Probable first report of a motor deafferentation syndrome in the Paraguayan War / Provável primeiro relato de uma síndrome de desaferentação motora na Guerra do Paraguai

ABSTRACT The Paraguayan War ended 150 years ago. Back then, there were outbreaks of combatants' limb weakness and tingling related to "palustrian cachexia", not clearly funded at the time on nutritional deficiency, the use of native flora to feed troops, and alcoholism. We report a case of a soldier with ascending paralysis, mental confusion and finally tetraplegia with preserved oculomotricity. This would probably be a case of locked-in syndrome (LIS) due to Gayet-Wernicke's encephalopathy consequent to thiamine deficiency. The role of thiamine in the peripheral or central nervous system expression was shown decades later to be related to poor diet, or use of foods containing thiaminase or thiamine antagonists, worsened by the fact that the bodily stores of thiamine are restricted, and deficits may grow fast.

RESUMO A Guerra do Paraguai terminou há 150 anos. Houve surtos de fraqueza dos membros dos combatentes e parestesias relacionadas à "caquexia palustre", não claramente fundamentados na época sobre deficiência nutricional, o uso da flora nativa para alimentar as tropas e o alcoolismo. Referimo-nos a um caso de um militar com paralisia ascendente, confusão mental e finalmente tetraplegia com oculomotricidade preservada. Esse relato seria provavelmente devido a um caso de "síndrome do encarceramento" secundário à encefalopatia de Gayet-Wernicke consequente à deficiência de tiamina. O papel da tiamina na expressão periférica ou do SNC foi previsto décadas mais tarde em relação a uma dieta pobre, ou ao uso de alimentos contendo tiamina ou antagonistas da tiamina, agravado pelo fato de que as reservas corporais de tiamina são restritas, e os déficits podem se manifestar rapidamente.

Infantile Thiamine Deficiency: New Insights into an Old Disease

Context: The wide spectrum of clinical presentation in infantile thiamine deficiency is difficult to recognize, and the diagnosis is frequentlymissed due to the lack of widespread awareness, and non-availability of costly and technically demanding investigations. Evidenceacquisition: The topic was searched by two independent researchers using online databases of Google scholar and PubMed. Weconsidered the related studies published in the last 20 years. The terms used for the search were ‘thiamine’, ‘thiamine deficiency’, ‘beri-beri’, ‘B-vitamins’,‘micronutrients’, ‘malnutrition’, ‘infant mortality’. ‘Wernicke’s syndrome’,‘Wernicke’s encephalopathy’, and ‘lacticacidosis’. Results: In the absence of specific diagnostic tests, a low threshold for a therapeutic thiamine challenge is currently the bestapproach to diagnose infantile thiamine deficiency in severe acute conditions. The practical approach is to consider thiamine injection asa complementary resuscitation tool in infants with severe acute conditions; more so in presence of underlying risk factors, clinicallyevident malnutrition or where a dextrose-based fluid is used for resuscitation. Further, as persistent subclinical thiamine deficiency duringinfancy can have long-term neuro-developmental effects, reasonable strategy is to treat pregnant women suspected of having thedeficiency, and to supplement thiamine in both mother and the baby during breastfeeding. Conclusions: Health care professionals in thecountry need to be sensitized to adopt a high level of clinical suspicion for thiamine deficiency and a low threshold for the administration ofthiamine, particularly when infantile thiamine deficiency is suspected.

Gastrointestinal Beriberi as a prodrome of non-alcoholic Wernicke’s encephalopathy: a study of an emerging nutritional deficiency disorder from Kashmir, India

Background: Gastrointestinal manifestations of thiamine deficiency have not been well described in literature. Authors aimed to study the symptoms of gastrointestinal beriberi in a cohort of patients of non-alcoholic Wernicke’s encephalopathy and review the relevant literature.Methods: In a retrospective analysis, case records of 52 patients diagnosed with non-alcoholic Wernicke’s encephalopathy were analyzed for the nature of gastrointestinal symptoms, their duration, severity and associated findings, investigations and response to treatment. The available literature on gastrointestinal symptoms in thiamine deficiency disorders and gastrointestinal beriberi was reviewed.Results: Gastrointestinal symptoms were found in 46 of the 52 patients. The most common gastrointestinal symptom in our patients was recurrent vomiting in 42 patients. Eight patients had water brash. Ten patients had epigastric pain and 10 patients had anorexia. Based on the nature and severity of symptoms, patients were evaluated for their symptoms using endoscopy, ultrasonography, amylase and lactate levels, and routine laboratory studies and the results were normal in the majority of patients.  Gastrointestinal symptoms settled in all the patients after receiving intravenous thiamine. On reviewing the literature multiple studies were found to have reported prominent gastrointestinal symptoms in patients of Wernickes encephalopathy and other thiamine deficiency related disorders. However, the definition of gastrointestinal beriberi is not clearly stated.Conclusions: Gastrointestinal symptoms were prominent prodromal manifestations in our cohort of Wernicke’s encephalopathy and have also been amply reported in literature. Presence of gastrointestinal symptoms in individuals predisposed to thiamine deficiency without alternative explanation should be enough to label a patient as gastrointestinal beriberi. The study highlights the importance of recognizing gastrointestinal beriberi as a distinct syndrome that may precede the development of Wernicke’s encephalopathy.

Most common cause of cardiomegaly without significant murmur in pediatric age group at tertiary care hospital, Hyderabad, India: a prospective observational study

Background: Following the invention of monaural stethoscope by Laennec and X ray by Roentgen in 18th century there was spectacular advancements in cardiology. The myocardium can be affected by various disease process unrelated to abnormal pressure or volume loads. These processes may be inflammatory, metabolic, infiltrative, ischemic or primary with significant overlap. These diseases usually present as cardiomegaly. In pediatric age group cardiac diseases will present early, sometimes without any signs and symptoms like sudden death due to less cardiac reserve. Few cases of sudden death also showed huge cardiomegaly in postmortem X rays. authors want to carry out this study to find out most common cause of cardiomegaly with silent chest as authors usually miss the diagnosis and these cases may present as sudden death without giving much time to intervene. The aim of the study is to know the most common cause of cardiomegaly without significant murmur in pediatric age group above one year.Methods: Prospective observational study done at a tertiary care hospital Hyderabad over a period of one year from January 2018 to January2019.Results: Most common cause of cardiomegaly without significant murmur was cardiac beriberi. It is mostly prevalent in rural areas of Telangana, mostly occurring in breastfed babies and below six years. All cases were recovered after proper treatment. Fortunately, it is associated with nil mortality, if timely treatment was initiated.Conclusions: Cardiac beriberi which is easily preventable and if treated in proper time it will associated with nil mortality. As it was occurring commonly breastfed babies supplementation of Thiamine to mothers was very useful as a preventive strategy.

Wernicke Encephalopathy Associated with Acute Wet Beriberi

Wernicke encephalopathy is usually accompanied with peripheral neuropathy, known as dry beriberi. In contrast, wet beriberi presenting as cardiovascular symptoms rarely occurs. The acute type of wet beriberi can be fatal, if untreated quickly. It is reported that the cerebellar vermis has a role of the coordination and control of cardiovascular and autonomic reflex activities. We report a 58-year-old man showing acute wet beriberi in Wernicke encephalopathy with cerebellar vermis lesion.

Implantação de um método para determinação da atividade da transcetolase eritrocitária para avaliação indireta da tiamina / Implementation of a method for determining the erythrocyte transketolase activity for indirect evaluation of thiamin

O teste de ativação da transcetolase eritrocitária (TK-E) pelo pirofosfato de tiamina (TPP) exógeno é um método indireto para mensurar a tiamina (vitamina B1). A diminuição da atividade da transcetolase eritrocitária e o aumento da estimulação in vitro com o TPP maior do que 17% indicam deficiência de tiamina. Este é um método plausível, pois são nos eritrócitos que estão concentradas a maior parte desta vitamina. Em virtude de surtos de beribéri que tem ocorrido no Brasil desde 2006, o Instituto Adolfo Lutz (IAL), como Laboratório Central de Saúde Pública, propôs a implantação desse método para auxiliar na investigação de novos surtos ou de casos isolados. Foram avaliados o teste de precisão, a linearidade, a estabilidade do hemolisado e da amostra, e estimados os limites de detecção e de quantificação. A atividade da TK-E sem ativação pelo TPP foi de 0,732 UI/gHb e com ativação foi de 0,827 UI/gHb. Todos os resultados dos parâmetros avaliados neste estudo apresentaram-se dentro dos critérios de aceitabilidade garantindo-se a confiabilidade do método. Fica, assim, disponível mais um ensaio bioquímico para a Rede Pública de Saúde, mas ainda necessário definir os valores de referência para estabelecer os limites clínicos da deficiência de tiamina.

Erythrocyte transketolase activation test (TK-E) by exogenous thiamine pyrophosphate (TPP)is an indirect method to measure thiamine (vitamin B1). The decrease in the erythrocyte transketolase activity and the increase of in vitro stimulation with TPP greater than 17 % indicate thiamine deficiency. It is a reasonable method as the major portion of this vitamin are concentrated in erithrocytes. Due to the beriberi outbreaks that have occurred in Brazil since 2006, the Adolfo Lutz Institute (IAL), as a Central Public Health Laboratory, proposed the implementation of this method to give support to the investigation on the new outbreaks or isolated cases. The evaluated parameters were precision, linearity, hemolysate and sample stability, and the limits of detection and quantification were estimated. The TK-E activity without activation by TPP was 0.732 UI/gHb, and with activation was 0.827 UI/gHb. All of the results obtained from the evaluated parameters showed to be within the eligibility criteria, ensuring the reliability of the proposed methods.Thus, this method showed to be adequate as biochemical assay for the Public Health Network. However, there is a need to define the reference values to establish the clinical limits of thiamine deficiency.

Implantação de um método para determinação da atividade da transcetolase eritrocitária para avaliação indireta da tiamina / Implementation of a method for determining the erythrocyte transketolase activity for indirect evaluation of thiamin

O teste de ativação da transcetolase eritrocitária (TK-E) pelo pirofosfato de tiamina (TPP) exógeno é um método indireto para mensurar a tiamina (vitamina B1). A diminuição da atividade da transcetolase eritrocitária e o aumento da estimulação in vitro com o TPP maior do que 17 % indicam deficiência de tiamina. Este é um método plausível, pois são nos eritrócitos que estão concentradas a maior parte desta vitamina. Em virtude de surtos de beribéri que tem ocorrido no Brasil desde 2006, o Instituto Adolfo Lutz (IAL), como Laboratório Central de Saúde Pública, propôs a implantação desse método para auxiliar na investigação de novos surtos ou de casos isolados. Foram avaliados o teste de precisão, a linearidade, a estabilidade do hemolisado e da amostra, e estimados os limites de detecção e de quantificação. A atividade da TK-E sem ativação pelo TPP foi de 0,732 UI/gHb e com ativação foi de 0,827 UI/gHb. Todos os resultados dos parâmetros avaliados neste estudo apresentaram-se dentro dos critérios de aceitabilidade garantindo-se a confiabilidade do método. Fica, assim, disponível mais um ensaio bioquímico para a Rede Pública de Saúde, mas ainda necessário definir os valores de referência para estabelecer os limites clínicos da deficiência de tiamina.

Erythrocyte transketolase activation test (TK-E) by exogenous thiamine pyrophosphate (TPP) is an indirect method to measure thiamine (vitamin B1). The decrease in the erythrocyte transketolase activity and the increase of in vitro stimulation with TPP greater than 17 % indicate thiamine deficiency. It is a reasonable method as the major portion of this vitamin are concentrated in erithrocytes. Due to the beriberi outbreaks that have occurred in Brazil since 2006, the Adolfo Lutz Institute (IAL), as a Central Public Health Laboratory, proposed the implementation of this method to give support to the investigation on the new outbreaks or isolated cases. The evaluated parameters were precision, linearity, hemolysate and sample stability, and the limits of detection and quantification were estimated. The TK-E activity without activation by TPP was 0.732 UI/gHb, and with activation was 0.827 UI/gHb. All of the results obtained from the evaluated parameters showed to be within the eligibility criteria, ensuring the reliability of the proposed methods. Thus, this method showed to be adequate as biochemical assay for the Public Health Network. However, there is a need to define the reference values to establish the clinical limits of thiamine deficiency.

Status of Thiamin deficiency in boarding school children from seven districts in Bhutan with previous history of peripheral neuropathy outbreaks: a cohort study.

Introduction: Peripheral neuropathy outbreaks have been a common occurrence amongst boarding schoolchildren from seven districts in Bhutan. Thiamin deficiency has always been suspected to be the cause but the status of the vitamin has never been established. This study aims to find the status of thiamin and dietary intake of micronutrients in boarding schoolchildren from seven districts with previous history of peripheral neuropathy outbreaks. Methods: Whole blood thiamin and dietary intake of micronutrients were assessed in 448 school children for four study periods (SP). Baseline data (SP1) was collected when the school children just joined the school at the start of the school academic year. SP2 was the first half of the school year and the data was collected just before the midterm break. SP3 was the short summer break and SP4 the second half of the school academic year. Results: 50.58% of the school children were found to be thiamin deficient at baseline which increased to 90.1% in SP2. The percentage of thiamin deficient school children increased to 91.8% in SP3 and then decreased to 79.82% in SP4. The requirements for vitamin B1, B12, vitamin A and iron were never met by dietary intakes in all the study periods. Conclusions: In conclusion, this study found a high prevalence of Thiamin deficiency in schoolchildren at baseline and the number of school children with Thiamin deficiency increased when in schools. The school children also had inadequate dietary intake of many micronutrients.

An Interesting Case of Disappearing Murmur

Cardiovascular manifestations in a patient with congestive heart failure, which disappeared in short course of time, ignited the idea to think of unusuality from common rheumatic heart disease (RHD). Cardiac events that reversed within 2 days of admission in a chronic alcoholic, whose diagnosis puzzled us, are presented here. A retrospective conclusion of wet beri-beri is made, as all the haemodynamic sequelae vanished with thiamine replacement.

History of Physical Fitness and Sports Medicine in Japan / 体力科学

Kanehiro Takaki, the founder of The Jikei University School of Medicine suggested that a nutritional factor was important for preventing beri-beri, which was a common disease in the Meiji era in Japan and Southeast Asia. He improved the rations fed to crews of the Imperial Japanese Navy to include wheat and meat. The rations he devised effectively prevented beri-beri. Some 30 years later, vitamin B₁ was discovered, and a deficiency of vitamin B₁ was found to be the cause of beri-beri. Takaki believed that nutrition and exercise were important for keeping our bodies fit. He often gave lectures on how people could keep fit to prevent diseases. Thus, his activities are considered to be the beginning of preventive medicine in Japan. The contributions of Takaki to the physical fitness of the Japanese people have been continued by the graduates of The Jikei University School of Medicine. Some of the graduates became professors of The Jikei University School of Medicine and Tokyo University of Education (now, Tsukuba University). Thus, both universities have the common basis and tradition for research and education in the fields of physical fitness and sports medicine, and have collaborated with each other in these fields. In this article, we provide a brief overview of the history of the development of research regarding physical fitness and sports medicine in Japan. We discuss the contribution of various persons including our graduates, to the health and physical fitness of the Japanese people.

Cardiovascular beriberi: rare cause of reversible pulmonary hypertension / 영남의대학술지

Cardiovascular beriberi is caused by thiamine deficiency and usually presents as high cardiac output failure associated with predominantly right-sided heart failure and rapid recovery after treatment with thiamine. Because of its rarity in developed countries, the diagnosis can often be delayed and missed. We recently experienced a case of cardiovascular beriberi with pulmonary hypertension which successfully treated with thiamine infusion. A 50-year-old man with chronic heavy alcoholics was refered to our department for dyspnea with mental change. Echocardiography showed marked right ventricular (RV) dilatation and flattening of the interventricular septum with a D-shaped deformation of the left ventricle. Moderate tricuspid valve regurgitation was found and estimated RV systolic pressure was 52 mm Hg. Because of his confused mentality and history of chronic alcohol intake, neurological disorder due to thiamine deficiency was suspected and intravenous thiamine was administered and he continuously received a daily dose of 100 mg of thiamine. Follow up echocardiography showed marked reduction of RV dilatation and improvement of a D-shaped deformation of the left ventricle. He finally diagnosed as cardiovascular beriberi on the basis of dramatic response to intravenous thiamine. Thiamine deficiency can cause reversible pulmonary hypertension, and can still be encountered in the clinical setting. Thus high index of suspicion is critically needed for diagnosis.

Experiences of Wet Beriberi and Wernicke's Encephalopathy Caused by Thiamine Deficiency in Critically Ill Patients / 대한구급학회지

Wet beriberi and Wernicke's encephalopathy (WE) are caused by thiamine deficiency and are potentially lethal and serious diseases. Thiamine deficiency occurs mainly due to poor oral intake or inadequate provision of thiamine in enteral or parenteral nutrition therapy. We report cases of wet beriberi and WE that developed after surgery in a surgical intensive care unit. The first patient, who was diagnosed with wet beriberi, underwent right total mastectomy and radical subtotal gastrectomy, simultaneously. The second was diagnosed with irreversible WE, respectively, due to long-term malnutrition. In both cases, intravenous replacement of thiamine was initiated after the admission to the surgical intensive care unit. However, comatose mentality of the second patient did not improve. As a result, we conclude that, if a patient's clinical feature is suspected to be thiamine deficiency, prompt intravenous thiamine replacement is needed.

A Case of Cardiac Beriberi: A Forgotten but Memorable Disease

Thiamine (vitamin B1) serves as an important cofactor in body metabolism and energy production. It is related with the biosynthesis of neurotransmitters and the production of substances used in defense against oxidant stress. Thus, a lack of thiamine affects several organ systems, in particular the cardiovascular and nervous system. The cardiac insufficiency caused by thiamine deficiency is known as cardiac beriberi, with this condition resulting from unbalanced nutrition and chronic excessive alcohol intake. Given that the disease is now very rare in developed nations such as Korea, it is frequently missed by cardiologists, with potentially fatal consequences. Herein, we present a case study in order to draw attention to cardiac beriberi. We believe that this case will be helpful for young cardiologists, reminding them of the importance of this forgotten but memorable disease.

Perfil epidemiológico do beribéri notificado de 2006 a 2008 no Estado do Maranhão, Brasil / Epidemiological profile of reported beriberi cases in Maranhão State, Brazil, 2006-2008

This study aimed to describe the epidemiological profile of beriberi cases and related deaths reported from 2006 to 2008 in Maranhão State, Brazil. Data were obtained from beriberi notification forms at the State Health Department. The global Moran index was used to evaluate spatial auto-correlation. 1207 cases and 40 deaths were reported. The western and central regions of the State showed strong spatial auto-correlation of incidence rates. Cases and deaths were concentrated from May to August, in young men (20-40 years). Regular alcohol consumption and smoking were recorded among fatal cases. Low income and heavy labor were widespread among cases. Common symptoms were asthenia, numbness, and swollen legs, difficulty walking, and calf pain. The profile of cases and their symptoms (except swollen legs) are characteristic of dry beriberi. We recommend further studies on the resurgence of beriberi in Brazil.

O objetivo do estudo foi descrever o perfil epidemiológico dos casos e óbitos de beribéri notificados de 2006-2008 no Estado do Maranhão, Brasil. Informações foram obtidas de fichas de notificação da Secretaria de Estado da Saúde do Maranhão e utilizou-se o Índice Global de Moran para avaliar autocorrelação espacial. Foram notificados 1.207 casos e 40 óbitos. Regiões oeste e central mostraram forte presença de autocorrelação espacial da incidência. Ocorrência de casos e óbitos concentrou-se de maio a agosto, em homens jovens (20-40 anos). Hábito de consumir álcool e fumar esteve presente entre os óbitos; baixa renda e ocupação com atividade pesada, entre os casos. Os sintomas mais comuns foram diminuição da força, dormência e edema das pernas, dificuldade para caminhar e dor na panturrilha. O perfil dos acometidos e os sintomas, exceto edema de membros inferiores, são característicos de beribéri seco. É pertinente que estudos sobre seu ressurgimento no país sejam aprofundados.

The Diagnosis of Infantile Beriberi and Lao infants with Vitamin B1 Deficiency without Apparent Signs / Lao Medical Journal

Beriberi (vitamin B1 or thiamin deficiency) is neglected health problem that probably remains as a significant cause of mortality among infants in Asia. There has been very little research in the last 4 decades. Although there are few data from Laos, the clinical experience of Lao pediatricians, along with some data from Mahosot Hospital in Vientiane, suggests that beriberi is probably an important cause of infant mortality, which is currently very high in Laos. Diagnosis of infantile beriberi can be clinically if signs are evident. However, a significant number of infants may have clinical unapparent vitamin B1 deficiency, complicating their illness, which is impossible to diagnose unless biochemical assays are performed. Unapparent vitamin B1 deficiency may complicate the illness of infants presenting with other diseases and supplementary treatment with vitamin B1 could potentially improve their outcome and reduce infant mortality. Two recently published papers by the Wellcome Trust – Mahosot Hospital – Oxford Tropical Medicine Research Collaboration suggested that approximately 13% of Lao sick infants admitted with diarrhea, pneumonia and sepsis (without clinical evidence of beriberi) at the Pediatric Wards, Mahosot Hospital, Vientiane had evidence of biochemical vitamin B1 deficiency particularly among those aged > 2 months. Infants with biochemical vitamin B1 deficiency had higher mortality than those who were not B1 deficient. The study also demonstrated that the activation coefficient (α), which has been used to diagnose vitamin B1 among adults living in non¬rice eating societies, cannot be reliably used for the diagnosis of vitamin B1 deficiency in infants, that basal ETK < 0.59 micromoles/min/gHb is a better biochemical marker of infantile beriberi, and that detection of the cardiac dysfunction marker troponin T may be useful indicator of infantile beriberi. The implication of the findings in these two papers were that (i) since clinical unapparent vitamin B1 deficiency is common among Lao sick infants, co¬treatment with vitamin B1 may reduce disease severity and mortality, (ii) since basal ETK is more accurate than activation coefficient (α) in the diagnosis of infantile beriberi, basal ETK should be used for the diagnosis of vitamin B1 deficiency among infants, and (iii) since troponin T may be useful in the diagnosis of infantile beriberi and as this assay is now available as a bedside test these should be evaluated as accessible markers.

Deficiência de tiamina como causa de cor pulmonale reversível / Thiamin deficiency as a cause of reversible cor pulmonale

A deficiência de tiamina pode apresentar quatro formas clássicas de apresentação clínica: polineuropatia periférica, anorexia e fraqueza muscular (beribéri seco); insuficiência cardíaca de alto débito com sinais congestivos (beribéri úmido); beribéri associado ao choque (Shoshin beribéri) e encefalopatia de Wernicke. Neste relato, descrevemos quadro sugestivo de hipertensão pulmonar grave e cor pulmonale, com estase jugular, hepatite congestiva e edema generalizado, que apresentou reversão completa após administração de tiamina.

Thiamine deficiency may present four classic clinical forms: peripheral polyneuropathy, anorexia and muscular weakness (dry beriberi); high output heart failure with signs of congestion (wet beriberi); beriberi associated with shock (Shoshin beriberi) and Wernicke's encephalopathy. In this report we describe a picture that is suggestive of severe pulmonary hypertension and cor pulmonale, with jugular stasis, congestive hepatitis and generalized edema that reversed completely after the administration of thiamine.

Déficit de Tiamina: Beriberi y síndrome de Wernicke-Korsakoff / Thiamine deficiency: Beriberi and Wernicke-Korsakoff syndrome

La historia de la medicina reporta que algunos años atrás, antes de que se describiera la vitamina B 1 llamada también tiamina, ya se había descrito una enfermedad en un grupo de navegantes japoneses que causaba lesiones en el sistema nervioso y cardiovascular, entidad que se la conocía con el nombre de beriberi. El objetivo de la revisión es recordar la función de la vitamina B 1 en nuestro metabolismo, su importancia y requerimientos, además de conocer las consecuencias de su déficit, signos, síntomas y cuadros clínicos que se presentarían en ausencia de ésta. El beriberi y el Síndrome de Wernicke-Korsakoff son cuadros clínicos que aparecen por la deficiencia de tiamina; sus manifestaciones son variadas, incluyen trastarnos neurológicos, cardiovasculares, psiquiátricos y pueden llevar incluso a la muerte.

Medicine history tells us that some years ago, before vitamine B1, also called thiamine, were described, it was already known a disease in a group of Japanese sailors. That disease caused damage in the nervous and cardiovascular systems and was known with the name of beriberi. The objective of this study is to remember the vitamine B1function in our metabolism, its importance and requirements as well as to know the consequences derived from its deficiency, signs, symptoms and medical profiles appearing because of thiamine deficiency; its features are varied, and include neurological, cardiovascular, and psychiatric disorders. They can even lead patients to death.

A Case of Shoshin Beriberi Presenting as Acute Coronary Syndrome with Shock: Shoshin Beriberi Mimicking Acute Coronary Syndrome

Cardiac beriberi is caused by thiamine deficiency. Shoshin beriberi is a rare and fulminant form of cardiac beriberi characterized by hypotension, high output heart failure, lactic acidosis and anuria. Without early recognition and immediate treatment, most of these patients will be fatal. Therefore clinical diagnosis of shoshin beriberi is most important in emergency situation. We report a case of shoshin beriberi with clinical features mimicking acute coronary syndrome. Fifty year old male patient with chronic alcoholism was presented with shock, hypoxia, right heart failure and severe acidosis. Electrocardiogram showed abnormal Q in V1-3 and mild ST elevation and level of troponin I was slightly elevated. All manifestations including lactic acidosis were dramatically subsided in 18 hours by thiamine infusion. Even in developed country, shoshin beriberi can be occurred in patients with malnutrition and/or chronic alcoholism and should be differentiated with acute coronary syndrome.

A Case of Beriberi Because of Continuous Rice-soup Feeding during One and Half Years / 대한소아소화기영양학회지

Beriberi, which is caused by thiamin deficiency, is a rare disease in recent years. But it has been described in the Eastern literature as far back as the 17th century. Early symptoms are fatigue, apathy, irritability, drowsiness, anorexia, nausea, vomiting and abdominal pain. Signs and symptoms of progression are peripheral neuritis, paresthesia, decreased tendon reflex and congestive heart failure. Thiamin deficiency remains as an important health care issue in many world population, specially in AIDS, pregnancy women and TPN associated patients. The best diagnostic test is assessing clinical response to administration of thiamin. We have experienced a case of Beriberi caused by continuous rice-soup feeding during one and half years in a 7-year-old boy.

The frequency of thiamine deficiency in chronic alcoholics and in patients at a long-term care facility / 대한내과학회지

BACKGROUND: As socioeconomic status has improved, malnutrition has become rare in Korea and generally it is no longer considered as a serious problem in medical practice. However, contrary to the above general belief we managed four patients with beriberi in 1999 and it became apparent that malnutrition might remain a problem in certain groups of patients. In this study, we assessed the nutritional state, especially with respect to thiamine deficiency, in chronic alcoholics and in patients residing at a long-term care facility (LTCF). METHODS: Fourteen chronic alcoholic patients and twenty patients being hospitalized in a long-term care facility were assigned as the study groups. The subjects' mean ages and standard deviations were 48.9+/-10.2 and 50.6+/-6.7, respectively. Medical records were reviewed to determine other aspects of their nutritional status and their dietary patterns. Ten peoples who visited the health promotion center at Inha University Hospital, for routine check-ups were allocated to the control group. Blood total thiamine levels were measured by high-performance liquid chromatography. RESULTS: Body mass indices were significantly lower in chronic alcoholics and in patients at the LTCF than in the control group (p=0.0065). Serum albumin levels were within the reference range in all three groups, but were significantly lower in patients at the LTCF than in the control group (p=0.0013). Moreover, no difference was detected between the alcoholic group and the control group in terms of thiamine levels. However, the mean thiamine level in patients at the LTCF was statistically lower than that of the control group and four (20%) patients in the LTCF group showed subnormal blood thiamine levels. The thiamine level tended to decrease with age in both alcoholics and patients at the LTCF. No correlation was found between thiamine level and the other variables examined, namely, hospital stay, body mass index, and serum albumin level. CONCLUSION: A considerable portion of patients in a long term care facility showed thiamine deficiency, however, no evidence of thiamine deficiency was found among alcoholics. This result suggests that thiamine deficiency in patients at long-term care facility may be more prevalent and that thiamine supplementation may be warranted, especially for those with other thiamine deficiency risk factors.