Edit concept Question Editor Create issue ticket

Beriberi


Presentation

The patients with beriberi do not report any signs or symptoms of thiamine deficiency. Signs and symptoms at the early stage are often nonspecific, such as fatigue, thigh failure of high cardiac-output can direct the diagnosis to thiamine deficiency.

Some of the neurological symptoms of beriberi are: poor memory, sleep disturbances, Korsakoff syndrome, irritability, muscle cramps, muscle atrophy, and foot drop. Beriberi also manifests with some cardiovascular symptoms such as tachycardia, heart failure, chest pain, hypotension and shock. The gastroenterologic symptoms of beriberi are anorexia, constipation, dysphagia, and abdominal discomfort [6] [7].

Malnutrition
  • This would constitute a second stage of the Modern Malnutrition and explain why some workers now hold the dominant diseases of modernized societies to be new, nutritionally based, pellagraform yet lipid-related and to range, once again, from heart disease[ncbi.nlm.nih.gov]
  • Beriberi was a disease of malnutrition caused by the consumption of overmilled rice.[dictionary.cambridge.org]
Congestive Heart Failure
  • This was defined as the presence of signs of congestive heart failure or shock in the absence of fever or other signs of sepsis, hypovolaemia or cardiac abnormalities, with rapid clinical improvement following parenteral thiamine.[ncbi.nlm.nih.gov]
  • Complications may include: Coma Congestive heart failure Death Psychosis Beriberi is extremely rare in the United States.[nlm.nih.gov]
  • Congestive heart failure may need to be excluded as may other vitamin deficiencies (vitamin B12, niacin) if neurological symptoms are present.[patient.info]
Burning Feet
  • Deficiency diseases: Pellagra, sub-acute combined degeneration, burning feet syndrome and pyridoxine deficiency. ii. Metabolic diseases: Diabetes Mellitus, Uremia, Porphyria etc. iii.[biologydiscussion.com]
  • feet, and later symptoms consist of painful parasthesias in the distal upper limbs as well, weakness and atrophy of the feet and hands, and distal atrophic skin and hair loss; the "wet" form is characterized by edema resulting from a high output form[medical-dictionary.thefreedictionary.com]
Tachypnea
  • Respiratory system examination revealed tachypnea and on auscultation there were bilateral basal fine crepitations, electrocardiogram showed T wave inversions. Abdominal examination revealed tender hepatomegaly.[jdrntruhs.org]
  • Opinion statement Congestive heart failure describes a syndrome with complex and variable symptoms and signs, including dyspnea, increased fatigability, tachypnea, tachycardia, pulmonary rales, and peripheral edema.[dx.doi.org]
Loss of Appetite
  • General symptoms include loss of appetite and overall lassitude, digestive irregularities, and a feeling of numbness and weakness in the limbs and extremities. (The term beriberi is derived from the Sinhalese word meaning “extreme weakness.”)[humantermuem.es]
  • In the childhood and adult versions of the disease there is a preliminary condition of fatigue, loss of appetite, and a numb tingling feeling in the legs. This condition can then lead to either wet or dry beriberi.[science.jrank.org]
  • Beriberi is a disease caused by a lack of Vitamin B1 (thiamin).The thiamin-deficiency disorder is characterized by muscle weakness, loss of appetite, nerve degeneration and sometimes oedema .[infonet-biovision.org]
Acute Abdomen
  • In this article, we report the case of a 7-month-old child with thiamine deficiency presented with neurological symptoms and simulation of acute abdomen.[ncbi.nlm.nih.gov]
Tachycardia
  • Parts of the heart, thus, undergo injury and the patient starts showing physical symptoms of tachycardia, edema and myocardial injury.[symptoma.com]
  • Later, patients experience weakness, peripheral neuropathy, headache, and tachycardia.[fpnotebook.com]
  • The patient developed progressive ascending weakness, limited extraocular movement, confusion, edema, tachycardia and hypotension. He was intubated and mechanically ventilated.[jcmr-online.biomedcentral.com]
  • Beriberi, also caused by thiamine deficiency, accounted for his tachycardia, polyneuropathy, areflexia, hypothermia and biochemical abnormalities.[casereports.bmj.com]
  • Tachycardia (increased pulse rate). . Lung congestion. . Enlarged heart - congestive heart failure. Infantile beriberi: . In infantile beriberi the child is usually breast fed & can have sudden convulsions, cyanosis and can go in coma.[specialityclinic.com]
Hypotension
  • "Shoshin beriberi" cardiac failure has a different presentation, with vasoconstriction, hypotension and severe metabolic acidosis. A three-month breast-fed infant developed these features (biochemical tests confirmed the diagnosis).[ncbi.nlm.nih.gov]
  • After 5 days of daily 100 mg IV thiamine and supportive care, the hypotension resolved and the patient was extubated and was released from the hospital 3 weeks later. Our case shows via CMR profound myocardial edema associated with wet beriberi.[ncbi.nlm.nih.gov]
  • He became hypotensive and laboratory evaluation revealed an elevated Troponin-I level of 20.95 ng/mL (Reference value 0.11 ng/mL).[jcmr-online.biomedcentral.com]
  • Beriberi also manifests with some cardiovascular symptoms such as tachycardia, heart failure, chest pain, hypotension and shock. The gastroenterologic symptoms of beriberi are anorexia, constipation, dysphagia, and abdominal discomfort.[symptoma.com]
Muscle Weakness
  • Electromyographic findings and slow improvement of muscle weakness were compatible with axonal degeneration of motor fibers.[ncbi.nlm.nih.gov]
  • CASE DESCRIPTION: A 49-year-old man visited the emergency department with acute confusion, muscle weakness in arms and legs and visual impairment after a period of dysphagia and recurrent vomiting.[ncbi.nlm.nih.gov]
  • ., leg cramps, muscle weakness), limb swelling, elevated pulse, and heart failure. Wernicke-Korsakoff syndrome is a related condition (with symptoms such as a jerky gait, disorientation, and impaired short-term memory) that occurs among alcoholics.[diet.com]
  • Symptoms include vomiting, seizures, muscle weakness, loss of muscle function in the legs, and mental confusion. Wet beriberi, which affects the cardiovascular system.[kidshealth.org]
Numbness of the Feet
  • Severe thiamin deficiency leads to a disease called beriberi with the added symptoms of tingling and numbness in the feet and hands, loss of muscle, and poor reflexes. Beriberi is not common in the United States and other developed countries.[web.archive.org]
  • The toes feel numb and the feet have a burning sensation; the leg muscles become sore and the calf muscles cramp. The individual walks unsteadily and has difficulty getting up from a squatting position.[encyclopedia.com]
Psychiatric Manifestation
  • Beriberi is one of several thiamine-deficiency related conditions which may occur concurrently, including Wernicke's encephalopathy (mainly affecting the central nervous system), Korsakoff's syndrome (amnesia with additional psychiatric manifestations[icd.codes]
Incontinence
  • METHODS: A 44-year-old male alcoholic patient from Morocco developed massive bilateral leg edema, a subacute sensorimotor neuropathy, and incontinence.[ncbi.nlm.nih.gov]
Peripheral Neuropathy
  • Abstract An adult with Crohn's disease on home total parenteral nutrition (TPN) for 8 months presented with peripheral neuropathy and ataxia. The patient was found to be deficient of thiamine.[ncbi.nlm.nih.gov]
  • Abstract The classical form of thiamine deficiency in children is comprised of peripheral neuropathy, encephalopathy and high-output cardiac failure, predominantly right-sided.[ncbi.nlm.nih.gov]
  • Author information 1 Department of Neurology, Japanese Red Cross Shizuoka Hospital, Japan. [email protected] Abstract Beriberi is a disease caused by thiamine deficiency resulting in peripheral neuropathy and myocardial dysfunction.[ncbi.nlm.nih.gov]
  • With the constellation of peripheral neuropathy, encephalopathy, ophthalmoplegia, unexplained heart failure, and lactic acidosis, thiamine deficiency was suspected.[ncbi.nlm.nih.gov]
  • The manifestations of the disease are peripheral neuropathy (impairment of the sensory, motor or reflex functions of the extremities), or degeneration of the myelin in muscle sheaths.[symptoma.com]
Nystagmus
  • We report a 25-year-old woman who developed subacute progressive weakness and areflexia followed by confusion, ophthalmoplegia, and nystagmus following bariatric surgery.[ncbi.nlm.nih.gov]
  • Classically, Wernicke encephalopathy is characterized by confusion (encephalopathy), ataxia , and nystagmus . Korsakoff syndrome is a more severe finding that includes confabulations.[pixorize.com]
  • In the pseudomeningitic variety there there are symptoms of nystagmus, vomiting and convulsions but normal cerebrospinal fluid (CSF).[patient.info]
  • Signs include: nystagmus (flickering of the eye), muscle twitching; a bulging fontanelle; and convulsions and unconsciousness.[web.archive.org]
  • Proximal myopathy, lower limb fasciculations and areflexia, restricted bilateral eye abduction and nystagmus were observed. Blood investigations demonstrated compensated lactic acidosis, acute kidney injury and leucocytosis.[casereports.bmj.com]
Amnesia
  • Beriberi is one of several thiamine-deficiency related conditions which may occur concurrently, including Wernicke's encephalopathy (mainly affecting the central nervous system), Korsakoff's syndrome (amnesia with additional psychiatric manifestations[icd.codes]
  • […] neurological syndromes are recognized: dry beri-beri (a patchy axonal polyneuropathy), Wernicke encephalopathy (characterized by the triad of confusion, ophthalmoplegia, and ataxia), and Korsakoff’s psychosis (manifesting as retrograde and anterograde amnesia[n.neurology.org]
  • Retrograde amnesia, inability to form new memories, confabulation and hallucinations are the most common signs and symptoms. Korsakoff’s psychosis isn’t curable; sufferers are permanently handicapped and often require ongoing supervision.[ems1.com]
  • The essential features are anterograde and retrograde amnesia, often with disorientation and confabulation. The last usually makes the patient delightful but any check of the authenticity of stories will reveal them as confabulation.[patient.info]
Apathy
  • Hypermetabolic states also predispose to deficiency and this includes fever , pregnancy, postoperative state, total parenteral nutrition and renal dialysis. [ 11 ] A loop diuretic can also increase the risk. [ 12 ] Presentation History Early features Fatigue and apathy[patient.info]
  • It is accompanied by a degree of apathy – lack of interest in life or other activities that were previously enjoyable. Often patients are diagnosed with depression at this point.[healthhype.com]
  • It is characterised by weakness of eye muscles, so that the patient cannot look upwards or sideways and a state of disorientation and apathy.[biologydiscussion.com]
  • These brain abnormalities are called the Wernicke-Korsakoff syndrome , which has two parts: Wernicke encephalopathy causes confusion, apathy, difficulty walking, and eye problems, including involuntary eye movements (nystagmus) and partial paralysis of[merckmanuals.com]
Paresthesia
  • Cases had lower extremity edema (85%), upper extremity paresthesias (84%), and lower extremity weakness and pain (78%).[ncbi.nlm.nih.gov]
  • A probable case patient was defined as a person detained in the center between October 2002 and April 2003 with at least two of the following symptoms: bilateral leg edema, dyspnea, positive squat test, motor deficiencies, and paresthesia.[ncbi.nlm.nih.gov]
  • Of 127 mothers, 60 (47.2%) reported edema and paresthesia as well as a positive squat test during pregnancy; 125 (98.4%) respected post-partum food avoidance and all ate polished rice.[ncbi.nlm.nih.gov]
  • […] and paresthesia in 9 (10%) patients.[ncbi.nlm.nih.gov]
  • In either form of beriberi, patients may complain of pain and paresthesia.[jdrntruhs.org]

Workup

Replacing of thiamine is the first step to ascertain the diagnosis of the disease. If the patient responds to the treatment, it would be safe to measure the thiamine deficiency as the cause of the trouble. Since thiamine is non-toxic at higher levels, this method of managing the condition offers little risk.

Measuring blood thiamine pyruvate, glyoxylate levels and alpha-ketoglutarate levels, urinary excretion of thiamine and its metabolites provides the correct diagnosis of the condition.

Thiamine loading test has been considered as the best indicator of thiamine deficiency. If there is an increase of more than 15% of the enzyme activity is seen, it is indicative of a deficiency of the vitamin. This test, however, is both expensive and time-consuming.

Urinary methylglyoxal levels: Measuring methylglyoxal levels and thyroid-stimulating hormone (TSH) also helps to rule out thyrotoxicosis-induced heart failure.

Troponin I: Higher levels of troponin I is seen in patients with heart failure induced by thiamine deficiency.

Metabolic acidosis is also caused by thiamine deficiency because of the increased lactic acid production. In gastrointestinal beriberi, patients report abdominal pain caused due to lactic acidosis [8] [9][10].

Thiamine Decreased
  • Daily needs for thiamine decrease when fat forms a large part of the diet and increase when the diet is high in carbohydrates. Pregnancy, lactation, an overactive thyroid and fever increase the requirement for thiamine.[health24.com]
  • Decreased uptake of thiamine from the GI tract: Active transport of thiamine into enterocytes is disturbed during acute alcohol exposure. Liver thiamine stores are reduced due to hepatic steatosis or fibrosis.[en.wikipedia.org]

Treatment

The goal of the treatment of beriberi is to substitute the deficiency of thiamine, reduce the morbidity associated with such deficiency and prevent complications. If the correct diagnosis is ascertained, there must be prompt administration of parenteral thiamine. Thiamine substitution therapy must be continued until all the symptoms associated with beriberi are gone [11].

Prognosis

Beriberi, if not cured on time, can be fatal. In this disease, the patient is robbed of the energy even for the daily activities making them lethargic. Beriberi is treatable even in the severe cases. Thus, the prognosis of the patient with beriberi is good. In case of wet beriberi, the improvement is observed within 12 hours.

Etiology

Development of beriberi is caused by the deficiency of thiamine. There are several mechanisms by which this can occur, such as lack of thiamine intake, increased consumption of thiamine, and decreased absorption.

Lack of thiamine intake: A diet with high levels of thiaminases (milled rice, raw freshwater fish, ferns), anti-thiamine factor (tea, coffee, or betel nuts), or high levels of sulfite causes a lack of thiamine. There are some diet-related factors that can cause a reduction in the thiamine intake are alcoholic state, starvation state and gastric bypass surgery or parental nutrition devoid of adequate thiamine levels.

Increase in the consumption of thiamine: The increase in the metabolism of thiamine can result from having a diet rich in carbohydrate or saturated fat, hypothyroidism, pregnancy, lactation, fever with severe infections. Increased depletion of thiamine occurs in patients with diarrhea, or one who are undergoing diuretic therapies, hemodialysis, or peritoneal dialysis. Thiamine loss is often associated with the increase in the rate of urine flow.

Decrease in the absorption of thiamine: Reduction in the absorption of thiamine is observed in patients with chronic intestinal disease, malnutrition, gastric bypass surgery, folate deficiency, and alcoholism. Folate deficiency causes indirect thiamine deficiency as thiamine of the body is not activated.

Infantile beriberi: Infantile beriberi occurs in the infants who are 2-4 months of age and are exclusively fed with mother’s milk, whose mother is thiamine deficient.

Patients with chronic alcoholism must be administered parenteral thiamine as alcohol is a direct neurotoxin and causes low and impaired thiamine intake and storage. It also leads to the accelerated destruction of the thiamine diphosphate. When the person is dieting, he often neglects the correct intake of micronutrients, and hence leads to several vitamin deficiency diseases [3] [4].

Epidemiology

The population of developing countries is at a higher risk of vitamin deficiency diseases. Though no accurate data is available, beriberi is reported in the refugees who are dependent on the emergency food aid, rich in carbohydrate and saturated fats. There is a lack of micronutrient supplementation in such diet [5].

Sex distribution
Age distribution

Pathophysiology

When the person is devoid of thiamine, the stores of this vitamin in the body get depleted within a month, after which there are several symptoms such as resting tachycardia, decrease in the deep tendon reflexes, or peripheral neuropathy. Beriberi is categorized into two types: dry beriberi and wet beriberi.

Dry beriberi: When the thiamine deficiency involves the nervous system, it is termed as dry beriberi. This type of beriberi is seen in patients with poor calorie-intake and higher physical inactivity. The manifestations of the disease are peripheral neuropathy (impairment of the sensory, motor or reflex functions of the extremities), or degeneration of the myelin in muscle sheaths.

One of the significant presentations of dry beriberi is Wernicke encephalopathy. In this condition, there is an orderly sequence of symptoms such as vomiting, horizontal nystagmus, fever, ataxia, and progressive mental impairment. All these symptoms lead to Korsakoff syndrome. Only 50% of the patients who reach this stage recover completely [7].

Wet beriberi: When beriberi involves the cardiovascular system, it is referred to as wet beriberi. There is peripheral vasodilation causing high cardiac output. Salt-water retention mediated by renin-angiotensin-aldosterone system is also observed. With vasodilation, the kidneys detects the loss of volume and thus starts conserving the salt.

When salt retention occurs, more fluid is absorbed causing edema of the extremities. This puts extra burden on the heart and it is severely overworked. Parts of the heart, thus, undergo injury and the patient starts showing physical symptoms of tachycardia, edema and myocardial injury.

Shoshin beriberi is a rapid form of wet beriberi causing predominant injury to the heart, and the inability of the heart muscles to fulfill its functions. In this case, edema is absent, however, cyanosis of the hands and feet, tachycardia, and anxiety is observed. If no treatment is initiated, death is almost certain within hours or days [6].

Complications: Some of the severe complications of beriberi are coma, congestive heart failure, psychosis and death.

Prevention

Correct dose of thiamine through diet daily can help prevent beriberi.

Summary

Beriberi is a disease that occurs due to deficiency of thiamine pyrophosphate. Thiamine pyrophosphate is the active form of the vitamin thiamine or vitamin B1. The functions of the active form of thiamine are that it acts as a coenzyme in the metabolism of carbohydrate by decarboxylation of alpha-ketoacids and in the pentose monophosphate pathway.

Thiamine is a water-soluble vitamin (which the body cannot produce) and is concentrated in the skeletal muscles, brain, kidneys, liver and heart. It is excreted by the kidneys. If the proper amount of Vitamin B1 is not taken through diet, it can lead to deficiency of this vitamin. In hyperthyroidism, pregnancy, severe liver disease and lactation, there is an excessive use of the vitamin contributing to the deficiency. Food is an excellent source of vitamin B1. Some of the food-items that are rich in thiamine are whole grain foods, milk and milk products, green leafy vegetables, juices (orange and tomato), and legumes [1] [2].

Patient Information

Patients must know that vitamins are very important for the working of the body. These micronutrients must be provided to the body in adequate amount in order to combat deficiency.

Beriberi is asymptomatic but as it progresses, its manifestations are severe. Alcohol and fad diet worsens the condition in such patients. Once the problem is addressed, the patients are advised to maintain the appropriate diet.

References

Article

  1. Wooley, JA. Characteristics of thiamin and its relevance to the management of heart failure. Nutr Clin Pract. Oct-Nov 2008;23:487-93.
  2. Masumoto K, Esumi G, Teshiba R, et al. Need for thiamine in peripheral parenteral nutrition after abdominal surgery in children. JPEN J Parenter Enteral Nutr. Jul-Aug 2009;33(4):417-22. [Medline].
  3. Matrana MR, Davis WE. Vitamin deficiency after gastric bypass surgery: a review. South Med J. October/ 2009;102:1025-31.
  4. Weise Prinzo Z, de Benoist B. Meeting the challenges of micronutrient deficiencies in emergency-affected populations. Proc Nutr Soc. May 2002;61(2):251-7. Weise Prinzo Z, de Benoist B. Meeting the challenges of micronutrient deficiencies in emergency-affected populations. Proc Nutr Soc. May 2002;61(2):251-7.
  5. Shenoy VV, Patil PV, Nagar VS, et al. Congestive cardiac failure and anemia in a 15-year-old boy. J Postgrad Med. Jul-Sep 2005;51(3):225-7.
  6. Zuccoli G, Gallucci M, Capellades J, et al. Wernicke encephalopathy: MR findings at clinical presentation in twenty-six alcoholic and nonalcoholic patients. AJNR Am J Neuroradiol. Aug 2007;28(7):1328-31.
  7. Tran HA. Increased troponin I in "wet" beriberi. J Clin Pathol. May 2006;59(5):555. 
  8. Falder S, Silla R, Phillips M, Rea S, Gurfinkel R, Baur E, et al. Thiamine supplementation increases serum thiamine and reduces pyruvate and lactate levels in burn patients. Burns. Mar 2010;36(2):261-9. 
  9. Donnino M. Gastrointestinal beriberi: a previously unrecognized syndrome. Ann Intern Med. Dec 7 2004;141(11):898-9. 
  10. Hamilton Wright. The Cause, Course, Prevention, and Treatment of Beriberi. Public Health Pap Rep. 1905; 31(Pt 1): 289–299.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2017-08-09 18:11