensive, diaphoretic
-Usually lasts about 3 days
Delirium tremens
Delirium tremens: Treatment
-... (administered before any ... is given so as not to precipitate Wernicke-Korsakoff Syndrome). Vitamin replacement
-Benzodiazepines reduce anxiety and tremors and may also help prevent seizures (usually always utilized)
-Beta-blockers or clonidine can help control autonomic dysfunction
-Phenytoin or phenobarbital (an anticonvulsant) for seizures, if needed (can both be given by IV)
Thiamine
glucose
Marchiafava-Bignami Disease:

Pathological changes in the ... of the ... (reason unknown)
-Long-term alcohol use is a risk factor, but not the only one
-This condition is very rare, and can be seen in non-alcoholics
-Used to be thought to occur only in Italians, but has been seen in other populations

Clinical presentation
-Progressive dementia, disinhibited, or aggressive
-... neurological deficits, often focal in nature (mini-strokes)
-Seizures and impaired consciousness may be terminal events
middle lamina
corpus callosum
Transient
Thiamine (B1) Deficiency
... Syndrome

The metabolically active form of thiamine is ...

TPP is critical in the intermediary metabolism of carbohydrate

TPP is involved in three enzyme systems
-Pyruvate dehydrogenase (pyruvate to acetyl coenzyme A)
-Alpha-ketogluterate dehydrogonase (alpha-ketogluterate to succinate)
-Transketolase (catalyzes the pentose monophosphate shunt)
Wernicke-Korsakoff
thiamine pyrophsphate (TPP)
Thiamine (B1):

-Most abundant in yeast, pork, legumes, grains, and rice
-Total body stores is 30 to 100 mg (heart, skeletal muscle, liver, kidneys, and brain) and must be constantly replenished
-Severe neurological problems may arise after... weeks of total depletion
6
... encephalopathy
-Confusion
-Ataxia
-Oculomotor palsies and nystagmus

... psychosis
-Confusion
-Memory impairment
*Inability to form new memories
Wernicke’s
Korsakoff’s
Thiamine (B1) Deficiency
Wernicke-Korsakoff Syndrome

Patients at risk for deficiency
-Carbohydrates derived primarily from ...
-Alcoholics
-... (vomiting due to pregnancy often develop this)
-Eating disorders/ reduced caloric intake
-After gastric bypass
-Intractable vomiting following gastric stapling
-Malabsorption

MRI brain may show abnormal signal in ... structures, including the periaqueductal gray matter
milled rice
Hyperemesis gravidarum
midline
Thiamine (B1) Deficiency
Wernicke-Korsakoff Syndrome

Neuropathological findings:
-capillary proliferation and ...
- degenerative changes in ... structures (medial thalamic nuclei, mammillary bodies, periaquaductal gray area of the mesencephalon, and pontine tegmentum
-Degeneration of the superior cerebellar ...
petechiae
midline
vermis
Thiamine (B1) Deficiency
Wernicke-Korsakoff Syndrome

Treatment
-Administer 100 mg of thiamine ... followed by 100 mg ... daily for 3 to 5 days
-Continue ... thiamine 50 mg daily
-Address the cause, if possible

Very important point!
-Wernicke-Korsakoff Syndrome can be precipitated in a patient if ... is administered before thiamine

Always give ... before ...!
intravenously
intramuscularly
oral
glucose
thiamine
glucose
Cobalamin (vitamin ...) deficiency:

-Total body store is 2000 to 5000 mcg, half of which is stored in the liver
-It takes about ... to ... years to deplete stores due to malabsorption and about ... to ... years due to strict vegetarian diet
-The most common cause of deficiency is ... (autoimmune parietal cell dysfunction)

Other causes of deficiency
-Ileal resection
-Parasitic infections
-Crohn’s disease and other malabsorption states
-Chronic alcoholism with poor diet
-History of gastric resection
B12
2 to 5
10 to 20
pernicious anemia
Cobalamin (B12) deficiency:

Clinical Features
-Sensorimotor and autonomic ... neuropathy
-... dysfunction (Dementia, psychosis)
-Subacute combined degeneration (Demyelination of the posterior columns, corticospinal tracts, and ... matter of the cerebral hemispheres)

Neurological Signs and Symptoms
-Paresthesias, Numbness, Gait ataxia, Incontinence, Weakness, Cognitive dysfunction, Spasticity, Other non-specific complaints

Laboratory Studies
-Check serum ... level, homocysteine level, and methylmalonic acid level, intrinsic factor antibody
peripheral
Cerebral
white
B12
... exposure can lead to Cobalamin (B12) Deficiency
Nitrous Oxide (NO)
Nitrous oxide is a potent oxidizing agent which irreversibly oxidizes the cobalt core of cobalamin from a 1+ valence state to 3+ valence state, rendering ... inactive
-This effectively inhibits the conversion of homocysteine to ..., thus interdiciting the supply of S-adenosylmethionine
methylcobalamin
methionine
Cobolamin (B12) Deficiency:

Treatment
-... injections of 1000 mcg daily for 5 days, weekly for 4 weeks, then monthly
-After IM treatment has replenished stores, can usually maintain level with oral or intranasal supplementation
Intramuscular (IM)
Pyridoxine (vitamin ...) deficiency

-Pyridoxyl phosphate is the active biochemical form
-It is a coenzyme of amino acid metabolism, particularly tryptophan and methionine
-Deficiency inhibits lipid and myelin synthesis
-Because tryptophan is required for niacin production, secondary niacin deficiency can occur
-Found in chicken, grains, oranges, tomato juice, bananas, avocados
B6
Pyridoxine (B6) deficiency:

Deficiency can result from
-Poor ...
-Patients on isoniazid and hydralazine (people being treated for ...)
-Chronic ... use
-Infants of pyridoxine-deficient mothers
diet
tuberculosis
alcohol
Pyridoxine (B6) deficiency:

Clinical features
-Peripheral neuropathy (burning sensory neuropathy)
-Skin changes (rough skin) very similar to pellagra (due to niacin deficiency) (Dementia, diarrhea, dermatological changes)
-Depression, confusion, irritability
-Neonatal seizures
-Treatment is with ...
oral replacement
Vitamin E Deficiency

... is the most active form of vitamin E in humans

Serves as an ... preventing free radical peroxidation and injury to cell membranes
-Deficiency results in cell ... injury

It is stored in ... tissue
Alpha-tocopherol
antioxidant
membrane
adipose
Vitamin E Deficiency:

Clinical presentation
-... (truncal and appendicular)
-Areflexia
-Posterior column dysfunction
-Opthalmoplegia
-Dysarthria
-Generalized ...
-... in individuals with abetalipoprotinemia

Treatment: Oral or injectable replacement
Ataxia
weakness
Retinitis pigmentosa
...:

Pyridoxine excess produces a predominantly sensory neuropathy

Vitamin E excess can cause muscle weakness (myopathy)

Vitamin A excess can be associated with benign intracranial hypertension (pseudotumor cerebri)
Hypervitaminoses
...:

-First described in 1959 in malnourished alcoholics
-Later noted to occur in hospitalized patients undergoing hydration

Pathophysiology
-Demyelinating lesions within the pons (lesions can also occur outside the pons)
-Appears to related to overcorrection of hyponatremia (an increase of 25 mEq/L during the first 24-48 hours) (due to low sodium)

Other possible contributing factors:
-Hypoxic event
-Severe liver disease
Central Pontine Myelinolysis
look at slide 49
ok
Central Pontine Myelinolysis:

Chronic hyponatremia should be corrected at a rate below ...mEq/L (slowly) during any 24 hour period

Avoid delay in correcting acute hyponatremia, since symptomatic hyponatremia may result in ... insufficiency
10
respiratory
...:

Potential complication of weight-reduction surgery

Syndrome consisting of:
-Acute to subacute sensory loss
-Weakness
-Areflexia
-Encephalopathy identical to Wernicke-Korsakoff Syndrome
-Usually follows a period of dramatic weight loss and repeated bouts of vomiting
Postgastroplasty Polyneuropathy
Postgastroplasty Polyneuropathy:

The pathophysiology is not known
-May be due to rapid mobilization of ...
-Likely not due simply to ... deficiency, since the condition can develop despite nutritional supplementation

Treatment is supportive
-Parenteral nutrition
-Vitamins
lipids
vitamin