Dry Beriberi Research Articles

Thiamine Deficiency Mimicking Guillain-Barré Syndrome

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

Dry Beriberi, an Unusual Complication of Acute Myeloid Leukemia

Dry Beriberi, an Unusual Complication of Acute Myeloid Leukemia

Bioactive Triterpenoids from the Twigs of Chaenomeles sinensis.

Chaenomeles sinensis has been consumed traditionally for the treatment of throat diseases, diarrhea, inflammatory diseases, and dry beriberi. Repeated chromatography of the CHCl3-soluble fraction from the 80% MeOH extract of C.sinensis twigs led to the isolation of three new triterpenoids, sinenic acid A (1), 3β-O-cis-feruloyl-2α,19α-dihydroxyurs-12-en-28-oic acid (2), and 3β-O-cis-caffeoylbetulin (3), together with 20 analogues. The chemical structures of 1-3 were determined using diverse NMR techniques and HRMS data analysis, chemical methods, and computational approaches supported by advanced statistics (CP3). All the purified compounds were evaluated not only for their cytotoxicity against four human tumor cell lines (A549, SK-OV-3, SK-MEL-2, and HCT-15) but for their potential neuroprotective effects through induction of nerve growth factor in C6 glioma cells. Their anti-inflammatory effects were also assessed by measuring nitric oxide levels in lipopolysaccharide-insulted murine microglia BV2 cells.

Dry beriberi in a patient of acute fatty liver of pregnancy

Dry beriberi is the development of a symmetrical peripheral neuropathy characterized by both sensory and motor impairments, mostly of the distal extremities due to deficiency of thiamine. Most dietary deficiency of thiamine worldwide is the result of poor dietary intake. In Western countries, the primary causes of thiamine deficiency are alcoholism and chronic illnesses such as cancer. At risk populations are women with prolonged hyperemesis gravidarum and anorexia, patients with overall poor nutritional status on parenteral glucose, patients after bariatric bypass surgery, and patients on chronic diuretic therapy due to increased urinary thiamine losses. We hereby report a case of thiamine deficiency (dry beriberi) caused by protracted vomiting secondary to the acute fatty liver of pregnancy successfully treated with intravenous thiamine.

Ascending Sensory Neuropathy caused by Mild Thiamine Deficiency after Gastric Bypass Surgery

Bariatric surgery is the current modality of choice for weight loss in morbid obese patients. Although bariatric surgery is well known to improve obesity related complications, however, patients may be affected by early and late complications. Nutritional deficiency is one of the late complications of bariatric surgery which is more common in patients who are non compliant with dietary recommendations. American Society for Metabolic & Bariatric Surgery stresses the importance of long term regular follow up for dietary adherence assessment and nutritional deficiency screening tests. Thiamine deficiency, though rare, is increasingly seen due to increasing population of patients with gastric bypass surgery. Thiamine deficiency after bariatric surgery usually presents with neurological symptoms, most commonly as Wernicke Encephalopathy or dry Beriberi, and in almost all such cases, thiamine deficiency is very severe. Isolated ascending sensory neuropathy is a very rare presentation, which was seen in out patients with mildly low thiamine levels.

Dry beriberi preceded Wernicke′s encephalopathy: Thiamine deficiency after laparoscopic sleeve gastrectomy

In recent times, pediatric obesity has become widely prevalent. If first-line treatment with lifestyle modification fails, bariatric surgery may be indicated for severely obese patients. Many patients now travel abroad to get these surgeries done. Some of these patients receive inadequate postoperative care. We described a morbidly obese 17-year-old girl who had a laparoscopic sleeve gastrectomy procedure for weight loss. Due to severe nausea, she stopped her multivitamin supplementation. Within a few weeks, she developed symptoms of dry beriberi was soon followed by classic symptoms of Wernicke's encephalopathy. The prompt diagnosis was made with confirmation from serum thiamine level and brain magnetic resonance imaging. Thiamine supplementation reversed ophthalmological symptoms promptly. However, the patient needed inpatient rehabilitation for neuropathy. This case describes that thiamine deficiency can occur after restrictive bariatric surgery, despite lower risk of malnutrition in the absence of intestinal bypass procedure. This report highlights that in the presence of risk factors: dietary noncompliance, inadequate follow-up, and severe nausea with and without vomiting can precipitate the development of Wernicke's encephalopathy, even after restrictive surgery. Physicians may increasingly encounter thiamine and other nutrient deficiencies in increasing numbers due to increasing prevalence of obesity disorders and availability of bariatric surgeries. This report also emphasized the importance of identifying vague sensory symptoms in thiamine deficiency.

Poster 78 Development of Dry Beriberi Following Gastric Bypass Surgery due to Inadequate Vitamin Supplementation: A Case Report

PM&RVolume 6, Issue 9S p. S209-S209 Friday Poster Presentations - Poster Hall Poster 78 Development of Dry Beriberi Following Gastric Bypass Surgery due to Inadequate Vitamin Supplementation: A Case Report Julie A. Ferris MD, Julie A. Ferris MD William Beaumont Hospital, Royal Oak, MI, United StatesSearch for more papers by this authorRonald Taylor MD, Ronald Taylor MD William Beaumont Hospital, Royal Oak, MI, United StatesSearch for more papers by this author Julie A. Ferris MD, Julie A. Ferris MD William Beaumont Hospital, Royal Oak, MI, United StatesSearch for more papers by this authorRonald Taylor MD, Ronald Taylor MD William Beaumont Hospital, Royal Oak, MI, United StatesSearch for more papers by this author First published: 29 September 2014 https://doi.org/10.1016/j.pmrj.2014.08.473Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume6, Issue9SSeptember 2014Pages S209-S209 RelatedInformation

Béribéri du nourrisson : à propos d’un cas

Thiamine deficiency is recognized in varied parts of the world. In Asia, it remains an important public health problem where highly polished rice is the major staple food and where other primary dietary sources of thiamine are in short supply. Beriberi, or clinically apparent thiamine deficiency, may present a variety of syndromes including myocardial dysfunction or wet beriberi, dry beriberi with neurological symptoms, and the more severe form Shoshin beriberi with cardiac failure and lactic acidosis. Infantile thiamine deficiency is a very rare condition in developed countries today. It occurs mainly in breastfed infants of mothers who have inadequate intake of thiamine. Clinical symptoms in such infants include gastrointestinal symptoms, cardiac failure, and lactic acidosis. We report the case of a 10-week-old girl, admitted with diarrhea, vomiting, acidosis, and cardiac failure. After excluding other etiologies of cardiomyopathy, biochemical thiamine deficiency confirmed the diagnosis of beriberi in an infant of a thiamine-deficient mother from Reunion Island, a French island where recently, with Mayotte Island, epidemic cases of beriberi have been described. This case is important to highlight the manifestations in young infants and to alert physicians to the possibility of thiamine deficiency in developed countries.

Mixed beriberi: Sub acute cardiac beriberi with neurological involvement

We present a case of mixed beriberi, with cardiac and neurological involvement (dry beriberi). Prolonged Thiamine deficiency causes beriberi, which is classically categorized as wet or dry; although, there is considerable overlap. In either form of beriberi, patients may complain of pain and paresthesia. This is a treatable condition sometimes with incomplete recovery, but it is probably under recognized yet increasingly common due to increasing levels of alcohol abuse. The disorder is a metabolic emergency and requires immediate treatment with intravenous thiamine. Sudden cardiac failure is common. Death occurs from right heart failure and the patient usually dies fully conscious. This patient was successfully treated with intravenous thiamine.

A case of dry beriberi following bariatric surgery

Case history A 45-year old obese Caucasian lady (155 kg, BMI 57) presented with progressive proximal limb weakness, upper and lower limb paraesthesia, ataxia and athetoid tremors 18 months following a Roux-en-Y gastric bypass surgery. Postoperatively, she had lost 57kg and maintained a healthy diet with moderate alcohol intake (<14 units/week). She admitted non-compl iance wi th mult iv i tamin and Adcal D3 supplementation.

Dry Beriberi and Wernicke’s encephalopathy following gastric lap band surgery

The incidence of neurologic complications from bariatric surgery is rising with the prevalence of obesity and the increasing number of bariatric surgeries. We report a 25-year-old woman who developed subacute progressive weakness and areflexia followed by confusion, ophthalmoplegia, and nystagmus following bariatric surgery. While the differential of generalized weakness with altered mental status is broad, vitamin deficiency should be routinely suspected after bariatric surgery to prevent permanent neurological injury. Multifocal neurological dysfunction in our patient represented beriberi and Wernicke’s encephalopathy related to vitamin B1 deficiency.

Shoshin béribéri: réémergence d’une pathologie ancienne ? À propos d’une série de 11 cas à Mayotte

In the French island of Mayotte in the Indian Ocean, the health and food situation remains contrasted. For a very long time dry beriberi women in postpartum had been suspected and treated. But in 2004 the first infantile epidemic of beriberi was scientifically authenticated and a program of thiaminic supplementation for the pregnant women and infants was set up. In this context, we describe an epidemic of 11 cases of shoshin beriberi among adults between January 2008 and Februar 2009. Over 11 cases of shoshin beriberi, 5 cases were confirmed biologically and 6 were probable. The sex ratio M/W was 0.37. The median age was 34 years. The clinic picture was typical: severe acute dyspnea, an agitation/drowsiness, right cardiac failure: polynevritis of the lower limbs was noted in 9 cases over 11. Biologically it was characterized by a lactic acidosis (average pH: 7.08, lactates: 12.08 mmol/l). The evolution was favorable in the 8 cases which could benefit from early thiaminic refill. The outbreak of an epidemic of shoshin beriberi among adults mainly in groups not having benefited from supplementation shows the effectiveness of the program but also its limits. We compare our series with others: the period from April to June when the food is less diversified, is confirmed as a higher risk period. The programs of nutritional education must be increased and a B1 vitamin supplementation for broader people during the rain season might be discussed.

Dry beriberi mimicking Guillain–Barre syndrome as the first presenting sign of thiamine deficiency

European Journal of NeurologyVolume 19, Issue 2 p. e14-e15 LETTER TO THE EDITOR Dry beriberi mimicking Guillain–Barre syndrome as the first presenting sign of thiamine deficiency R. Faigle, R. Faigle Authors contributed equally to this work.Search for more papers by this authorM. Mohme, M. Mohme Authors contributed equally to this work.Search for more papers by this authorM. Levy, M. Levy Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USASearch for more papers by this author R. Faigle, R. Faigle Authors contributed equally to this work.Search for more papers by this authorM. Mohme, M. Mohme Authors contributed equally to this work.Search for more papers by this authorM. Levy, M. Levy Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USASearch for more papers by this author First published: 05 December 2011 https://doi.org/10.1111/j.1468-1331.2011.03602.xCitations: 13 M. Levy, MD, PhD, Johns Hopkins University, Medical Director of General Neurology, Johns Hopkins Hospital, 600 N. Wolfe Street, Pathology 509, Baltimore, MD 21287, USA (tel.: 443-287-4412; fax: 443-287-4062; e-mail: mlevy@jhmi.edu). Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume19, Issue2February 2012Pages e14-e15 RelatedInformation

Perfil epidemiológico do beribéri notificado de 2006 a 2008 no Estado do Maranhão, Brasil

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.

Thiamine (Vitamin B1)

Thiamine (vitamin B 1) was the first B vitamin to have been identified. It serves as a cofactor for several enzymes involved in energy metabolism. The thiamine-dependent enzymes are important for the biosynthesis of neurotransmitters and for the production of reducing substances used in oxidant stress defenses, as well as for the synthesis of pentoses used as nucleic acid precursors. Thiamine plays a central role in cerebral metabolism. Its deficiency results in dry beriberi, a peripheral neuropathy, wet beriberi, a cardiomyopathy with edema and lactic acidosis, and Wernicke—Korsakoff syndrome, whose manifestations consist of nystagmus, ophthalmoplegia, and ataxia evolving into confusion, retrograde amnesia, cognitive impairment, and confabulation. Patients on a strict thiamine-deficient diet display a state of severe depletion within 18 days. The most common cause of thiamine deficiency in affluent countries is either alcoholism or malnutrition in nonalcoholic patients. Treatment by thiamine supplementation is beneficial for diagnostic and therapeutic purposes.

Severe thiamine deficiency following bariatric surgery – Case report

Thiamine deficiency has 4 clinical forms: dry beriberi, wet (chronic and acute), Wernicke encephalopathy and Korsakoff syndrome. It can be related to intake reduction, impaired absorption or increased consumption conditions. The present report shows the case of an obese patient who underwent bariatric surgery, and after 3 months presented with severe vitamin deficiency and evident beriberi symptoms and Wernicke, with significant improvement after nutrient replenishment.

Rapidly progressive polyneuropathy due to dry beriberi in a man: a case report

IntroductionWe describe a case of rapidly progressive and severely debilitating polyneuropathy in a patient with confirmed hypovitaminosis B1, consistent with dry beriberi. Crucially, this is a treatable condition, although sometimes with incomplete recovery, but it is probably under-recognized yet increasingly common given increasing levels of alcohol abuse in the western world.Case presentationA 49-year-old Caucasian British man presented with progressive weakness of both lower limbs of approximately seven months' duration. He noted difficulty climbing stairs. He also complained of lethargy, and loss of muscle bulk, including his thighs. He had a history of type 2 diabetes mellitus and admitted prior alcohol abuse but denied excessive alcohol intake in the five years prior to presentation. Initial clinical and neurophysiological examinations were consistent with a mild peripheral neuropathy and probable proximal myopathy. However, over the subsequent four months he evolved a marked tetraparesis, with profound sensory disturbance of all limbs. Repeat neurophysiology revealed a widespread polyneuropathy with extensive acute and sub-acute denervation changes in all four limbs, and reduced or absent sensory nerve action potentials. Hypovitaminosis B1 was confirmed (45 nmol/L, reference range 66-200 nmol/L). His rapid clinical deterioration was in keeping with dry beriberi. He was treated with thiamine. Subsequent follow-up revealed slow but significant improvement, such that by 15-16 months from the initial onset of symptoms, and approximately six months after the onset of his marked tetraparesis, he was able to stand independently and was gradually gaining confidence in walking pending a period of in-patient neurorehabilitation.ConclusionA potentially wide differential diagnosis exists for this type of presentation. Confirming hypovitaminosis B1 by requesting the assay prior to vitamin replacement ensures accurate diagnosis and appropriate ongoing treatment. An increasingly high index of suspicion is likely to be required in the context of increasing levels of alcohol abuse in the western world and the possible increasing prevalence of dry beriberi.

Cardiac Beriberi: Often a Missed Diagnosis

Thiamine deficiency leads to various manifestations due to dysfunction of nervous or cardiovascular system, commonly known as dry and wet beriberi, respectively. The latter, also known as cardiac beriberi is usually missed in clinical practice because of the absence of classically described symptoms such as pedal edema/anasarca. We investigated 55 such infants and prospectively followed their clinical course. All the babies were exclusively breast-fed and their mothers belonged to low socio-economic status with their staple diet consisting of non-parboiled polished rice. Majority presented with tachypnea, chest indrawing and tachycardia and cardiomegaly with dilatation of right heart and pulmonary hypertension on 2D-echocardiography. Low levels of erythrocyte transketolase activity suggested thiamine deficiency that was confirmed by reversion of several clinical features including cardiologic abnormalities to normalcy on thiamine supplementation. We recommend thiamine therapy for infants with unexplained congestive cardiac failure or acute respiratory failure from precarious socio-economic background since it is life-saving in many instances.

Clinical Presentation of Beriberi After Roux-en-Y Gastric Bypass (RYGB) Surgery

Purpose: RYGB is the most common surgical procedure performed for medically-complicated obesity. We previously reported a high prevalence of thiamine deficiency associated with small intestinal bacterial overgrowth (SIBO) after RYGB (Nutrition Res, 2008). Clinical manifestations of Beriberi include: 1) Neuropsychiatric; 2) High output cardiovascular disease (wet Beriberi); 3) Neurological/Neuropathies (dry Beriberi); or 4) Gastrointestinal (nausea/emesis/megajejunum or constipation/megacolon). The purpose of this study is to estimate the prevalence of and subtypes of Beriberi after RYGB. Methods: Prospective study performed in an urban community hospital. Consecutive RYGB patients seen at a new joint Medical/Surgical Bariatric Clinic from February 1, 2008 to May 1, 2009 were included in this study. Data included date of and type (open or laparoscopic) of RYGB, sex, age, thiamine diphosphate levels, Beriberi symptoms (Types 1-4), thiamine supplementation, and potential resolution with thiamine treatment. Beriberi is defined in this study by: 1) consistent clinical symptoms and examination and 2) either low blood thiamine level (n=22), or resolution of consistent clinical symptoms after intramuscular (IM) thiamine (n=5). Results: Of 151 patients evaluated, 25 females and 2 males met the criteria for Beriberi (estimated prevalence of 18%); age range is 30-68 years (mean age: 50 years); 4 patients had laparoscopic while 23 had open RYGB. Symptoms were noted 2 months to 9 years (mean: 5.0 years) after RYGB. In these 27 RYGB patients, 12 have one symptom consistent with Beriberi while 15 have symptoms consistent with multiple subtypes. Among these patients, 52% had Type 1 Beriberi, 67% had Type 2, 11% had Type 3, and 48% had Type 4 (GI) Beriberi. Of 20 patients with symptoms of Beriberi prior to treatment with IM thiamine, all 20 (100%) noted post-treatment symptomatic improvement. In 3 patients, a symptom of Beriberi returned after replacing IM thiamine therapy with oral thiamine supplements. Conclusion: In our patient population, a high prevalence of Beriberi was identified on average 5.0 years after RYGB. The most common Beriberi identified was Type 2 (wet Beriberi). General gastroenterologists are seeing an increasing number of bariatric patients. For symptoms of nausea, emesis or constipation, GI Beriberi should be considered. However, other types of Beriberi may be present. Oral thiamine alone may be an ineffective treatment in these patients, supporting malabsorption. If there is a clinical suspicion of Beriberi in a RYGB patient, therapy with IM thiamine should be started. Further studies are required to determine whether treating SIBO in RYGB patient prevents Beriberi or may be effective as an adjuvant therapy in patients with Beriberi.

Was it really beriberi?

This case suggests that the Guillain–Barre syndrome (GBS) could have been mimicked by “dry beriberi” and that we should be aware of this confusion when we diagnose GBS. However, the...