Background: Gayet-Wernicke’s encephalopathy is a serious complication of thiamine deficiency. Chronic alcoholism is recognized as the most commun cause of Gayet-Wernicke’s encephalopathy, but other causes including malnutrition, chronic vomiting, prolonged fasting, and exclusive artificial feeding have been documented.

Objectives: We report a case of Gayet-Wernicke’s encephalopathy complicating uncontrollable vomiting secondary to severe Methotrexate intolerance.

Methods: Case report

Results: A 47-year-old women with rheumatoid arthritis. She was put under methotrexate at the dose of 15 mg/week, 1 month prior to admission into our department for the management of an acute febrile polyarthritis associated to severe and uncontrollable gastrointestinal intolerance to Methotrexate. There was no abdominal pain or transit problem. One month later, she experienced temporo-spatial disorientation, somnolence, horizontal nystagmus, and vertigo attacks with visual hallucinations and memory problems. The muscular forces at the four limbs were decreased to 3/5 with abolished osteotendinous reflexes at the two lower limbs. MRI showed hyperintense signals on T2 and FLAIR image in thalamus, periaqueducal area and mamillary bodies. Electroneuromyography (ENMG) showed axonal motor neuropathy in all 4 limbs. The hemogram showed normochromic normocytic anemia. Laboratory testing for Vitamin B12, vitamin D, folate and minerals showed multiple deficiencies. A multivitamin supplementation was introduced with good evolution.

Conclusion: This is the first case of severe digestive intolerance to methotrexate leading to a serious neurological complication. Although digestive intolerance to methotrexate is considered benign, it can be daunting. Thorough knowledge of complications and close monitoring of patients must be imperative. Gayet Wernicke encephalopathy is a rare and serious pathology. We should keep it in mind and prevent it in risky situations.

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[2] osiezagha K, ali s, freeman c, et al. thiamine deficiency and delirium. Innov clin neurosci 2013;10:26-32.

[3] manzo g, de gennaro a, cozzolino a, et al. mr imaging findings in alcoholic and nonalcoholic acute wernicke’s encphalopathy : a review. Biomed res Intern 2014; 2014:503596.

Disclosure of Interests: None declared