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

  FEX: Thiamine content of F-75 for complicated severe acute malnutrition: time for a change? Summary of research1 Location: Global What we know: Complicated cases of severe acute malnutrition (SAM) are usually severely ill with comorbidities. [ennonline.net]

  The most common sickness amongst the internees were malaria, malnutrition and its associated diseases, beriberi, and pellagra. For lack of nutrition, many people succumbed to beriberi and malaria. [collinsdictionary.com]

  Other causes of thiamine deficiency are malnutrition, total parenteral nutrition deficient in thiamine, formula deficient in thiamine, postbariatric surgery–induced malnutrition, hyperemesis gravidarum, and hemodialysis-induced thiamine deficiency in [web.archive.org]

  "Shoshin beriberi", which is a fulminant form of cardiovascular beriberi accompanied by hemodynamic deterioration with high cardiac output and decreased systemic blood pressure, caused by thiamine deficiency due to alcoholic abuse or malnutrition, is [ncbi.nlm.nih.gov]

• Congestive Heart Failure

  Complications may include: Coma Congestive heart failure Death Psychosis Beriberi is extremely rare in the United States. [medlineplus.gov]

  Possible Complications Complications may include: Coma Congestive heart failure Death Psychosis When to Contact a Medical Professional Beriberi is extremely rare in the United States. [mountsinai.org]

  Although, untreated Beriberi can eventually lead to death Commencing thiamine supplementation can cause an improvement in the symptoms If congestive heart failure occurs, the prognosis is poor. [dovemed.com]

• Fatigue

  The most common symptoms of chronic beriberi due to thiamine deficiency include dyspnoea, fatigue, leg oedema, lower extremity weakness and numbness. [ncbi.nlm.nih.gov]

  Symptoms are fatigue, diarrhea, appetite and weight loss, disturbed nerve function causing paralysis and wasting of limbs, edema, and heart failure. [medical-dictionary.thefreedictionary.com]

  Other possible symptoms of beriberi include: Weakness and muscle loss Mental confusion Tingling or loss of sensitivity in the fingers or feet Fatigue Rapid heart beat Chest pain Nausea or vomiting Fever If these symptoms aren’t attended to when they first [webmd.com]

  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]

• 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]

  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. [medical-dictionary.thefreedictionary.com]

  feet), - targeted compensation of detected deficiencies, - life-long supplementation and controlled adjustment, - periodic follow-up examinations to close inspection intervals. [karger.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]

  Recent surveys using whole blood thiamine diphosphate (TDP) revealed that thiamine deficiency was associated with cardiac dysfunction and tachypnea in Cambodian infants [32,34]. [ncbi.nlm.nih.gov]

• 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]

  This syndrome is usually preceded by non-specific symptoms such as generalized fatigue, loss of appetite, and abdominal pain. [nutritionj.biomedcentral.com]

• Heart Failure

  Congestive heart failure may need to be excluded as may other vitamin deficiencies (vitamin B12, niacin) if neurological symptoms are present. [patient.info]

  Shoshin beriberi, a fulminant form of heart failure due to thiamine deficiency has a different presentation to the classical form of beriberi heart failure. [ncbi.nlm.nih.gov]

  This progresses to oedema, cyanosis and breathlessness with signs of heart failure: increased pulse rate; enlargement of the heart; additional heart sounds; a systolic murmur; pulmonary oedema; liver enlargement and low urine volume. [ennonline.net]

  failure Hyperthyroidism Beriberi High-output heart failure from AV fistula AVM Paget disease Anemia Pregnancy Evaluation Chest x-ray showing cardiomegaly with mild pulmonary congestion and pleural effusion in a patient with wet beriberi. [wikem.org]

  Complications may include: Coma Congestive heart failure Death Psychosis Beriberi is extremely rare in the United States. [medlineplus.gov]

• Tachycardia

  Parts of the heart, thus, undergo injury and the patient starts showing physical symptoms of tachycardia, edema and myocardial injury. [symptoma.com]

  Dry Beriberi Symmetrical peripheral neuropathy (motor and sensory) mostly distal extremities Wet Beriberi CHF, high output heart failure, cardiomegaly, peripheral edema, tachycardia, DOE/PND/orthopnea Can include neuropathy seen in Dry Beriberi Infantile [wikem.org]

  Research suggests that thiamine deficiency has been reported to cause severe neuropathies or specific conditions like postural orthostatic tachycardia syndrome. [icliniq.com]

  Beriberi, also caused by thiamine deficiency, accounted for his tachycardia, polyneuropathy, areflexia, hypothermia and biochemical abnormalities. [ncbi.nlm.nih.gov]

  The patient developed progressive ascending weakness, limited extraocular movement, confusion, edema, tachycardia and hypotension. He was intubated and mechanically ventilated. [jcmr-online.biomedcentral.com]

• Hypotension

  Moreover, thiamine replacement should be considered without delay in hypotensive patients with signs of WE and/or risk factors for beriberi. [nature.com]

  Persistent hypotension despite adequate fluid resuscitation required use of vasopressors. [nutritionj.biomedcentral.com]

  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]

  "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]

• Jugular Venous Distention

  He had slight jugular venous distention, edema of the face and upper and lower extremities, ascites, and loud heart sounds with an S3 gallop. [ncbi.nlm.nih.gov]

• Muscle Weakness

  A 61-year-old male patient was admitted to our hospital for progressive leg edema, dyspnea on exertion, and lower-extremity muscle weakness. Echocardiography showed a hyperkinetic left ventricle and a moderate amount of pericardial effusion. [ncbi.nlm.nih.gov]

  Dry beriberi is characterized by bilateral polyneuritis (numbness of hands and feet), loss of tendon and periosteal reflexes, paresthesia of limbs and muscle weakness. Wet beriberi is characterized by swelling. [wikilectures.eu]

  Symptoms include nervous system abnormalities (e.g., leg cramps, muscle weakness), limb swelling, elevated pulse, and heart failure. [diet.com]

• Numbness of the Feet

  It causes tingling and numbness in the hands and feet, severe memory loss, disorientation, and confusion. What are some effects of thiamin on health? Scientists are studying thiamin to better understand how it affects health. [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]

• Muscular Atrophy

  Classically it is characterized by multiple neuritis, muscular atrophy, weakness, cardiovascular changes, and progressive edema. beriberi the name given to thiamin deficiency in humans. See thiamin nutritional deficiency. [medical-dictionary.thefreedictionary.com]

• Arthralgia

  Amerindian communities of Uiramutã, state of Roraima, Brazil, June 2008 Signs and symptoms N Percent Lower extremity edema 77 85 Lower extremity parasthesias 76 83 Leg pain 71 78 Weakness 71 78 Difficulty walking 69 76 Fatigue 67 74 Difficulty running 60 66 Arthralgia [ncbi.nlm.nih.gov]

• 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]

  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 [ipfs.io]

• Nystagmus

  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. [ncbi.nlm.nih.gov]

  Neurologically, she had mild confusion, with almost complete ophthalmoplegia and vertical nystagmus, normosthenia, normoreflexia, distal apallesthesia and abatesthesia, and truncal ataxia. [n.neurology.org]

  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]

• Peripheral Neuropathy

  This may explain peripheral neuropathy symptoms in dry beriberi. Thiamine deficiency types Wernicke-Korsakoff syndrome Beriberi Clinical Features Dry Beriberi with symmetric peripheral neuropathy. [wikem.org]

  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]

  Our study result is likely to sensitize the health professionals of this region about this neglected health issue by increasing awareness of the clinical spectrum of Thiamine Deficiency related Peripheral Neuropathy. [clinicaltrials.gov]

• Paresthesia

  Cases had lower extremity edema (85%), upper extremity paresthesias (84%), and lower extremity weakness and pain (78%). [ncbi.nlm.nih.gov]

  Dry beriberi is characterized by bilateral polyneuritis (numbness of hands and feet), loss of tendon and periosteal reflexes, paresthesia of limbs and muscle weakness. Wet beriberi is characterized by swelling. [wikilectures.eu]

  Pregnancy: pain and paresthesia of upper and lower extremities. The symptoms increased after delivery. [journals.plos.org]

• Amnesia

  […] 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]

  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]

  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]

  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]

• 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]

  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]

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]

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].

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.

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].

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].

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.

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

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].

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.