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CASE REPORT
Year : 2016  |  Volume : 38  |  Issue : 2  |  Page : 147-149  

Marchiafava: Bignami disease treated with parenteral thiamine


1 Department of Psychiatry, Government Medical College, Surat, India
2 Department of Psychiatry, B. J. Medical College, Ahmedabad, Gujarat, India

Date of Web Publication16-Mar-2016

Correspondence Address:
Ritambhara Yeshwant Mehta
E 2/7 Professors Bungalow, New Civil Hospital, Majura Gate, Surat - 395 001, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7176.178810

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   Abstract 

Marchiafava - Bignami disease is rare sequelae of chronic alcohol use. We present a case with transient ischemic attack like presentation and its management with parenteral thiamine. A 53 year old male with history of country liquor use since 32 years was brought to hospital with acute onset of delirium & mild weakness involving motor functions of left side of the body, non-reactive planters and exaggerated tendon reflexes on left side. The MRI showed bilateral hyper intense signal on T2W and FLAIR images & Hypo intense lesion on T1W images involving body, genu and splenium of corpus callosum. The features are suggestive of Marchiafava - Bignami Disease. There have been few guidelines for management of MBD and literature supports use of parenteral thiamine 500mg leading to remission of symptoms and symptomatic improvement. It is advisable to use parenteral thiamine in all cases as it overlaps management of other co-morbidities of chronic alcoholism.

Keywords: Alcohol, marchiafava bignami disease, parenteral thiamine


How to cite this article:
Nemlekar SS, Mehta RY, Dave KR, Shah ND. Marchiafava: Bignami disease treated with parenteral thiamine. Indian J Psychol Med 2016;38:147-9

How to cite this URL:
Nemlekar SS, Mehta RY, Dave KR, Shah ND. Marchiafava: Bignami disease treated with parenteral thiamine. Indian J Psychol Med [serial online] 2016 [cited 2019 Sep 15];38:147-9. Available from: http://www.ijpm.info/text.asp?2016/38/2/147/178810


   Introduction Top


Patients of Alcohol use disorder have a conglomeration of clinical features. Marchiafava-Bignami (MBD) a disease seen mostly in chronic alcoholics that results in progressive demyelination and necrosis of the corpus callosum. [1] Magnetic Resonance Imaging (MRI) of brain showing Corpus Callosum (CC) involvement forms the hallmark of the disease. The clinical presentation however includes a large variety of presentations, with no specific or pathognomonic clinical features. Following is a case report of a patient who presented with clinical picture resembling a transient ischaemic attack.


   Case report Top


A 53-year-old illiterate man, working as a peon, was brought to hospital with acute onset of unresponsiveness and a fall at home. Thereafter he was unable to walk by himself and not able to speak clearly. Patient had been consuming alcohol (Both Indian Manufactured foreign liquor and country Liquor) for last 32 years. Daily use was up to 1200-1500 ml/day of country liquor. Patient had developed heavy use for last 12 years; there was a past history of hepatic de-compensation with history of jaundice.

Patient had poor built and nourishment with darkened areas over the sun exposed parts indicative of pellagra lesions. The patient was not oriented to time and place and had difficulty in speaking clearly. Patient was able to identify his relatives. The neurological examination revealed mild weakness involving left side of the body, non-reactive planters and exaggerated tendon reflexes on left side. Patient also had impaired joint position sense and fine touch involving lower extremities with swelling of both knee joints. Mini Mental Status Examination (MMSE) was 11 at the time of admission.

Blood investigations showed reduced platelets (92000/cu.mm) and raised ALT (112 IU/l). Patient's computed tomography (CT) scan showed features suggestive of changes of global ischemia. Due to suspected cerebrovascular event and inconclusive CT findings MRI was done.

The MRI revealed findings of bilateral hyper intense signal on T2W and FLAIR images. There was Hypo intense lesion on T1W images involving body, genu and splenium of corpus callosum (CC). Subtle restriction diffusion noted. The features are suggestive of Marchiafava-Bignami Disease (MBD).

Hyper intense signal on T2W and FLAIR images involving bilateral fronto-parietal subcortical region [Figure 1] and [Figure 2].
Figure 1: T2 weighted showing hyperintense lesion at Genu of Corpus callosum

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Figure 2: Image showing hyperintense lesion involving body of corpus callosum

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Patient was given intravenous (IV) Thiamine 500 mg/day with Injection 5% Dextrose and Normal Saline (NS). For alcohol withdrawal Tab. Lorazepam 2 mg HS was started and tapered slowly. During the course of admission gradually there was return of power and gait improved. Increment in MMSE was till 21 but deficits in memory, attention and language remained [Figure 3].
Figure 3: Showing the improvement of MMSE score on parenteral thiamine therapy

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   Discussion Top


MBD was named after two Italian pathologists who described acute demyelination of the CC at necropsy in three South-Italian male red-wine drinkers. [2] The CC comprises axons connecting the cortices of the two cerebral hemispheres and is the principal white matter fiber bundle in the brain. [3] The best method to assess Callosal lesions is sagittal MRI for visualizing the entire CC, which also assumes a pivotal role in distinguishing MBD from other diseases, as the lesions affect the central layers of the CC and are remarkably symmetric. [4]

Heinrich et al., [5] have discussed it as two principal subtypes of MBD may be differentiated: Coma or stupor is the predominant clinical feature in one - referred to as type A-, versus a normal or at most slightly impaired level of consciousness in the other, type B respectively. Since neuroimaging has proved to be a suitable tool for in-vivo diagnosis of MBD. [5]

Raina et al., [13] have described on basis of the onset as acute MBD disease includes seizures, Impairment of consciousness, and rapid death. Sub-acute MBD includes variable degrees of mental confusion, dysarthria, behavioural abnormalities, memory deficits, signs of interhemispheric disconnection, and impairment of gait. Chronic MBD, which is less common, is characterised by mild dementia that is progressive over years. [Table 1] shows few case reports in literature with respect to clinical presentation, treatment and outcome.
Table 1: Case reports of marchiafava bignami disease

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   Conclusion Top


It is evident from above that it may be imperative to suspect MBD in a patient with delirium and neurological signs, which show improvement with Thiamine therapy. Clinical clues for the disease are reduced consciousness, psychotic and emotional symptoms, depression and apathy, aggression, seizures, hemiparesis, ataxia, apraxia and frequently leading to coma and death. [10] Hence sharp clinical acumen and urgent neuroimaging can help in early diagnosis. It is advisable to use parenteral thiamine in all cases as it overlaps management of other co-morbidities of nutritional deficiencies and Wernicke Korsakoff syndrome commonly seen in alcohol use disorders. There have been few guidelines for management of MBD and literature supports use of parenteral thiamine [14] (500 mg/day for 5 days atleast) leading to remission of symptoms and symptomatic improvement.

 
   References Top

1.
Arbelaez A, Pajon A, Castillo M. Acute Marchiafava-Bignami disease: MR findings in two patients. AJNR Am J Neuroradiol 2003;24:1955-7.  Back to cited text no. 1
    
2.
Marchiafava E, Bignami A. Spora unàlterazione del corpo callosoosservata in soggeti alcoolisti. Riv Patol Nerv Ment 1903;8:544-9.  Back to cited text no. 2
    
3.
Mooshagian E. Anatomy of the corpus callosum reveals its function. J Neurosci 2008;28:1535-6.  Back to cited text no. 3
    
4.
Friese SA, Bitzer M, Freudenstein D, Voigt K, Küker W. Classification of acquired lesions of the corpus callosum with MRI. Neuroradiology 2000;42:795-802.  Back to cited text no. 4
    
5.
Heinrich A, Runge U, Khaw AV. Clinicoradiologic subtypes of Marchiafava-Bignami disease. J Neurol 2004;251:1050-9.  Back to cited text no. 5
    
6.
Tung CS, Wu SL, Tsou JC, Hsu SP, Kuo HC, Tsui HW. Marchiafava-Bignami disease with widespread lesions and complete recovery. AJNR Am J Neuroradiol 2010;31:1506-7.  Back to cited text no. 6
    
7.
Wagh SJ, Dabhi AS, Thorat PB, Vasava JF, Modia JP, MJ Shah Marchiafava-Bignami disease - A rare presentation of chronic alcoholism. J Indian Acad Clin Med 2012;13:59-61.  Back to cited text no. 7
    
8.
Hoshino Y, Ueno Y, Shimura H, Miyamoto N, Watanabe M, Hattori N, et al. Marchiafava-Bignami disease mimics motor neuron disease: Case report. BMC Neurol 2013;13:208.  Back to cited text no. 8
    
9.
Sena P, Nzwalo H, Ferreira F, Drago J, Soleiro L. marchiafava-bigmani disease in relation to pure alcohol consumption. J Neuropsychiatry Clin Neurosci 2013;25:E71-2.  Back to cited text no. 9
    
10.
Duk LN, Tae GL, Han BL, Seong HP, Kee HC. Marchiafava-Bignami disease: Clinical and MRI findings in two patients. Seoul J Med 1994;35:203-6.  Back to cited text no. 10
    
11.
Haas L, Tjan D, Van Die J, Vos A, van Zanten A. Coma in an alcoholic: Marchiafava-Bignami disease. N Z Med J 2006;119:U2280.  Back to cited text no. 11
    
12.
Rawat JP, Pinto C, Kulkarni KS, Muthusamy MA, Dave MD, Marchiafawa bignami disease possibly related to consumption of a locally brewed alcoholic beverage: Report of two cases. Indian J Psychiatry 2014;56:76-8.  Back to cited text no. 12
    
13.
Raina S, Mahesh DM, Mahajan J, Kaushal SS, Gupta D, Dhiman DS. MarchiafavaBignami Disease. JAPI. 2008; 56:633-35.  Back to cited text no. 13
    
14.
The Maudsley′ Prescribing Guidelines. 10 th ed. Editor - David Taylor. Informa Health Care; 2009, Pg. 295.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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