A man in his 70s with a history of chronically elevated lactate levels, alcoholic cirrhosis, and chronic cognitive decline attributed to hepatic encephalopathy despite lack of asterixis or response to lactulose presented with 1 week of confusion worsened from baseline. On examination, he had anterograde worse than retrograde memory deficits without asterixis, nystagmus, ophthalmoplegia, or ataxia. Findings on magnetic resonance imaging of the brain (Figure) were consistent with previously undiagnosed Korsakoff syndrome.1 His subacute decline was attributed to a urinary tract infection, and the patient’s orientation returned to baseline with antibiotics. His lactate level returned to within a normal range with parenteral thiamine, although his memory deficits persisted.