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Vitamin B1
54%
78/144
Vitamin B2
4%
6/144
Vitamin B3
7%
10/144
Vitamin B9 and B12
22%
31/144
IV fluids (50/50 normal saline/dextrose)
10%
15/144
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This patient is presenting with a history suggestive of nutritional deficiency, congestive heart failure (CHF), and peripheral neuropathy suggesting a diagnosis of thiamine (B1) deficiency (beriberi). In a patient who does not take care of themselves (such as this depressed patient) and also abuses alcohol, a nutritional deficiency should be suspected. It is reasonable for this alcoholic patient to be deficient in multiple substances. This patient has multiple findings suggesting a diagnosis of thiamine deficiency. First, he is suffering from a peripheral neuropathy which could be due to B1 deficiency (or B12). In addition, he is also suffering from congestive heart failure as revealed by JVD and pitting edema on physical exam, in addition to a chest radiograph demonstrating an enlarged cardiac silhouette. These finding suggest a diagnosis of beriberi for which the best initial step in management is to replete thiamine. Once thiamine has been repleted, then IV fluids with glucose can be given to correct electrolyte abnormalities and this patient's hypoglycemia. Figure A demonstrates pitting edema which occurs due to increased hydrostatic pressure in the vessels of the lower extremities due to poor cardiac function in CHF. Figure B is a chest radiograph demonstrating an enlarged cardiac silhouette that would be seen in CHF. Illustration A demonstrates JVD which occurs due to a buildup of blood from decreased cardiac function in CHF. Incorrect Answers: Answer 2: Vitamin B2 (riboflavin) deficiency presents with angular cheilosis and dermatitis. The only symptoms that supports this diagnosis is the patient's dry skin. Answer 3: Vitamin B3 (niacin) deficiency (pellagra) presents with diarrhea, dermatitis, dementia and, if untreated, death. Though this patient may be suffering from dermatitis (dry skin) the other symptoms of niacin deficiency are not present. Answer 4: Vitamin B9 (folate) and B12 deficiency presents with megaloblastic anemia and peripheral neuropathy. This patient's hemoglobin is low but within normal limits. In addition his MCV does not suggest a megaloblastic anemia. The peripheral neuropathy this patient is experiencing could be explained by B12 deficiency; however, the other symptoms point more toward B1 deficiency. Answer 5: IV fluids (50/50 normal saline/dextrose) should be started after thiamine has been administered. Administration of glucose containing fluids prior to administration of thiamine can result in further depletion of thiamine (due to thiamine being a cofactor in glycolysis) which could worsen a thiamine depleted state, and in some patients, precipitate Wernicke-Korsakoff syndrome. Bullet Summary: Treatment of beriberi includes administration of thiamine and correction of any other nutritional deficiencies.
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