Lessons of the month 1: Shoshin beriberi: A case report of fulminant cardiovascular collapse, intractable hyperlactatemia and deteriorating consciousness.

Shoshin beriberi is a fulminant variant of thiamine deficiency, often presenting with severe lactic acidosis and cardiogenic shock. Due to the sparsity of this condition, delays in diagnosis can lead to fatality. However, rapid reversal of symptoms can be easily achieved through intravenous thiamine replacement.In this case report, we discuss a 57-year-old woman, who was previously fit and well, who presented to the emergency department with a 3-day history of extreme malaise, breathlessness and abdominal pain, with marked hypotension and tachycardia requiring vasopressor support and a severe rising lactic acidosis. Upon further questioning, a history of alcohol excess was noted. Rapid reversal of the marked haemodynamic instability was achieved upon administration of intravenous thiamine and the patient was discharged within 48 hours.

First report of the successful use of bosentan in refractory vasospastic angina.

Variant angina is caused by focal spasm of the epicardial coronary arteries and is variably associated with atherosclerotic coronary disease. We present the clinical course of profound coronary spasm in a woman which resulted in life-threatening symptoms. Although not previously reported, administration of the endothelin antagonist bosentan resulted in complete resolution of her symptoms which were refractory to commonly used anti-anginals, and these symptoms recurred when the drug was inadvertently withdrawn, confirming efficacy of the agent. The details of her clinical outcome and a review of the role of endothelin and its antagonists in coronary vasospasm are discussed.