Vitamin B1 Thiamine Deficiency (Beriberi)


Article Author:
Kimberly Wiley


Article Editor:
Mohit Gupta


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
1/2/2019 8:38:54 PM

Introduction

Thiamine was the first vitamin identified (vitamin B1) many years ago. It functions as a catalyst in the generation of energy through decarboxylation of branched-chain amino acids and alpha-ketoacids and acts as a coenzyme for transketolase reactions in the form of thiamine pyrophosphate. Thiamine also plays an unidentified role in the propagation of nerve impulses and takes part in myelin sheath maintenance.[1]

This water-soluble vitamin is present in meat, beef, pork, legumes, whole grains, and nuts; however, milled rice and grains have little amounts of thiamine as the processing involved in creating these food products removes thiamine. Additionally, certain food products such as tea, coffee, raw fish, and shellfish, contain thiaminases - enzymes that destroy thiamine.

Deficiency of thiamine can affect the cardiovascular, nervous, and immune system, as is commonly seen in wet beriberi, dry beriberi, or as Wernicke-Korsakoff syndrome.  Worldwide it is most widely reported in populations where polished rice and milled cereals are the primary food source, and also in patients with chronic alcohol abuse.  Dry beriberi presents as symmetrical peripheral neuropathy while wet beriberi presents with high-output heart failure.  Wernicke-Korsakoff syndrome (WKS) can manifest with CNS symptoms such as gait changes, altered mental status, and ocular abnormalities.[2]

Etiology

Deficiency of thiamine can be related to [3]:

Poor intake

  • Diets primarily high in polished rice/processed grains
  • Chronic alcoholism
  • Parental nutritional without adequate thiamine supplementation
  • Gastric bypass surgery

Poor absorption

  • Malnutrition
  • Gastric bypass surgery
  • Malabsorption syndrome

Increased loss 

  • Diarrhea
  • Hyperemesis gravidarum
  • Diuretic use
  • Renal replacement therapy

Increased thiamine utilization

  • Pregnancy
  • Lactation
  • Hyperthyroidism
  • Refeeding syndrome

Epidemiology

Worldwide, thiamine deficiency is primarily due to inadequate dietary intake, specifically in diets comprised mainly of polished rice and grains. In Western countries, it most commonly presents in patients suffering from alcoholism or chronic illness. Special populations of individuals also at risk for thiamine deficiency include pregnant women, those requiring parental feeding, individuals who have undergone bariatric surgery, those with overall poor nutritional status, and patients on chronic diuretic therapy as it increases urinary losses. Deficiency of this vitamin in women can cause infantile beriberi, which this article will not specifically address.[4]

History and Physical

History

When evaluating for thiamine deficiency, the typical history may include poor nutritional intake, excessive alcohol intake, or the patient belonging to the special populations of individuals previously mentioned (pregnant women, recipients of bariatric surgery, patients with prolonged diuretic use, anyone with poor overall nutritional status, etc.).  

Initial symptoms of B1 deficiency include anorexia, irritability, and difficulties with short-term memory. With prolonged thiamine deficiency, patients may endorse loss of sensation in the extremities,  symptoms of heart failure including swelling of the hands or feet and chest pain related to demand ischemia, or feelings of vertigo, double vision, and memory loss.  Additionally, close friends and family of the patient may describe confusion or symptoms of confabulation. 

Physical Exam

Dry beriberi:

  • Evidence of symmetric peripheral neuropathy with motor and sensory changes
  • Diminished reflexes

Wet beriberi - cardiovascular compromise related to impaired myocardial energy metabolism and dysautonomia:

  • Dilated cardiomyopathy
  • Tachycardia
  • High-output congestive heart failure
  • Peripheral edema

Wet and dry beriberi often have overlapping features, and in either condition, paresthesias may be a presenting feature.

Wernicke’s encephalopathy (WE) is a classic triad of ocular abnormalities (nystagmus, ophthalmoplegia), confusion, and gait changes such as ataxia.

Wernicke’s encephalopathy with additional symptoms of memory loss and psychosis with confabulation is consistent with WKS.[1][5]

Evaluation

Detection of thiamine deficiency relies on relevant history and physical exam findings and follow up with laboratory testing for confirmation.[6]Laboratory Studies:

  • Functional enzymatic assay of transketolase activity - the activity of transketolase is measured before and after the addition of thiamine pyrophosphate; >25% stimulation response is abnormal
  • Measurement of thiamine or the phosphorylated esters of thiamine in serum or blood using high-performance liquid chromatography
  • Urine studies exist but are not a reliable test for evaluation of total body thiamine

Consider other diagnostic studies based on presentation and comorbid conditions (transthoracic echo or TSH measurements in new heart failure, for example).

Radiographic Studies:

MR: most common abnormalities seen with WE are symmetric changes in the thalamus, mamillary bodies, periaqueductal area, and tectal plate.[7]

Treatment / Management

Treatment of acute thiamine deficiency with cardiovascular or neurologic signs/symptoms [4]

200mg intravenous (IV) or orally (PO) thiamine three times daily until symptoms resolve or improvement plateaus, at which time the patient should transition to 10mg/day oral thiamine until expected recovery is complete.

Treatment of thiamine deficiency with suspected WKS [8]

  • 500mg IV thiamine infused over 30mins three times on days 1 and 2 of therapy
  • 250mg thiamine IV or intramuscularly on days 3- 5 of therapy

**Always give thiamine during the re-feeding period in a patient with alcoholism to prevent acute thiamine deficiency with lactic acidosis.**

Symptoms consistent with Wernicke-Korsakoff syndrome may persist for several months or may be permanent.  

Other symptoms of thiamine deficiency such as anorexia and irritability are expected to improve gradually.

Differential Diagnosis

The differential diagnosis for thiamine deficiency is broad given the number of nonspecific symptoms which may occur during the initial stages of this condition and the extensive range of cardiac and nervous dysfunction related to thiamine deficiency.

Conditions to consider:

  • Delirium
  • Depression
  • Folic acid deficiency
  • Hyperthyroidism
  • Cardiomyopathy secondary to other causes such as alcoholic or diabetic heart disease
  • Delusional disorder
  • Nerve entrapment syndromes
  • Other psychiatric disorders
  • Diabetic ketoacidosis

Prognosis

The overall prognosis for patients with thiamine deficiency is good as it is easily treatable and most signs and symptoms of the deficiency fully resolve with thiamine supplementation.  Cardiac dysfunction seen in wet beriberi can be expected to improve within 24 hours of initiation of treatment. Symptoms of dry beriberi may improve or resolve.  Unfortunately, once the deficiency has progressed to Korsakoff syndrome, the patient may show minimal improvement during initial treatment, and remaining symptoms may be permanent.

Complications

There are no known toxicities associated with thiamine repletion.

Some reports of anaphylaxis and bronchospasm with high-dose intravenous thiamine exist.

Deterrence and Patient Education

Preventing this condition is as simple as ensuring total body levels of thiamine are adequate for metabolic processes. Education of patients who are at risk of deficiency is imperative, and any further counseling should point towards the underlying cause of the condition.  For instance, patients who are undergoing alcohol detoxification should receive counseling on the signs, symptoms, and long-term effects of Korsakoff syndrome and a multidisciplinary team should be engaged to ensure the patient has adequate resources for detoxication and follow-up care. 

Enhancing Healthcare Team Outcomes

Enhancing healthcare team outcomes related to this condition is dependent on the cause.  For deficiency related to excessive alcohol intake, steps to ensure the successful cessation of alcohol use may involve a multidisciplinary approach involving the medical team, social workers, community resources, and the use of inpatient or outpatient treatment strategies. In instances of inadequate dietary intake, nutritional counseling with a nutritionist or certified dietician may be in order.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Vitamin B1 Thiamine Deficiency (Beriberi) - Questions

Take a quiz of the questions on this article.

Take Quiz
Deficiency of which vitamin causes beriberi?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Beriberi is caused by a deficiency of which of the following vitamins?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Dilated cardiomyopathy can be seen in patients with which nutritional deficiency?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following vitamin deficiencies causes beriberi?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is caused by thiamine deficiency?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has edema and a dilated cardiomyopathy due to a dietary deficiency. What is the most likely etiology?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Thiamine would most likely be beneficial to a patient who is suffering from what condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What vitamin deficiency causes beriberi?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is a result of a vitamin B1 deficiency?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
On a medical relief mission trip to a third-world country, you encounter a patient who has beriberi. What nutrient deficiency causes this condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What class of medication can lead to thiamine deficiency?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 54-year-old man presents to the emergency department with a head laceration after being found down in his garage. The patient states that he has no memory of the events leading up to his arrival. His medical history is unremarkable except a recent diagnosis of difficult to characterize vertigo, with work-up not consistent with Meniere disease or benign paroxysmal positional vertigo. On further questioning, the patient’s daughter who accompanied the patient, states he has a several year habit of drinking to excess, including up to and at times exceeding, 1 L intake of bourbon daily. On physical exam, the patient has end gaze nystagmus and an unsteady, ataxic gate. What imaging findings would one expect to see on brain MRI?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 75-year-old Korean woman presented to the emergency department with progressive dyspnea, fatigue, and mild lower leg swelling. She is traveling to the U.S. to visit her children, and her past medical history is unremarkable. She denies alcohol, tobacco, and drug use. She lives at home with her husband, and they eat a diet consisting primarily of white rice. She denies recent illness and sick contacts. She’s had no changes in her exercise habits. Her vital signs are within normal limits, including oxygen saturation of 99% on room air. Physical exam shows 1+ pitting edema to the knee, distal lower extremity sensation loss bilaterally, and jugular venous distension. EKG showed non-specific T-wave changes. The x-ray showed cardiomegaly and mild pulmonary congestion. Labs were largely unremarkable. Transthoracic echocardiogram showed left ventricular (LV) global hypokinesis, reduced LV ejection fraction, dilated LV, and moderate pulmonary hypertension. What should be done to treat the patient's underlying disease?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Vitamin B1 Thiamine Deficiency (Beriberi) - References

References

Thiamine. Monograph. Alternative medicine review : a journal of clinical therapeutic. 2003 Feb;     [PubMed]
DiNicolantonio JJ,Liu J,O'Keefe JH, Thiamine and Cardiovascular Disease: A Literature Review. Progress in cardiovascular diseases. 2018 May - Jun;     [PubMed]
Attaluri P,Castillo A,Edriss H,Nugent K, Thiamine Deficiency: An Important Consideration in Critically Ill Patients. The American journal of the medical sciences. 2018 Oct;     [PubMed]
Wooley JA, Characteristics of thiamin and its relevance to the management of heart failure. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2008 Oct-Nov;     [PubMed]
Whitfield KC,Bourassa MW,Adamolekun B,Bergeron G,Bettendorff L,Brown KH,Cox L,Fattal-Valevski A,Fischer PR,Frank EL,Hiffler L,Hlaing LM,Jefferds ME,Kapner H,Kounnavong S,Mousavi MPS,Roth DE,Tsaloglou MN,Wieringa F,Combs GF Jr, Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programs. Annals of the New York Academy of Sciences. 2018 Oct;     [PubMed]
Sriram K,Manzanares W,Joseph K, Thiamine in nutrition therapy. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2012 Feb;     [PubMed]
Zuccoli G,Pipitone N, Neuroimaging findings in acute Wernicke's encephalopathy: review of the literature. AJR. American journal of roentgenology. 2009 Feb;     [PubMed]
Osiezagha K,Ali S,Freeman C,Barker NC,Jabeen S,Maitra S,Olagbemiro Y,Richie W,Bailey RK, Thiamine deficiency and delirium. Innovations in clinical neuroscience. 2013 Apr;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Podiatry Cert Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Podiatry Cert Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Podiatry Cert Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Podiatry Cert Medicine. When it is time for the Surgery-Podiatry Cert Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Podiatry Cert Medicine.