Wagner Phillip, Bui Thuy
Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
Int Med Case Rep J. 2022 Aug 4;15:399-403. doi: 10.2147/IMCRJ.S377779. eCollection 2022.
We present the case of a 49-year-old woman who underwent a 237-day hunger strike on the streets of Pittsburgh, Pennsylvania. Despite medical supervision and appropriate micronutrient supplementation, including higher-than-recommended dosing of oral thiamine, the patient developed Wernicke's Encephalopathy and subsequent Korsakoff Syndrome. She is now permanently impaired.
Hunger strikers are subject to numerous sequelae of micronutrient deficiency. Among these are the paired conditions of Wernicke's Encephalopathy and Korsakoff Syndrome, conditions secondary to prolonged thiamine deficiency. Unfortunately, few published guidelines exist regarding the medical management of hunger strikers. Preventative dosing guidance is borrowed from what is recommended for prolonged malnourishment from eating disorders or chronic alcohol use. Available guidelines are rarely academic. Rather, they were created by governmental agencies for the management of hunger strikers in prison or similar states of detention or incarceration. There is an indirect body of evidence that oral thiamine supplementation is rarely protective against the sequelae of thiamine deficiency in hunger strikers. We discuss supplementation recommendations and the evidence for their failure in practice. We briefly explore the historical evidence for the anatomic and physiologic changes of prolonged starvation that potentially explain this treatment failure, and offer alternatives to standard supplementation.
The current recommendations of the management of hunger strikers regarding the prevention of thiamine deficiency are inadequate, and rarely prevent the clinical sequelae. Alternate management strategies need to be both researched and empirically used, while that research is being carried out. Novel lipid-soluble thiamine derivatives have promise, but prophylactic intravenous/intramuscular thiamine should be explored as the current standard of care.
我们报告一例49岁女性，她在宾夕法尼亚州匹兹堡街头进行了为期237天的绝食抗议。尽管有医疗监督并补充了适当的微量营养素，包括高于推荐剂量的口服硫胺素，但该患者仍患上了韦尼克脑病及随后的科萨科夫综合征。她现在留下了永久性损伤。
绝食抗议者易出现多种微量营养素缺乏的后遗症。其中包括韦尼克脑病和科萨科夫综合征这两种相关病症，它们是长期硫胺素缺乏的继发病症。不幸的是，关于绝食抗议者医疗管理的已发表指南很少。预防性给药指导借鉴了饮食失调或长期酗酒导致的长期营养不良的推荐方案。现有的指南很少是学术性的。相反，它们是由政府机构制定的，用于管理监狱或类似拘留或监禁状态下的绝食抗议者。有间接证据表明，口服硫胺素补充剂很少能预防绝食抗议者硫胺素缺乏的后遗症。我们讨论了补充剂的建议及其在实践中失败的证据。我们简要探讨了长期饥饿导致的解剖学和生理学变化的历史证据，这些变化可能解释了这种治疗失败的原因，并提供了标准补充剂的替代方案。
目前关于绝食抗议者硫胺素缺乏预防管理的建议并不充分，很少能预防临床后遗症。在进行相关研究的同时，需要对替代管理策略进行研究并加以实际应用。新型脂溶性硫胺素衍生物有前景，但预防性静脉注射/肌肉注射硫胺素应作为当前的护理标准进行探索。
