Clinical Case Summary

Diseases damaging the enteric mucosa cause malabsorption that may trigger neurologic symptoms, both by immune-related processes and impaired absorption of essential vitamins.
Celiac disease (CD) is found in patients presented with nonhereditary ataxia. In these patients, abnormalities referred to as “gluten ataxia”, are probably the result of immunologic damage to the CNS and peripheral nerves.
B1 is an essential vitamin which its deficiency has broad clinical spectrum; thus, its diagnosis is challenging, and a sensitized clinician is needed to prompt identification. The encephalopathic form of adult thiamine deficiency is called Wernicke-Korsakoff syndrome.
A 40-y/o/w, G4P2, suffered from severe hyperemesis gravidarum resistant to antiemetics during trimester 1.
On 13^th week of pregnancy, she went to the ER, d/t confusion & extensive weakness. Her lab tests showed severe electrolytes deficiencies with transaminitis and elevated CPK levels. She was diagnosed with rhabdomyolysis secondary to her continuous vomiting. On her neurological examination psychomotor slowness and ataxia were found. Thus, Wernicke encephalopathy was suspected and her B1 level was tested and found low: 12 ug/L. She was hospitalized in the ICU to get electrolytes replacement and intravenous thiamine. To confirm the diagnosis, brain MRI was performed and demonstrated a classic picture of Wernicke encephalopathy (1).
6m later she gave birth, but her neurological deficits got worse. TTG level was tested and found positive. Gastroscopy showed duodenal scalloping (2) and Marsh 3C on biopsy (3). She started GFD and neurological rehabilitation. On repeated anamnesis she had abdominal pain before the pregnancy, but her investigation was negative.
This case illustrates a rare herald of CD and increases the awareness of possible manifestation of B1 def.
Points to discuss:

1. Two-hit theory of B1 def. (hyperemesis gravidarum and CD)
2. Neurologic manifestation of CD & B1 def.
3. Vitamins’ malabsorption in CD

References

1. Brain MRI with classic picture of Wernicke encephalopathy
2. Endoscopic picture of duodenal scalloping
3. H&E staining that demonstrates Marsh 3C in duodenal biopsy

Introduction

The peripherally inserted central catheter (PICC-Line) is an essential vascular access method used across various clinical settings. It is particularly indicated in patients requiring prolonged antibiotic therapy, mid-term parenteral nutrition, extended hospitalization with intravenous treatments, or who have poor peripheral venous access. PICC lines are typically delivered in standard lengths (approx. 60 cm) and must be individually trimmed to the correct length prior to insertion. Various approaches exist to estimate the optimal insertion length. While traditional practice relies on clinician experience and anatomical landmarks, this study aims to compare the precision of clinician predictions against those made by a predictive formula developed in a previous retrospective study.

Aims & Methods

To evaluate the accuracy of a previously derived formula for estimating ideal PICC-line length and compare it with estimates made by experienced clinicians.
Patient data on a total of 60 PICC lines was previously retrospectively analyzed to develop a multivariate regression formula. The data of that data set was summarized in 60 individual cases, each to be shown to participants in this study. Participants included both clinicians of varying level of experience in the placement of PICC lines. The participants were asked to estimate the ideal PICC length for each anonimized clinical case. Their estimates were compared to the formula-based ideal lengths using absolute deviation and proximity categories (±2 cm, ±3 cm, ±4 cm).

Results

A total of 264 estimates were recorded from 10 participants. The average deviation from the ideal PICC length was 6.3 cm (range: 2.8–12.5 cm). The proportion of estimates falling within the predefined accuracy margins were:

• ±2 cm: 65 estimates (24.6%) [participant range: 1.7%–45.0%]
• ±3 cm: 97 estimates (36.7%) [range: 3.3%–61.7%]
• ±4 cm: 114 estimates (43.2%) [range: 3.3%–73.3%]

• ±2 cm: 30 out of 60 (50.0%)
• ±3 cm: 49 out of 60 (81.7%), p<0.05
• ±4 cm: 57 out of 60 (95.0%), p<0.05

Conclusion

Clinician estimations of PICC-line length based on experience and anatomical reasoning show considerable variability and are frequently inaccurate. The findings of this study demonstrate that the formula significantly outperforms the average clinician estimate in terms of accuracy. A formula-driven approach, developed from empirical data and integrated into a web-based calculator, provides superior precision and reproducibility. This suggests that routine use of the calculator could improve patient outcomes by minimizing malposition-related complications and unnecessary repositioning. Further validation in larger and more diverse clinical settings is warranted.