<prompt> In alcoholics which vitamin should be replenished with carbohydrates?Vitamin B12RiboflavinThiaminFolic acid  <response>: Ans. c Thiamin Ref: Harrisons Internal medicine 18thch. 275 and fig. 275-7WERNICKES SYNDROME Due to Thiamine deficiency, seen in alcoholic patients. See for.- Global confusion- Ophthmaparesis- Ataxia Site of lesion:- Demylination and atrophy of mamillary bodies- DM nuclei of thalamus PATHOGENESIS: Thiamine is a cofactor of several enzymes, including transketolase, pyruvate dehydrogenase, and alpha-ketoglutarate dehydrogenase. Thiamine deficiency produces a diffuse decrease in cerebral glucose utilization and results in mitochondrial damage. Glutamate accumulates owing to impairment of alpha-ketoglutarate dehydrogenase activity and, in combination with the energy deficiency, may result in excitotoxic cell damage. CEMRI :reveals abnormal enhancement of the mammillary bodies, typical of acute Wernickes encephalopathy. TREATMENT: It is a medical emergency. It requires immediate administration of thiamine, in a dose of 100 mg either IV or IM. The dose should be given daily until the patient resumes a normal diet and should be begun prior to treatment with IV glucose solutions. Glucose infusions may precipitate Wernickes disease in a previously unaffected patient or cause a rapid worsening of an early form of the disease. For this reason, thiamine should be administered to all alcoholic patients requiring parenteral glucose.Wernicke-Korsakoff syndrome--confusion, ophthalmoplegia, ataxia classic triad confabulation, personality change, memory loss permanent. May progress to irreversible memory loss, confabulation, personality change Korsakoff psychosis.Amygdala bilateralKluver-Bucy syndrome hyperorality, hypersexuality, disinhibited behavior.Associated with HSV-1.Frontal lobeDisinhibition and deficits in concentration, orientation, and judgment; may have reemergence of primitive reflexesRight parietal-temporal cortexSpatial neglect syndrome agnosia of the contralateral side of the worldLeft parietal-temporal cortexAgraphia, acalculia, finger agnosia, and left-right disorientationGerstmann syndrome.Reticular activating system midbrainReduced levels of arousal and wakefulness e.g., comaMammillary bodies bilateralWernicke-Korsakoff syndrome: confusion, ophthalmoplegia, ataxia; memory lossanterograde and retrograde amnesia, confabulation, personality changes.Associated with thiamine Bl deficiency and excessive EtOH use; can be precipitated by giving glucose without Bl.Basal gangliaMay result in tremor at rest, chorea, or athetosisCerebellar hemisphereIntention tremor, limb ataxia, and loss of balance; damage to the cerebellum results in ipsilateral deficits; fall toward side of lesionCerebellar vermisTruncal ataxia, dysarthriaSubthalamic nucleusContralateral hemiballismusHippocampus bilateralParamedian pontine reticularAnterograde amnesia--inability to make new memoriesformationEyes look away from side of lesionFrontal eye fieldsEyes look toward lesion 