Beriberi: Difference between revisions

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==Background==
==Background==
*Dry Beriberi: neuro sx caused by thiamine deficiency
*Dry Beriberi: neuro symptoms caused by thiamine deficiency
*Wet Beriberi: cardiac sx caused by thiamine deficiency
*Wet Beriberi: cardiac symptoms caused by thiamine deficiency
*Infantile Beriberi: neuro/cardiac sx caused by thiamine deficiency in <1 year old infant
*Infantile Beriberi: neuro/cardiac symptoms caused by thiamine deficiency in <1 year old infant


===Causes===
===Causes===
*Anything that causes thiamine (vitamin B1) deficiency: poor dietary intake, malabsorption, increased metabolic requirement
*Anything that causes [[thiamine deficiency|thiamine (vitamin B1) deficiency]]: poor dietary intake, malabsorption, increased metabolic requirement
**Chronic alcoholism, dieting/fasting/starvation, anorexia, vomiting/diarrhea, unbalanced TPN, GI surgery, malignancy, dialysis, AIDS, IBD, pancreatitis, liver disease, thyrotoxicosis
**Chronic [[alcoholism]], dieting/fasting/starvation, [[anorexia nervosa|anorexia]], [[vomiting]]/[[diarrhea]], unbalanced TPN, GI surgery, malignancy, [[dialysis complications|dialysis]], [[AIDS]], [[IBD]], [[pancreatitis]], liver disease, [[thyrotoxicosis]]


===Pathophysiology===
===Pathophysiology===
*Thiamine is a cofactor for enzymes required in:
*Thiamine is a cofactor for enzymes required in:
**krebs cycle
**Krebs cycle
**Pentose phosphate pathway
**Pentose phosphate pathway
**Alpha-ketoglutarate dehydrogenase
**Alpha-ketoglutarate dehydrogenase
**pyruvate dehydrogenase.
**Pyruvate dehydrogenase.
*Because thiamine is an important cofactor in critical pathways for energy production, deficiency results in lactic acidosis and alteration of brain metabolism.
*Because thiamine is an important cofactor in critical pathways for energy production, deficiency results in lactic acidosis and alteration of brain metabolism.
*Thiamine is also important for lipid metabolism and may affect myelin sheath formation. This may explain peripheral neuropathy symptoms in dry beriberi.
*Thiamine is also important for lipid metabolism and may affect myelin sheath formation. This may explain peripheral neuropathy symptoms in dry beriberi.
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==Clinical Features==
==Clinical Features==
===Dry Beriberi===
===Dry Beriberi===
*Symmetrical peripheral neuropathy (motor and sensory) mostly distal extremities
*Symmetrical peripheral neuropathy ([[weakness|motor]] and [[numbness|sensory]]) mostly distal extremities


===Wet Beriberi===
===Wet Beriberi===
*CHF, high output heart failure, cardiomegaly, peripheral edema, tachycardia, DOE/PND/orthopnea
*[[CHF]], [[high output heart failure]], cardiomegaly, peripheral edema, [[tachycardia]], [[SOB|DOE/PND/orthopnea]]
*Can include neuropathy seen in Dry Beriberi
*Can include neuropathy seen in Dry Beriberi


===Infantile Beriberi===
===Infantile Beriberi===
*CHF, cardiomegaly, tachycardia, cyanosis, dyspnea, weight loss, marasmus, vomiting, loud cry, nystagmus, seizure
*[[CHF]], cardiomegaly, [[tachycardia]], [[hypoxia|cyanosis]], [[shortness of breath (peds)|dyspnea]], [[failure to thrive (peds)|weight loss]], marasmus, [[nausea and vomiting (peds)|vomiting]], loud cry, [[nystagmus]], [[seizure (peds)|seizure]]


===Bariatric Beriberi===
===Bariatric Beriberi===
*Occurs 1-3 months post-op
*Occurs 1-3 months post-[[weight loss surgery complications|bariatric surgery]]
*Causes are multifactorial, including low nutritional intake, poor baseline nutrition, persistent vomiting, malabsorption
*Causes are multifactorial, including low nutritional intake, poor baseline [[malnutrition|nutrition]], persistent [[vomiting]], malabsorption


==Differential Diagnosis==
==Differential Diagnosis==
{{Thiamine deficiency types}}
{{Vitamin deficiencies DDX}}


==Diagnosis==
==Evaluation==
*Clinical diagnosis
*Clinical diagnosis


==Treatment==
==Management==
''If you suspect Beriberi then treat it! Diagnosis is clinical and difficult to confirm, treatment is simple/inexpensive/effective, there is little risk to treatment, and the risk of morbidity/mortality from not treating is high''
''If you suspect Beriberi then treat it! Diagnosis is clinical and difficult to confirm, treatment is simple/inexpensive/effective, there is little risk to treatment, and the risk of morbidity/mortality from not treating is high''
#Thiamine 50-100 mg IV/IM q day x 7-14 days, then 10 mg PO q day until complete recovery
#[[Thiamine]] 50-100mg IV/IM q day x 7-14 days, then 10mg PO q day until complete recovery
#Magnesium; hypomagnesemic state may be resistant to thiamine administration
#[[Magnesium]]; hypomagnesemic state may be resistant to thiamine administration
#Multivitamin (at risk for other vitamin deficiencies)
#Multivitamin (at risk for other vitamin deficiencies)
*For chronic alcoholics consider banana bag: thiamine 100 mg + magnesium 2-4 g + folate 1 mg + multivitamin; all in 1L NS or D5W
*Give thiamine BEFORE glucose in patients requiring glucose who are at risk for thiamine deficiency; glucose without thiamine can precipitate/worsen WE by driving thiamine intracellularly
*Give thiamine BEFORE glucose in patients requiring glucose who are at risk for thiamine deficiency; glucose without thiamine can precipitate/worsen WE by driving thiamine intracellularly
==Disposition==
==Prevention==
{{Vitamin prophylaxis for ETOH}}


==Disposition==
==Disposition==


==See Also==
==See Also==
*[[Thiamine]]
*[[Thiamine deficiency]]
*[[Thiamine deficiency]]


==References==
==References==
# Donnino, Michael, et al. “Myths and misconceptions of wernicke’s encephalopathy: what every emergency physician should know.” Annals of emergency medicine.  2007. Vol 50, no 6. Pages 715-721.
#Donnino, Michael, et al. “Myths and misconceptions of wernicke’s encephalopathy: what every emergency physician should know.” Annals of emergency medicine.  2007. Vol 50, no 6. Pages 715-721.
# Sechi, GianPietro; Serra, Alessandro.  “Wernicke’s encephalopathy: new clnical settings and recent advances in diagnosis and management.” Neurology. Vol 6, May 2007.  Pages 442-455
#Sechi, GianPietro; Serra, Alessandro.  “Wernicke’s encephalopathy: new clnical settings and recent advances in diagnosis and management.” Neurology. Vol 6, May 2007.  Pages 442-455
[[Category:Neuro]]
<references/>
[[Category:Cards]]
[[Category:Neurology]]
[[Category:Cardiology]]

Revision as of 16:51, 16 October 2019

Background

  • Dry Beriberi: neuro symptoms caused by thiamine deficiency
  • Wet Beriberi: cardiac symptoms caused by thiamine deficiency
  • Infantile Beriberi: neuro/cardiac symptoms caused by thiamine deficiency in <1 year old infant

Causes

Pathophysiology

  • Thiamine is a cofactor for enzymes required in:
    • Krebs cycle
    • Pentose phosphate pathway
    • Alpha-ketoglutarate dehydrogenase
    • Pyruvate dehydrogenase.
  • Because thiamine is an important cofactor in critical pathways for energy production, deficiency results in lactic acidosis and alteration of brain metabolism.
  • Thiamine is also important for lipid metabolism and may affect myelin sheath formation. This may explain peripheral neuropathy symptoms in dry beriberi.

Clinical Features

Dry Beriberi

  • Symmetrical peripheral neuropathy (motor and sensory) mostly distal extremities

Wet Beriberi

Infantile Beriberi

Bariatric Beriberi

Differential Diagnosis

Vitamin deficiencies

Evaluation

  • Clinical diagnosis

Management

If you suspect Beriberi then treat it! Diagnosis is clinical and difficult to confirm, treatment is simple/inexpensive/effective, there is little risk to treatment, and the risk of morbidity/mortality from not treating is high

  1. Thiamine 50-100mg IV/IM q day x 7-14 days, then 10mg PO q day until complete recovery
  2. Magnesium; hypomagnesemic state may be resistant to thiamine administration
  3. Multivitamin (at risk for other vitamin deficiencies)
  • Give thiamine BEFORE glucose in patients requiring glucose who are at risk for thiamine deficiency; glucose without thiamine can precipitate/worsen WE by driving thiamine intracellularly

Disposition

Prevention

Vitamin Prophylaxis for Chronic alcoholics

  • At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
  • Give multivitamin PO; patient at risk for other vitamin deficiencies

Banana bag

The majority of chronic alcoholics do NOT require a banana bag[1][2]

Disposition

See Also

References

  1. Donnino, Michael, et al. “Myths and misconceptions of wernicke’s encephalopathy: what every emergency physician should know.” Annals of emergency medicine. 2007. Vol 50, no 6. Pages 715-721.
  2. Sechi, GianPietro; Serra, Alessandro. “Wernicke’s encephalopathy: new clnical settings and recent advances in diagnosis and management.” Neurology. Vol 6, May 2007. Pages 442-455
  1. Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
  2. Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.