Ear twitching, incoordination, and hypersensitivity to any stimulus are the earliest detectable signs. Cases are often dull, apparently blind, and they may head press against fixed objects or stand with the head pulled back (star gazing). Sometimes they are found convulsing, comatose or dead.
Injections of large doses of thiamine (vitamin B1) at this stage may be diagnostic if they cause rapid recovery (within hours). If untreated they will become recumbent with retraction of head, arching of back, rapid eye movement, dog-sitting, convulsions and death.
Differential diagnoses in cattle include lead poisoning, water deprivation/salt poisoning, Histophilus meningoencephalitis, coccidiosis with nervous involvement, nervous ketosis and vitamin A deficiency.
At necropsy, flattening of the gyri of the brain and coning of the cerebellum may be suggestive. The whole brain should be submitted to the laboratory in buffered formalin for histology. Water and fodder may be tested in the laboratory for sulphur levels.
PEM in sheep and goats needs to be differentiated from salt intoxication/water deprivation, lead toxicity, and bacterial and viral brain infections.