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1
Q

Wool processing, fever, chest pain, hemoptysis, widened mediastinum, gram positive rods form medusa head colonies on standard media. The bacteria most likely produce?

A

Antiphagocytic D glutamate gapsule

Pulmonary anthrax–>Hemorrhagic mediastinitis
Spores–>Cells–>Three part anthrax toxin
Antiphagocytic capsule is required for pathogenicity. Capsule contains D glutamate instead of polysaccharide.
B. anthracis is aerobic organism that can be grown on standard culture media and forms nonhemolyzing colonies. Forms chains=Serpetine or medusa head colonies.

Other virulence factors:
Protein A=Staph aureus (binds Fc portion of IgG and prevents opsonization and complement killing of bacteria)
Polyphosphate granules=Corynebacterium diptheriae can be seen on Loeffler medium and stained with methylene blue.
Peritrichous flagella: Flagella distributed uniformly over entire surface of bacterial cell. Characteristic of motile organisms like Proteus mirabilis.

2
Q

Crohn’s disease: Patient overexpresses transcription factor NF-KB which stimulates:

A

Cytokine production

Genetics:
Crohn’s=HLA-DR1/DQw5
Ulcerative colitis=HLA-DR2
NOD2=Nucleotide binding oligomerization domain. Acts as intracellular microbial receptor that triggers NF-kB pathway. NF-kB is responsible for cytokine production. Causes chronic inflammation in GI tract.

3
Q

5 yo boy with severe recurrent respiratory infections (infected by specific type of bacteria every time). Patient’s T lymphocytes lack IL-12 receptor. Supplementation with which substances would improve patient’s condition?

A

No IL12 receptor=Helper T cells can’t differentiate into Th1 population. Synthesis of IFN-gamma doesn’t occur which is required to activate macrophages.
Macrophages req. for delayed hypersensitivity reactions and cytotoxicity against intracellular organisms such as mycobacteria. Individuals with IL12 receptor deficiency suffer from severe mycobaterial infections. IFN-gamma administration is needed.

Formation of TH2 helper T cells is induced by IL-4 and B cell differention into palsma cells and secretion of Ig is dependent on cytokines produced by TH2 cells. Administration of Ig or IL-4 would improve response to extracellular viruses or bacteria.

4
Q

Tetrology of Fallot: What does squatting do?

A

Increases SVR and decreases right to left shunting thereby increasing pulmonary blood flow.

5
Q

Intellectual disability, 47 chromosomes, what is likely on further evaluation?

A
Tall stature, gynecomastia, azoospermia, cryptochidism, infertility.
Klinefelter Syndrome (47, XXY)
Meitoic nondisjunction during parental gametogenesis that resutls in 47, XXY. Variants include 46XY/47XXy mosaicism and 48, XXXY. Higher number of X chromosomes=WORSE manifestations. 

Features:

  1. Primary testicular failure due to fibrosis of seminiferous tubules. Small firm testes. Tesosterone deficiency from leydig cell dysfunction. Gonadotropin levels increased secondary to gonadal failure.
  2. Eunuchoid body habitus: Gynecomastia, absent facial/body hair, decreased muscle mass, tall.
  3. Intellectual disability/psychosocial problems.
Other conditions:
Marfan=Aortic root dilation, scoliosis, arachnodactyly, inherited defect of extracelluar matrix protein fibrillin.
Fragile X syndrome: Macroorchidism, large jaw, intellectual disability. Mutations in Fragile X mental retardation 1 gene.
Turner syndrome (45, XO): Short stature, broad chest, primary amenorrhea. 
Prader Willi syndrome: Short stature, hypotonia, ID, obesity. Microdeletion affecting paternal chromosome 15q11-13 region.
6
Q

6 month old male recurrent infections: Defective Ig isotype switching. Large tonsils and palpable lymph nodes. Which of the following Ig most likely overproduced?

A

IgM

Genes coding for constant regions of heavy Ig chains lie next to each other in order: IgM, IgD, IgG, IgE, IgA. No modification=IgM will be only Ig expressed by B lymphocytes. 
This is initial Ig synthesized by all B lymphoctyes prior to class switching. Modification of Ig genome during class switching happens by DNA recombinase enzyme. 

Clinical effects of hyper IgM=recurrent sinus and airway infections (deficient IgA). Treatment is with IV gamma globulin. Results most commonly from genetic absence of CD-40 ligand on T lymphocytes or from genetic deficiency in enzymes responsible for DNA modification that takes place during isotype switching.

IgA class switching is induced by B lymphocyte stimulation with Transforming Growth Factor-beta. 
IgE responsible for atopic disease: Allergic rhinitis, asthma, atopic dermatitis. Defnse against helminth parasites. IgE isotype switching initiated by IL-4 stimulation. When two IgE bound to mast cell or basophil attach to Ag they signal release of granular contents.
IgG: Provides passive immunity to infants for up to 6 months. IgG is able to fix complement. IgG is most effective opsonin. Immunity against bacterial toxins.
IgD: Concurrently expressed with IgM on membranes of B lymphocytes. Acts as cell surface Ag receptor for these cells.
7
Q

10 yo boy brought to ER after fevers and chills. Dull pain above left knee. Tenderness 3 cm above kneecap. Radiographs show soft tissue swelling and periosteal reaction over lower end of femur. What organism caused this?

A

Staph aureus. Childhood. Hematogenous seeding during episode of bacteremia. Long bones.

Sickle cell: Hematogenous seeding to infarcted bone. Salmonella. Staph aureus. Long bones.

Pott disease: Hematogenous seeding from lungs. Mycobacterium tuberculosis. Vertebrae.

Diabetes: Spread from infected foot ulcer. Polymicrobial. Bones of feet.

Patients with impaired mobility: Spread from pressure sores. Polymicrobial. Sacrum and heels.

Recent trauma or surgery: Direct inoculation. Polymicrobial.

Enterococcus faecalis-Endocarditis, meningitis, UTI, vertebral osteomyelitis after recent UTI via bacteremic spread.
Morazella catarrhalis: Part of normal flora of URI. Otitis media and sinusitis. Exacerbation of COPD.
Staphylococcus epidermidis: Colonize IV catheters and prosthetic heart valves, orthopedic hardware. Bacteremia and sepsis.
Streptococcus agalactiae: GI and UG tract. Infants=sepsis, pneumonia, meningitis.
Streptococcus pneumoniae: Most common etiologic agent of community acquired pneumonia. Can cause otitis media in kids, sinusitis, meningitis, sepsis.
Strep pyogenes: Second most common cause of hematogenous osteomyelitis. Pharyngitis and skin infections=impetigio and necrotizing fascitis.

8
Q

Ulnar nerve course

A

Posteromedially in upper arm and enters forearm after passing posterior to medial epicondyle of humerus. Funny bony=ulnar nerve injury.
Can be injured where it passes between hook of hamate and pisiform bone.

Radial nerve injury causes wrist drop, sensation loss to posterior arm, posterior forearm, part of dorsal thumb.
Musculocutaneous nerve injury: Loss of sensation over lateral forearm and paralysis of forearm flexors at elbow.
Axillary nerve injury: Results from fracture of surgical neck of humerus or other shoulder trauma. Lose sensation over lateral upper arm.

9
Q

52 yo male: Chronic cough with hemoptysis for past three weeks.
PE: Right sided face and right arm swelling. Engorgement of subcutaneous veins on right side of neck. Which vein is obstructed?

A

Brachiocephalic
Formed by union of right subclavian vein and right internal jugular vein.
External jugular vein drains into right subclavian. Obstruction of right brachiocephalic will cause venous congestion of structures drained by external jugular. Right brachiocephalic vein also drains lymph from right UE, right face and neck, right hemithorax, right upper quadrant of abdomen. BRACHIOCEPHALIC VEIN DRAINS IPSILATERAL JUGULAR AND SUBCLAVIAN VEINS. Bilateral brachiocephalic come together to form SVC.

Internal jugular vein drains brain and superficial face and neck. Obstruction of internal jugular would not cause arm swelling.
External jugular vein drains scalp and portions of lateral face.
Subclavian vein is continuation of axillary vein: Both drain blood from UE.
SVC obstruction: BOTH sides of face, neck, and chest, and BOTH ARMS.

10
Q

Fractured 12th rib may injure?

A

Parietal pleura medially
Kidney laterally.
11th and 12th ribs are floating (not bound to anterior rib cage by cartilage. Distal tip of 12th rib can be displaced into retroperitoneum and lacerate kidney.

Left 9th, 10th, 11th ribs overlie spleen.
8th, 9th, 10th, 11th ribs overlie liver.
Inferior margin of left lung is at 10th rib. 1sth through 6th rib fractures have greatest chance of damaging visceral pleura.

11
Q

Tachycardia, fast and irregular heart beat, consumed large amount of alcohol. Which EKG finding?

A

Absent P waves.
Atrial fibrillation: Precipitating factors=binge alcohol consumption, increased cardiac sympathetic tone, pericarditis.

QT prolongation predisposes to torsades de pointes where heart rate is usually regular.
High QRS voltage=sign of ventricular hypertrophy. Most commonly results from prolonged untreated HTN. No irregular rhythm.
QRS prolongation=BBB; regular heart rate; ventricular dyssynchrony or slowed impulse conduction.
ST elevation=transmural MI.

12
Q

Idiopathic thrombocyotopenic purpura

A

Formation of autoantibodies against platelets. Petechiae, ecchymoses, bleeding after minor trauma. May follow viral infection or immunization.

Shaken baby syndrome: Subdural hematoma with bilateral retinal hemorrhages.

13
Q

Increased AG metabolic acidosis. Mental status improves with treatment and increase in serum bicarb and sodium levels, decrease in serum osmolality and drop in serum potassium. Which was given to the patient?

A

Insulin and N.S.

Patient is suffering from diabetic ketoacidosis: Pts present with AMS, dehydration, abdominal pan, tachypnea, fruity odor to breath.
Insulin and hydration are primary treatments for DKA.
Insulin allows cells to use glucose as energy and decreases lipolysis and production of ketone bodies. Decrease in production of ketone bodies will rise plasma bicarb since ketone bodies are principal acid produced in DKA. Insulin causes shift in K+ resulting in decrease in K+ in serum.

Metabolic acidosis may develop in hypoaldosteronism which is treated with mineralocorticoids. However, acidosis is typically mild and without increased AG. Mineralocorticoids act by causing retention of sodium, water, and increases excretion of K+ and H+ ions. AMS is not characteristic. Treatment with mineralocorticoids would increase serum osmolality too.

Loop diuretics would decrease potassium concentration and increase serum bicarb. But decrease sodium concentration and increase serum osmolality due to increase in free water excretion.

14
Q

Prokaryotic ribosomes contain three types of rRNA and >50 proteins. What is function of 16S rRNA in prokaryotic ribosomes?

A

Contains nucleotide sequence complementary to mRNA sequence.
16S has sequence complementary to Shine-Dalgarno sequence in all prokaryotic mRNA (10 bases upstream from AUG start codon on prokarytoic mRNA).

Complementary sequences allow mRNA and 30S ribosomal subunit to bind in preparation for protein translation. Once mRNA bound to 30S subunit, protein synthesis starts.

Peptidyltransferase=Function of 23S rRNA found in 50S ribosomal subunit facilitates peptide bond formation in protein translation.

Aminoacyl-tRNA synthetases present in cytosol facilitate formation of aminoacyl tRNAs.

Translocation: ribosome advanced to next mRNA codon to be translated. Facilitated by elecongation factor G with energy from GTP.

During translation: mRNA codon in ribosomal A site binds income aminoacyl tRNA. Occurs over and over until stop codon enters A site. Release factors bind ribosome terminating translation and causing separation of ribosomal complex.

15
Q

Gradual thinning of epidermis happens in aging.

A

Aesthetic impact: Decrease in dermal collagen and elastic fibers. Inelastic skin sags and demonstrates fine wrinkles.

Proline hydroxylatoin would decrease indirectly during aging because collagen created decrease. Most direct cause of wrinkling is reduced synthesis of collagen fibrils.

Fibrillin 1 aids in development of extracellular matrix microfibirls: Create scaffolding for deposition of elastic fibers. MARFAN.

16
Q

Severe headache; abrupt onset. BP=160/90. Pulse 90/min. Pupils symmetric and reactive to light. Can move all four extremities without weakness.

A

Subarachnoid hemorrhage. Hyperdensity in cisterns/sulci. Generalized severe headache of SAH=worse headache of my life. Fever and nuchal rigidity can be present.

Saccular BERRY aneurysms most common cause of SAH. Usually at anterior communicating artery. Associated with Ehlers Danlos and ADPKD. Lumbar puncture shows gross blood or xanthochromia (yellow discoloration).

Charcot Bouchard aneurysms=small and occur in patients with HTN. Arterioles that supply basal ganglia, internal capsule, deep white matter. Cause intracerebral hemorrhage not SAH.

Cerebral amyloid angiopathy=elderly. May lead to recurrent intracerebral hemorrhage. Bleeds affect small area: Present with headache and focal neuro deficits.

17
Q

Episode of fever, headache, feeling weak that lasts 2-3 days. Immigration from Pakistan. Difficulty walking. Weakness of right leg extension. Lumbar puncture and PCR yield viral RNA from CSF. Infection transmitted via which route?

A

Fecal-oral.

Patient has poliomyelitis: Polio in unvaccinated immigrant patients from endemic regions. Sx: Fever, malaise, aspetic meningitis, severe myalgias and asymmetric paralysis (affecting legs). Damage to anterior horn lower motor neuron cell bodies. HYPOREFLEXIC paralysis.

Fever, headache, photophobia, painful extraocular movements. Isolation of viral RNA from patient’s CSF: RNA virus most likely cause of aseptic meningitis.
Enterovirus infection!! MOST COMMON CAUSE OF VIRAL ASEPTIC MENINGITIS. Single stranded RNA viruses that include coxsackievirus, echoviruses, polioviruses. Enteroviruses named because fecal oral transmission, ability to replicate in GI tract. DO NOT CAUSE GASTROENTERITIS.

Varicella, mumps, adenoviridae can cause aseptic meningitis or encephalitis (respiratory secretion spread).

STD: HIV, HSV 1 and 2, EBV, CMV can cause aseptic meningitis.

Arboviruses: ARthropod BOurne VIRUS are transmitted by insect bites and can cause aseptic meningitis. Togaviridae, flaviviridae, bunyaviridae. These viruses are most common in summer and fall.

18
Q

BPH Treatment that reduces prostate volume.

A

5 alpha reductase inhibitors reduce prostate volume and work on fixed component of bladder outlet obstruction. Inhibit conversion of testosterone to DHT in prostate. NOT AS EFFECTIVE IN RELIEVING SYMPTOMS AS ALPHA ADRENERGIC ANTAGONISTS. 6-12 months to achieve maximal effect.

Alpha adrenergic antagonists (terazosin, tamsulosin) work on bladder outlet obstruction by relaxing smooth muscle in bladder neck, prostate capsule, and prostatic urethra. Preferred initial therapy to treat BPH and can work in days to weeks. These drugs do not significantly affect prostate volume.

Phenazopyridine is urinary analgesic that provides relief of dysuria, urinary frequency and urgency in UTI and after urologic procedures.

Tadalafil is phosphodiesterase 5 inhibitor that treats ED.

Antimuscarinics (tolterodine) useful in men with low post-void residaul volume and overactive bladder symptoms. Often combined with one of other agents. Do not affect prostate volume.

19
Q

Acute cholecystitis–which test is most specific?

A

Obstruction of cystic duct in 90% of cases. Ingestion of fatty foods stimulates contraction of gallbladder against impacted stone resulting in colicky pain.

Disruption of gallbladder mucosa and release of inflammatory mediators=obstructed gallbaldder to become inflamed and edematous.

Blood supply to organ becomes compromised and secondary bacterial infection happens.

Ultrasound is preferred initial imaging test. HOWEVER nuclear medicine hepatobiliary scanning can be done with U/S is inconclusive. Gallbladder will not be visualized due to obstruction.

Presence of echogenic structures in gallbladder can be suggestive of acute cholecystitis in setting of fever and abdominal pain but it is not diagnostic. Can cause more benign biliary colic or an incidental asymptomatic finding in setting of other abdominal pathology. Can id signs of gallbladder inflammation: wall thickening, pericholecystic fluid.

20
Q

Vasospasm leading to clinical symptoms occurs in 20-30% of patients with subarachnoid hemorrhage caused by berry aneurysm. Happens 3-8 days after hemorrhage. Symptoms of cerebral vasospasm=AMS, focal neuro deficits. Substances generated by degradation of subaracnoid blood clots are believed to be cause. What drug could help?

A

CCB=Nimodipine. Decreases morbidity and mortality due to cerebral vasospasm when used as preventive agent following SAH. Vasdodilation and neural protection.

21
Q

Why is gonococcal vaccine not effective?

A

Antigenic variation. Gonococcal pili used to attach to cells. Genes undergo antigenic variation at high frequency. Structural genes for pilus proteins undergo recominbation with each other to produce new antigenic types of pili.

Meningococcal and pneumococcal vaccines are both examples of polysaccharide vaccines.

22
Q

Hypoxic ischemic encephalopathy

A

Profound systemic hypotension due to cardiac arrest or shock diminishes blodd supply to entire brain causing global cerebral ischemia. Neurons do not store glycogen and are highly sensitive to ischemia.
Hippocampus pyramidal cells and Purkinje cells of cerebellum are most vulnerable to ischmeic injury. Necrosis of areas supplied by distal branches of cerebral arteries happens first: Watershed infarction. Located at borders between ACA, MCA, and PCA. BILATERAL WEDGE SHAPED STRIPS OF NECROSIS.

Patients with severe carotid artery stenosis may develop unilateral infarcts.

Cardiac embolism causes multiple infarcts in different vascular territories.

Cerebral amyloid angiopathy results in lobar hemorrhages (occipital/parietal) in elderly.

Charcot-Bouchard aneurysm rupture involves deep brain structures (Basal ganglia, cerebellar nuclei, thalamus, pons).

Hypertensive arteriolar sclerosis occurs in pts with long-standing HTN–>Lacunar infarcts occur in basal ganglia, internal capsuel, pons, thalamus.

Hypertensive encephalopathy is characterized by headache, vomiting, and confusion, may lead to coma and death. Brain edema and petechial hemorrhages found in gray and white matter.

23
Q

Bronchi lined with pseudostratified epithelium. As airways continue distally, epithelium changes. Which of the following features is last to disappear as epithelium changes along respiratory tube?

A

Cilia
By terminal bronchioles, airway epithelium has changed from pseudostratified ciliated columnar to ciliated simple cuboidal. Cilia are present through respiratory bronchioles but not present in alveolar ducts or in alveoli themselves.

Bronchioles lack goblet cells, glands, and cartilage.

24
Q

Oral nitrate preparations used to treat stable angina. Which has highest bio availability if given orally?

A

Nitroglycerin is given sublingually because if given orally it would undergo significant first pass metabolism in liver.

Isosorbide dinitrate is parent compound of isosorbide mononitrate. Extensive first pass metabolism by glucuronidation in liver.

Isosorbide mononitrate is 100% bioavailable when taken orally.

Amyl nitrite is volatile inhalant used historically in treatment of angina pectoris. Side effects of extreme cutaneous flushing and postural hypotension limit its use. Not possible to take this med orally.

Sodium nitroprusside only available as IV agent. Used in treatment of hypertensive emergency. Most notable for ability to cuase cyanide toxicity.

25
Q

Assuming normal rate of metabolic CO2 production, hypocapnia implies alveolar hyperventilation. Hyperventilation can result from V/Q mismatch that causes decreased O2 and CO2 exchange. Hypoxemia stimulates peripheral chemoreceptors and increases respiratory drive above normal levels. This leads to excessive CO2 excretion by lungs.

A

Hypoxemia continues because blood flowing through highly oxygenated lung cannot absorb extra O2 to compensate for hypoxemic blood.

Decreased chest wall compliance would increase work of breathing resulting in respiratory muscle fatigue and alveolar hypoventilation. INCREASE PaCO2.

Deficient alveolar ventilation=INCREASED PaCO2. Respiratory acidosis.

Respiratory muscle fatigue, poor respiratory drive, upper airway obstruction-increased PaCO2 and decreased PaO2.

26
Q

Duodenal ulcer due to H. pylori. Endoscpic biopsy can show organisms.

A

Colonizes antrum of stomach in prepyloric area where there are few acid-secretory parietal cells. Colonization is associated with increased gastric acid secretion and duodenal bulb is are most exposed to acid.

H pylori can only colonize areas of gastric metaplasia.

27
Q

ACE inhibitors and ARBs have been shown to delay progression of diabetic nephropathy in Type 1 and Type II diabetics prior to the onset of proteinuria and after proteinuria.

A

Also they decrease chances of progression to end-stage renal disease and need for dialysis.

Loss of albumin in urine of 20mg/day or less is normal.

Microalbuminuria is albumin loss between 30-300 mg/day and is indicative of diabetic nephropathy in diabetic patients. Urinalysis can only detect protein concentrations of greater than 300 mg/day.

Alpha 1 blockers: Doxazosin, prazosin, terazosin treatment of HTN and BPH. Not best choice for diabetic patient.

Beta blockers: Metoprolol, atenolol are drugs of choic in patients with CAD and CHF along with HTN.

HCTZ is first line medication for treatment of essential HTN. And first line for osteoporosis since it increases serum calcium.

Spironolactone is aldosterone antagonist and is potassium sparing diuretic. Used for hyperalodsterone states like aldo secreting tumor. Used in conjunction with other diuretics.

Nifedipine is dihydropyridine CCB that is selective for vascular smooth muscle and doesn’t affect the heart like verapamil. Helps with blood pressure control.

Isosorbide dinitrate is used for stable angina pectoris (will lead to decrease in CO by producing venodilation and decrase in preload and decrease in work).

28
Q

Gallstones in pregnancy. Why?

A

Estrogen induced cholesterol hypersecretion and progesterone induced gallbladder hypomotility.

Cholelithiasis: Most common in fat, fertile, female, forty. Pregnancy and use of oral contraceptives predispose to gallstone formation.

29
Q

Screening assay for presence of urease activity. Test for what condition?

A

H. pylori (cause of duodenal ulcer). Consuming solution of isotopically labeled urea. When present, urease degrades urea into carbon dioxide and ammonia.

Isotopically labeled CO2 is absorbed in bloodstream and exhaled in patient’s breath.

High resolution CT chest=Bronchiectasis
CT scan, chest x-ray, PFT, lung biopsy, serology=important in pulmonary fibrosis.

30
Q

Alcoholic with pneumonia. Treat with?

A

Clindamycin (most activity against oral anaerobes and aerobic gram positive organisms like S. pneumoniae. )
Clindamycin works by binding to 50s ribosomal subunit and disrupting protein synthesis.

Vancomycin is active only against gram positive bacteria and doesn’t provide good coverage against anaerobes.

Klebsiella is common pathogen in aspiration pneumonia and can cause lung abscesses. However, lung abscesses are poly-microbial usually. Ciprofloxain and cefazolin have poor coverage against anaerobes.

Metronidazole has excellent coverage against anaerobes but not against aerboic organisms. Adequate coverage of both is needed for treatment of lung abscesses.

31
Q

Alzheimer’s treatments

A

AD specific therapies offer 1) Enhanced cholinergic neurotransmission. 2) Neuroprotection via antioxidants 3) NMDA receptor antagonism.

Donepezil=cholinesterase inhibitor is AD medication. Cholinesterase inhibitors improve cognition, behavior, functioning in activities of daily living in AD patients. Do not prevent progression of neurodegeneration.

Vitamin E is neuroproteictve agent that may slow functaional losses in AD.
Memantine is NMDA receptor antagonist. It is thought NMDA receptor overstimulation by glutamate may contribute to AD symptoms.

32
Q

Patient with paroxysmal supraventricular tachycardia. PSVT results from re-entrant impulse traveling through slowly and rapidly conducting segments of AV node.

A

Treatment: Carotid sinus massage which increases cardiac parasympathetic tone and Valsalva maneuver.
Parasympathetic nervous system primarily functions to slow hear rate by slowing conduction through AV node. Slowed conduction in AV node is beneficial for arrhythmia because it abolishes re-entrant circuit.

Carotid sinuses are innervated by CN 9 and help regulated blood pressure. Nerves are constantly firing. Pressure at carotid bodies increases, number of impulses sent to CNS also increases. Carotid sinus massage increases baroreceptor firing and increases parasympathetic influence on heart/vessels. Prolongs AV node refractory period which stops AV re-entrant tachycardias.

33
Q

Charcot Bouchard vs Saccular (Berry) Aneurysms

A

Charcot: HTN=associated condition; location=basal ganglia, thalamus, pons, cerbellum; size=

34
Q

Wernicke encephalopathy: Thiamine and glucose

A

Alpha ketoglutarate dehydrogenase requires thiamine as cofactor. Administration of glucose to thiamine deficient patients will result in Wernicke encephalopathy due to increased thiamine demand.

Wernicke encephalopathy presents with acute confusion, ophthalmoplegia, and ataxia.