Marchiafava Bignami disease usually affects men who are chronic alcoholics and are middle- aged or elderly [1], prefer to consume hard liquor and are severely malnourished with vitamin B complex deficiency [2]. Symptoms may commence in an abrupt or progressive manner. Some present with psychiatric disturbances like dementia, others with more or less severe neurologic impairment, like gait disturbances, seizures, hemiparesis or tetraparesis, limb spasticity, tremor or weakness. Aphasia and ideomotor apraxia, although less frequent, seem to be more specific [3]. Diagnosis is complicated by the fact that the patients may also have alcoholic hepatitis or Wernicke-Korsakoff syndrome and can become even more difficult when the patient is experiencing delirium tremens, is in a coma or even lethargic, as some neurologic tests cannot be performed. In such cases, the interhemispheric disconnection, also called "split brain syndrome" [4] caused by corpus callosum demyelination is difficult to prove. The disconnection of the hemispheres may cause agraphia of the dominant hand [5] or hemianopia [6]. However, any patient presenting with Wernicke-Korsakoff syndrome should be suspected to have Marchiafava Bignami disease.

The neurologic examination often reveals further abnormalities: dysarthria, mutism, nystagmus, gaze palsy, diplopia, peripheral sensory loss, deep tendon reflex loss or Babinski sign or even the presence of primitive reflexes. Mental state impairment may not be as severe and may consist of confusion, disorientation or memory loss and inability to memorize new information.

Marchiafava Bignami disease has occasionally been described in non-alcoholic patients, such as individuals suffering from Plasmodium falciparum infection [7] or gynecologic malignancies.

• Tongue Atrophy

  Neither tongue atrophy nor fasciculation were found. Bilateral upper and lower limb weakness with increased bilateral upper limb reflexes and Babinski reflexes were found. [ncbi.nlm.nih.gov]

  Neither tongue atrophy nor fasciculation were found. The tongue could be protruded from the mouth and remained midline, and moved adequately from side to side. [bmcneurol.biomedcentral.com]

• Trismus

  Muscle rigidity and facial trismus may be severe. Most patients presenting with the acute type of MB will go into coma and eventually die, although as illustrated in this report, some survive. [ajnr.org]

• Psychiatric Symptoms

  Psychiatric symptoms may be challenging to treat because of drug resistance. [ncbi.nlm.nih.gov]

• Nystagmus

  RESULTS: The mimicking conditions were differentiated from MBD by the occurrence of solitary and rapidly disappearing splenial lesions; fewer signs and symptoms with exception of seizures, hemiparesis and tetraparesis; nystagmus; and rapid and complete [ncbi.nlm.nih.gov]

  Results The mimicking conditions were differentiated from MBD by the occurrence of solitary and rapidly disappearing splenial lesions; fewer signs and symptoms with exception of seizures, hemiparesis and tetraparesis; nystagmus; and rapid and complete [dx.doi.org]

  Patients with Wernicke encephalopathy have ataxia, ophthalmoplegia, nystagmus, and confusion. Subacute form of MB is characterized by dementia, disarthria, and muscle hypertonia—may survive for years. [neuroradiologycases.com]

  Gaze paretic nystagmus and finger-to-nose incoordination were also improved. [bmcneurol.biomedcentral.com]

• Altered Mental Status

  Marchiafava-Bignami disease, a rare alcohol-related disorder, characterized by altered mental status, seizure, and multifocal central nervous system signs, which results from progressive demyelination and necrosis of corpus callosum. [ncbi.nlm.nih.gov]

  Case Report: A 36-year-old man was found with altered mental status on a street. The past medical history could not be obtained, but he appeared to be a chronic alcoholic with significant malnutrition. [e-jnc.org]

  Case Description: Patient is a 30 year old left handed African-American with history of hypertension, diabetes type I, hypothyroidism, alcohol use disorder, who presented with c/o altered mental status, urinary incontinence, slurred speech and left-sided [omicsonline.org]

  Case 2 A 65-year-old man known to be a chronic alcoholic and to have hepatic cirrhosis presented with an acute onset of altered mental status, seizures, and Parkinson-like movements. [ajnr.org]

• Neglect

  "Crossed left hemispatial neglect" was not seen with the left hand, but neglect of the left hemifield was seen with the right hand. CT and MRI showed a lesion occupying almost the entire corpus callosum. [ncbi.nlm.nih.gov]

  Clinical evidence of left hemispatial neglect remained 8 months later, with neuropsychological tests showing few changes. [elsevier.es]

  Finally, no visual neglect was shown by the Albert line-crossing test performed with both hands. Figure 1. Top, Handwriting specimens (left hand, left; right hand, right). [jamanetwork.com]

  Moriya, H. and Hirayama, K. (1993) “Crossed homonymous hemianopia” and “crossed left hemispatial neglect” in a case of MarchiafavaBignami disease. [scirp.org]

• Irritability

  There were no lateralizing deficits and no signs of meningeal irritation. Laboratory tests showed a normal haemogram, liver and renal function tests and serum electrolytes. [indianjpsychiatry.org]

  Normal serum electrolytes, absence of signs of meningeal irritation and normal CSF examination ruled out delirium due to electrolyte imbalance or meningo-encephalitis. [tropicalgastro.com]

  Signs of meningeal irritation including neck rigidity and kernig sign were absent. Pupils were of normal size and normal reacting. Motor examination showed no neurological deficit. Laboratory results revealed normal haematological profile. [jcdr.net]

  Coping Si Tratament.Alcohol depresses nerves that control involuntary actions such as breathing and the gag reflex, Abuse and Alcoholism (NIAAA A Word About Alcohol Poisoning.Alcohol poisoning can kill. irritate the stomach which causes vomiting and it [vygepulo.4fan.cz]

  On admission, his Glasgow coma score was 7, and he showed no signs of meningeal irritation, focal deficits or cranial nerve abnormalities. IV thiamine (500 mg/day) and high doses of parenteral B vitamins were administered. [scielo.br]

• Pyramidal Tract Signs

  Type A: acute to subacute onset of consciousness impairment, pyramidal tract signs, limb hypertonia, seizures, hyperintense swelling of the corpus callosum on T2-weighted MR sequences and is associated with poor prognosis. [jcdr.net]

As soon as the patient is identified as a chronic alcohol abuser, the physician should order serum glucose, serum electrolytes, and toxicology screening. Blood workup should also include a complete cell blood count. If the individual presents with acute neurologic symptoms like seizures or coma, a cerebral mass or stroke must be urgently excluded using computer tomography or magnetic resonance imaging scans. The latter is considered the most useful diagnostic tool for this condition [8] [9] and is able to describe myelin and neuron loss in the corpus callosum, as well as cyst formation. Corpus callosum initially becomes edematous, followed by the genu and the splenium [10]. The edema is initially vasogenic and then converts to cytotoxic [11]. Lesions may initially involve the central areas and spare the ventral and dorsal extremities. This finding is known as " the sandwich sign". When present, cysts are described as hyperintense, whereas myelin damage causes hypointensity. Magnetic resonance imaging may also reveal the presence of associated cortical lesions [12]. The chronic phase involves corpus callosum atrophy.

A novel technique, the fluid-attenuated inversion recovery is also contributory, offering important information when available, such as the extent of myelin damage.

A central nervous system or meningeal infection sometimes must also be ruled out, and that is accomplished using a lumbar puncture.

Electroencephalography is uninformative in Marchiafava Bignami disease [13].

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