Thiamine Deficiency Mimicking Guillain-Barré Syndrome

Abstract

SESSION TITLE: Critical Care 4 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Tuesday, October 31, 2017 at 07:30 AM - 08:30 AM INTRODUCTION: Thiamine (Vitamin B1) is an essential vitamin utilized in a number of cellular functions and metabolic pathways. Thiamine deficiency can be associated with peripheral neuropathy (termed dry beriberi), lactic acidosis and cardiovascular insufficiency (wet beriberi). Shoshin beriberi refers to a variant of this condition characterized by acute onset and rapidly progressive deterioration of cardiovascular function which, if not treated could result in cardiovascular collapse and death. CASE PRESENTATION: A 47 year old Cambodian male with no significant past medical history presented with numbness, tingling and progressive weakness of his lower extremities for a month. He drank alcohol occasionally. He was alert and oriented but had decreased lower extremity strength and decreased patellofemoral reflexes bilaterally. Lab work was significant for hyponatremia, hypokalemia, mild renal failure and an elevated lactic acid of 6.1 mg/dL. He was admitted and given fluids for presumed dehydration but had persistent weakness and lactic acidosis. On the third day of his admission, he developed hypotension requiring vaseopressor support. DISCUSSION: An extensive initial work-up including cultures, HIV, hepatitis panel, urine toxicology screen, RPR and rheumatologic testing was negative. An echocardiogram showed normal left ventricular function and evidence of pulmonary hypertension and mild right ventricular dysfunction. CT of the head, cervical spine, chest, abdomen and pelvis were all unremarkable. Electromyography showed demyelination and a diagnosis of Guillain-Barre Syndrome was considered, despite a lumbar puncture showing normal protein levels in the CSF. The patient was administered IVIG. A thiamine level sent on day 2 of his admission resulted at 7 nmol/L (normal 8 -30) 5 days after it was sent confirming a diagnosis of thiamine deficiency. Aggressive thiamine repletion was started, IVIG was stopped and the patient improved with rapid normalization of his lactic acidosis and blood pressure. He also slowly recovered his motor strength. CONCLUSIONS: Severe thiamine deficiency is rare in developed countries, and is likely vastly under-detected in the absence of standardized testing. As has been previously reported1, this case highlights to physicians caring for critically ill patients the potential for missed diagnoses and poor outcomes in patients with thiamine deficiency. Reference #1: 1. Koike, et al “Rapidly developing weakness mimicking Guillain-Barré syndrome in beriberi neuropathy: two case reports.” Nutrition, 2008 DISCLOSURE: The following authors have nothing to disclose: Anton Edwards, Nader Azab, Gerardo Carino No Product/Research Disclosure Information