Histopathological changes of biopsied myocardium in Shoshin beriberi

An Overview of Type B Lactic Acidosis Due to Thiamine (B1) Deficiency

Type B lactic acidosis can occur secondary to several factors, including thiamine deficiency, and is not as common as type A. Recognizing thiamine deficiency-associated lactic acidosis is challenging because serum thiamine concentrations are not routinely obtained, and a thorough and specific history is necessary for clinicians to suspect thiamine deficiency as a root cause. Furthermore, the appropriate dose and duration of thiamine treatment are not well defined. Untreated thiamine deficiency-associated lactic acidosis can lead to critical illness requiring lifesaving extracorporeal therapies. Additionally, if thiamine and glucose are not administered in an appropriate sequence, Wernicke encephalopathy or Korsakoff syndrome may occur. This review aims to summarize therapeutic treatment for thiamine deficiency-associated lactic acidosis, based on case reports/series and nutritional guidance. After a literature search of the PubMed database, 63 citations met inclusion criteria, of which 21 involved pediatric patients and are the focus of this review. -Citations describe dosing regimens ranging from 25 to 1000 mg of intravenous (IV) thiamine as a single dose, or multiple daily doses for several days. Specific guidance for critically ill adults recommends a thiamine range of 100 mg IV once daily to 400 mg IV twice daily. Although there are no specific recommendations for the pediatric population, given the relative safety of thiamine administration, its low cost, and our review of the literature, treatment with thiamine 100 to 200 mg IV at least once is supported, with ongoing daily doses based on clinical response of the patient, regardless of age.

PET imaging of 11C-labeled thiamine tetrahydrofurfuryl disulfide, vitamin B1 derivative: First-in-human study

Vitamine B₁ thiamine is an essential component for glucose metabolism and energy production. The disulfide derivative, thiamine tetrahydrofurfuryl disulfide (TTFD), is more absorbent compared to readily-available water-soluble thiamine salts since it does not require the rate-limiting transport system required for thiamine absorption. However, the detailed pharmacokinetics of thiamine and TTFD under normal and pathological conditions were not clarified yet. Recently, ¹¹C-labeled thiamine and TTFD were synthesized by our group, and their pharmacokinetics were investigated by PET imaging in normal rats. In this study, to clarify the whole body pharmacokinetics of [¹¹C]TTFD in human healthy volunteers, we performed first-in-human PET imaging study with [¹¹C]TTFD, along with radiation dosimetry of [¹¹C]TTFD in humans.

METHODS

Synthesis of [¹¹C]TTFD was improved for clinical study. Dynamic whole-body PET images were acquired on three young male normal subjects after intravenous injection of [¹¹C]TTFD. VOIs were defined for source organs on the PET images to measure time-course of [¹¹C]TTFD uptake as percentage injected dose and the number of disintegrations for each organ. Radiation dosimetry was calculated with OLINDA/EXM.

RESULTS

We succeeded in developing the improved synthetic method of [¹¹C]TTFD for the first-in-human PET study. In the whole body imaging, uptake of [¹¹C]TTFD by various tissues was almost plateaued at 10 min after intravenous injection, afterward gradually increased for the brain and urinary bladder (urine). %Injected dose was high in the liver, kidney, urinary bladder, heart, spine, brain, spleen, pancreas, stomach, and salivary glands, in this order. %Injected dose per gram of tissue was high also in the pituitary. By dosimetry, the effective radiation dose of [¹¹C]TTFD calculated was 5.5 μSv/MBq (range 5.2-5.7).

CONCLUSION

Novel synthetic method enabled clinical PET study with [¹¹C]TTFD, which is a safe PET tracer with a dosimetry profile comparable to other common ¹¹C-PET tracers. Pharmacokinetics of TTFD in the pharmacological dose and at different nutritional states could be further investigated by future quantitative PET studies. Noninvasive in vivo PET imaging for pathophysiology of thiamine-related function may provide diagnostic evidence of novel information about vitamin B₁ deficiency in human tissues.

Case report: pericardial effusion with constrictive physiology in a patient with wet beriberi

Wet beriberi-induced pericardial effusion has rarely been previously described. Little is known about the effect of beriberi-induced pericardial effusion on hemodynamics. Here we present a case of wet beriberi with pericardial effusion that exhibited constrictive physiology, which was dramatically improved after treatment. 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. Hemodynamic measurements, including simultaneous measurement of left and right ventricular pressures, revealed high output heart failure and constrictive physiology. Blood test showed lactic acidosis, and low level of serum thiamine levels; consistent with a diagnosis of wet beriberi. After thiamine replacement therapy, the patient’s hemodynamic state rapidly improved. Additionally, pericardial effusion decreased and constrictive physiology was successfully resolved. No other possible causes of pericardial effusion could be identified, with the exception of thiamine deficiency. This case illustrates the importance of considering wet beriberi as a possible cause of pericardial effusion with constrictive physiology.

Shoshin Beriberi With Low Cardiac Output and Hemodynamic Deterioration Treated Dramatically by Thiamine Administration

"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 often difficult to address because of its rarity and non-specific symptoms. We here present a patient with a history of alcoholic abuse who had suffered hemodynamic deterioration with extremely low cardiac output refractory to extracorporeal membrane oxygenation and intravenous catecholamine support, which was improved dramatically by bolus intravenous thiamine administration. Such a type with low cardiac output would be the most severe form of Shoshin beriberi, and cannot be rescued without diagnostic administration of thiamine.

Current aspects of thiamine deficiency on heart function

Beriberi is a disease caused by thiamine deficiency (TD), which may lead to heart problems, including heart failure. Despite the fact that thiamine prevalence is reduced in the industrialized world, it remains a health hazard especially due to chronic alcohol consumption. Diagnosing the presence of TD based on both electrocardiogram and echocardiogram exams is particularly challenging because of its non-specific symptoms. TD diagnosis is unique, which then leads to determination of its severity. If thiamine infusion abrogates its symptomology, only then can the case be definitely diagnosed as TD. Another condition eliciting increased likelihood of developing TD in humans is furosemide administration to heart failure patients. Furosemide administration worsens heart failure due to heightened TD. However, literature data provided are contradictory and require clarification. Up until now, the rat has been the preferred TD animal model. However, the results are even more contradictory than those in humans. It seems that if the rat TD models are separated into two distinct groups, according to animal age, the results appear to be more consistent: younger rats are more prone to develop TD signs similar to those found in humans. Their symptoms stem from changes in cardiac myocyte function that are reversed after thiamine supplementation. However, it remains an open question as to why only younger rats are able to develop human-like symptoms and deserve further investigation.

Use of central venous saturation monitoring in a patient with pediatric cardiac beriberi

The patient was a 1-year-and-4-mo-old boy. He had drunk about 1 L of an isotonic drink for infants daily since about 10 mo after birth. He was examined by a local doctor due to anorexia and vomiting, found to have cardiomegaly, and transported to our hospital with suspected myocarditis. After admission, the patient showed polypnea, a decreased level of consciousness, and marked metabolic acidosis and lapsed into circulatory insufficiency, requiring catecholamine administration, endotracheal intubation, and extracorporeal membrane oxygenation. Initially, low-output heart failure due to acute myocarditis was suspected, but the central venous oxygen saturation was high, at 82%. Considering high-output heart failure to be more likely, we evaluated its cause and noted, by urinary organic acid analysis, increases in lactate, pyruvate, 3-OH-butyrate, acetoacetate, metabolic products of branched-chain amino acids, 2-ketoglutarate, 2-OH-glutarate, 2-keto-adipate, and 2-OH-adipate. Since the vitamin B1 level was reduced to 12 ng/mL (normally 20-50 ng/mL), a diagnosis of cardiac beriberi due to vitamin B1 deficiency was made. When unexplained heart failure is observed in children, cardiac beriberi must be excluded as a differential diagnosis of myocarditis and cardiomyopathy. The measurement of the central venous oxygen saturation may be useful for the diagnosis.

Cardiac beriberi: morphological findings in two fatal cases

Cardiovascular beriberi is categorized into two main groups, according to its cause: alcoholic and non-alcoholic (dietary). Cardiovascular beriberi can also be divided into a fulminant form (Shoshin beriberi) and a chronic form. Shoshin beriberi is characterized by hypotension, tachycardia, and lactic acidosis and is mainly encountered in non-alcoholic patients in Asian countries, although it has also been seen in alcoholics in Western countries. Due to the complex clinical presentation and to the lack of diagnostic tests, thiamine deficiency is still being missed, especially among non-alcoholics patients. We present two fatal cases of non - alcohol associated cardiac beriberi. An acute myocardial infarction was observed in one case; extensive colliquative myocytolisis (grade 2) was described in the second case respectively. Morphologically, myocardial necrosis and colliquative myocytolysis are the histologic hallmarks of this acute, rare clinical entity. An increase in apoptotic myocytes was demonstrated probably sustaining the cardiogenic shock.

Severe anasarca due to beriberi heart disease and diabetic nephropathy

A 40-year-old man was transferred to our hospital because of severe anasarca. He was a heavy drinker for more than 20 years, and diagnosed with diabetes mellitus 8 years earlier and treated with retinal photocoagulation 8 months earlier. He reported loss of appetite after divorce 10 months prior to admission. On admission, he presented with systemic edema and dyspnea. Chest radiography showed massive pleural effusion and cardiomegaly. Serum total protein was 5.6 g/dl, albumin 2.6 g/dl, and urinary protein excretion was 5.3 g/day. Glucose tolerance test showed normal pattern. Ultrafiltration and continuous hemofiltration resulted in loss of 40 kg body weight in 5 days. Echocardiography revealed high-output heart failure and blood tests showed low serum thiamine level of 12 ng/ml (normal, >28 ng/ml). Accordingly, the diagnosis was established as beriberi heart disease complicated with nephrotic syndrome. Treatment with 50 mg/day thiamine intravenously and 80 mg/day furosemide resulted in increase in urine output, decrease in cardiac output, resolution of pulmonary effusion, and about 70 kg body weight loss. Percutaneous renal biopsy showed nodular glomerulosclerosis, mesangial matrix expansion, and thickening of glomerular basement membrane (GBM). Immunofluorescence study showed no glomerular deposition of immunoglobulin or complement. Electron microscopy showed GBM thickening and mesangial matrix deposition without electron-dense deposits or fibrils. These findings were compatible with diabetic glomerulosclerosis. In this patient, extreme malnutrition altered glucose tolerance but, on the other hand, nephrotic syndrome associated with diabetic nephropathy made the diagnosis of beriberi heart disease difficult.

Properties of thiamin transport in isolated perfused hearts of chronically alcoholic guinea pigsThis article is one of a selection of papers published in the special issue Bridging the Gap: Where Progress in Cardiovascular and Neurophysiologic Research Meet

The aim of this study was to determine the mechanism of transport of 14C-thiamin in the hearts of healthy (nonalcoholic) and chronically alcoholic guinea pigs. We used the single-pass, paired-tracer dilution method on isolated and retrogradely perfused guinea pig hearts. The maximal cellular uptake (Umax) and total cellular uptake (Utot) of 14C-thiamin were determined under control conditions and under influence of possible modifiers. We tested how the presence of unlabeled thiamin, metabolic inhibitors, or absence of sodium ions influence the transport of 14C-thiamin. The results of our experiments show that the transport of 14C-thiamin is specific and energy-dependent and that its properties are significantly changed under the influence of chronic alcoholism. The latter effect occurs by increase in both Umax and Utot, as a manifestation of a compensatory mechanism in thiamin deficiency.

Thiamine deficiency as a rare cause of reversible severe pulmonary hypertension

In developed countries, the incidence of cardiac beriberi is rare. It can lead to high output cardiac failure and pulmonary hypertension. We hereby report an atypical case of beriberi heart with reversible right heart failure and severe pulmonary hypertension. Thiamine deficiency can cause reversible pulmonary hypertension, and it must be included in the differential diagnosis in patients with high risk of nutritional deficiency.