Thiamin deficiency (causing beriberi) is most common among people subsisting on white rice or highly refined carbohydrates in countries with high rates of food insecurity and among people with alcohol use disorder. Symptoms include diffuse polyneuropathy, high-output heart failure, and Wernicke-Korsakoff syndrome. Thiamin is given to help diagnose and treat the deficiency.
Thiamin is widely available in the diet, particularly in whole grains, meat (especially pork and liver), enriched cereal products, nuts, legumes, and potatoes (see table Sources, Functions, and Effects of Vitamins). Thiamin is involved in carbohydrate, fat, amino acid, glucose, and alcohol metabolism and is particularly important in the function of central and peripheral nerve cells and the myocardium.
Thiamin is essentially nontoxic.
(See also Overview of Vitamins.)
Etiology of Thiamin Deficiency
Primary thiamin deficiency is caused by
Inadequate intake of thiamin
It is commonly due to a diet of highly refined carbohydrates (eg, polished rice, white flour, white sugar) in countries with high rates of food insecurity. It also develops when intake of other nutrients is inadequate, as may occur in young adults with severe anorexia nervosa or in older adults who are commonly undernourished due to multiple factors; it often occurs with other B vitamin deficiencies.
Secondary thiamin deficiency is caused by
Increased demand (eg, due to hyperthyroidism, pregnancy, lactation, strenuous exercise, or fever)
Impaired absorption (eg, due to prolonged diarrhea)
Impaired metabolism (eg, due to hepatic insufficiency)
In people with alcohol use disorder, many mechanisms contribute to thiamin deficiency; they include decreased intake, impaired absorption and use, increased demand, and possibly an apoenzyme defect.
Pathophysiology of Thiamin Deficiency
Thiamin deficiency causes degeneration of peripheral nerves, thalamus, mammillary bodies, and cerebellum. Cerebral blood flow is markedly reduced, and vascular resistance is increased in the brain.
The heart may become dilated; muscle fibers become swollen, fragmented, and vacuolized, with interstitial spaces dilated by fluid. Peripheral vasodilation occurs and can result in edema in the feet and legs. Arteriovenous shunting of blood increases. Eventually, high-output heart failure may occur.
Symptoms and Signs of Thiamin Deficiency
Early symptoms of thiamin deficiency are nonspecific: fatigue, irritability, poor memory, sleep disturbances, precordial pain, anorexia, and abdominal discomfort.
Different forms of beriberi cause different symptoms.
Dry beriberi refers to peripheral neurologic deficits due to thiamin deficiency. These deficits are bilateral and roughly symmetric, occurring in a stocking-glove distribution. They affect predominantly the lower extremities, beginning with paresthesias in the toes, burning in the feet (particularly severe at night), muscle cramps in the calves, pains in the legs, and plantar dysesthesias. Calf muscle tenderness, difficulty rising from a squatting position, and decreased vibratory sensation in the toes are early signs. Muscle wasting occurs. Continued deficiency worsens polyneuropathy, which can eventually affect the arms.
Wernicke-Korsakoff syndrome, which combines Wernicke encephalopathy and Korsakoff psychosis, occurs in some people with alcohol use disorder who do not consume foods fortified with thiamin. Wernicke encephalopathy consists of psychomotor slowing or apathy, nystagmus, ataxia, ophthalmoplegia, impaired consciousness, and, if untreated, coma and death. It probably results from severe acute deficiency superimposed on chronic deficiency. Korsakoff psychosis consists of mental confusion, dysphonia, and confabulation with impaired memory of recent events. It probably results from chronic deficiency and may develop after repeated episodes of Wernicke encephalopathy.
Cardiovascular (wet) beriberi is myocardial disease due to thiamin deficiency. The first effects are vasodilation, tachycardia, a wide pulse pressure, sweating, warm skin, and lactic acidosis. Later, heart failure develops, causing orthopnea and pulmonary and peripheral edema. Vasodilation can continue, sometimes resulting in shock.
Infantile beriberi occurs in infants (usually by age 3 to 4 weeks) who are breastfed by thiamin-deficient mothers. Heart failure (which may occur suddenly), aphonia, and absent deep tendon reflexes are characteristic.
Because thiamin is necessary for glucose metabolism, glucose infusions may precipitate or worsen symptoms of deficiency in thiamin-deficient people.
Diagnosis of Thiamin Deficiency
Favorable response to thiamin
Diagnosis of thiamin deficiency is usually based on a favorable response to treatment with thiamin in a patient with symptoms or signs of deficiency. Similar bilateral lower extremity polyneuropathies due to other disorders (eg, diabetes, alcohol use disorder, vitamin B12 deficiency, heavy metal poisoning) that do not respond to thiamin. Single-nerve neuropathies (mononeuropathies—eg, sciatica) and multiple mononeuropathies (mononeuritis multiplex) are unlikely to result from thiamin deficiency.
Electrolytes, including magnesium, should be measured to exclude other causes. For confirmation in equivocal cases, erythrocyte transketolase activity (low with thiamin deficiency) and 24-hour urinary thiamin excretion may be measured.
Diagnosis of cardiovascular beriberi can be difficult if other disorders that cause heart failure are present. A therapeutic trial of thiamin can help.
Treatment of Thiamin Deficiency
Supplemental thiamin, with dose based on clinical manifestations
Ensuring that dietary supplies of thiamin are adequate is important regardless of symptoms.
Because IV glucose can worsen thiamin deficiency, people with alcohol use disorder and others at risk of thiamin deficiency should receive IV thiamin 100 mg before receiving IV glucose solutions.
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For mild polyneuropathy: 10 to 20 mg orally once a day for 2 weeks
For moderate or advanced neuropathy: 20 to 30 mg/day (as a single or divided dose), continued for several weeks after symptoms disappear
For edema and congestion due to cardiovascular beriberi: 100 mg IV once a day for several days
Heart failure is also treated.
For Wernicke-Korsakoff syndrome, thiamin is given for several days. Although evidence has not established any single superior regimen, a common one is 500 mg IV infused over 30 minutes 3 times a day for 2 consecutive days and 250 mg IV or IM once a day for an additional 5 days in combination with other B vitamins. Anaphylactic reactions to IV thiamin are rare. Symptoms of ophthalmoplegia may resolve in a day; improvement in patients with Korsakoff psychosis may take 1 to 3 months. Recovery from neurologic deficits is often incomplete in Wernicke-Korsakoff syndrome and in other forms of thiamin deficiency.
Because thiamin deficiency often occurs with other B vitamin deficiencies, multiple water-soluble vitamins are usually given for several weeks. Patients should continue to consume a nutritious diet, supplying 1 to 2 times the daily recommended intake of vitamins. All alcohol intake should stop.
Key Points
The risk of thiamin deficiency is increased in people who subsist on highly refined carbohydrates such as polished rice and white flour (as occurs in countries with high rates of food insecurity) or people with alcohol use disorder.
Early findings can be nonspecific; peripheral neurologic deficits, high-output heart failure, and Wernicke-Korsakoff syndrome (mainly in people with alcohol use disorder) may also develop.
Diagnose based on clinical findings, including a favorable response to treatment with supplemental thiamin.
