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Thiamine Deficiency
- Symptomatic thiamine deficiency is a medical emergency; consideration of possible thiamine deficiency warrants immediate treatment with parenteral thiamine 3 5
Key Points
- Thiamine deficiency is characterized by inadequate levels of thiamine diphosphate, the biologically active form of vitamin B₁, and may result in a range of clinical manifestations
- Thiamine deficiency may present in infants and children with cardiovascular (heart failure, often referred to as wet beriberi), neurologic (encephalopathy, sometimes referred to as dry beriberi), and metabolic (hyperlactatemia) features, usually related to a staple diet of polished rice (most common in parts of Southeast Asia) 1
- Thiamine deficiency may present in children and adults with peripheral neuropathy (sometimes also referred to as dry beriberi) 1 2
- Even in resource-rich regions, thiamine deficiency can occur in children and adults with eating disorders, overly selective diets, or a history of bariatric surgery
- In economically well-resourced settings, especially among adults who overuse alcohol but also possibly in other malnourished individuals, thiamine deficiency can present with Wernicke-Korsakoff syndrome
- The diagnosis is made on the basis of characteristic signs and symptoms in a patient with known geographic, dietary, or medical predisposition. 3
- Symptomatic thiamine deficiency is a medical emergency and can result in permanent disability or death if not treated promptly; thiamine administration is safe and should not be delayed pending definitive confirmation of the diagnosis 3 4
- For individuals and populations at risk for thiamine deficiency, food fortification and personal supplementation can be effective in preventing symptomatic thiamine deficiency
Pitfalls
- Consider Wernicke-Korsakoff syndrome in any intoxicated patient who does not recover fully from his or her intoxicated state.
- Administer thiamine before glucose to a patient with suspected Wernicke-Korsakoff syndrome, particularly a patient who is intoxicated or who uses alcohol excessively, presenting with hypoglycemia.
- Administration of glucose without thiamine can precipitate or worsen the patient’s encephalopathy
Introduction
- Thiamine (vitamin B₁) is an essential water-soluble vitamin. Humans are dependent on dietary intake to maintain adequate thiamine status 6
- Thiamine deficiency is an inadequate level of thiamine diphosphate (also referred to as thiamine pyrophosphate), the biologically active form of thiamine, which may result in a range of clinical manifestations 6
- Historically, some forms of thiamine deficiency have been referred to as beriberi 7
- Severe deficiency can lead to infantile beriberi, neurologic deficits, and Wernicke-Korsakoff syndrome. 7
- Infantile beriberi is typically seen in infants born to and breastfed by mothers with thiamine deficiency; most prevalent in Southeast Asia 1 2 6 8
- Children and adults can have neurologic deficits of beriberi due to basal ganglia disease with encephalopathy and/or to peripheral neuropathy
- Wernicke-Korsakoff syndrome is a particular form of encephalopathy due to short-term thiamine deficiency; it is most often associated with alcohol abuse 1 2 9
Classification
- Traditionally, thiamine deficiency was described as: 710
- Wet beriberi: usually infants, with right heart failure, often aphonia
- Dry beriberi: usually older children and adults, with peripheral neuropathy
- Shoshin beriberi: usually infants and children with hyperlactatemia
- Wernicke-Korsakoff syndrome: often adults with alcohol use disorder, with encephalopathy
- Currently, thiamine deficiency is best described by the specific clinical features of thiamine deficiency, which are somewhat age specific, with overlapping age ranges and overlapping symptoms: 81112
- Cardiac beriberi
- Infants: peak 1 to 3 months, with right heart failure 13
- Aphonic: peak 4 to 6 months, with aphonia and heart failure 14
- Children/adults: left with or without right heart failure
- Children/adults: heart failure, sometimes with severe metabolic acidosis
- Neurologic beriberi:
- Infantile: first year of life, encephalopathy, sometimes nystagmus, basal ganglia disease on imaging; can present similarly to meningoencephalitis 1
- Children/adults: peripheral neuropathy, weakness, perhaps hyporeflexia
- Adults, Wernicke Korsakoff syndrome: initial encephalopathy with ataxia and nystagmus followed by amnesia
- Neurometabolic: sometimes associated with eating disorders and bariatric surgery, with hyperlactatemia and encephalopathy 12
- Subclinical: low levels of thiamine can be seen in seemingly healthy individuals and in individuals with vague nonspecific symptoms not clearly related to thiamine deficiency
- Cardiac beriberi
- Wernicke-Korsakoff syndrome
- Usually seen with alcohol use disorder complicated by thiamine deficiency
- Typically begins with confusion and loss of energy with ataxia and abnormal eye movements (Wernicke encephalopathy) which potentially reversible with treatment
- Progresses to memory loss, confabulation, hallucinations, and apathy (Korsakoff syndrome) which is mostly irreversible
Clinical Presentation
History
- Features suggestive of risk of thiamine deficiency 17
- Malnutrition
- Eating disorders
- Bariatric surgery
- Obesity
- Self-restricted diet seen in some children with autism spectrum disorder
- Excessive alcohol use
- Dependence on standardized diet (limited dietary quality and diversity)
- Breastfed infant in an area where thiamine deficiency is common
- Symptoms suggestive of cardiac manifestations of thiamine deficiency 17
- Rapid and/or difficult breathing
- Tachycardia
- Sweating
- Fatigue
- Symptoms suggestive of neurologic manifestations of thiamine deficiency
- Altered mental status
- Twitching, seizures
- Abnormal eye movements
- Ataxia
- Abnormal superficial sensations
- Weakness, difficulty walking
- Delirium, memory loss, confusion
- Confabulation (filling in memory gaps with false information)
- Other general symptoms suggestive of thiamine deficiency
- Dysphagia
- Dysphonia, aphonia
- Fussiness, difficulty sleeping (infants)
Physical examination
- Findings suggestive of cardiac manifestations of thiamine deficiency 2
- Tachypnea
- Tachycardia
- Retractions, respiratory distress
- Hoarse cry, aphonia (infants)
- Rales
- Hepatomegaly
- Peripheral edema
- Findings suggestive of neurologic manifestations of thiamine deficiency 17
- Altered mental status
- Nystagmus
- Ophthalmoplegia
- Ptosis
- Developmental delay
- Ataxia
- Weakness
- Abnormal gait
- Decreased deep tendon reflexes
- Altered position sense
- Confabulation
- Amnesia
Causes
- Inadequate dietary intake and absorption of thiamine 15
- Decreased intake
- Breastfed infant of mother with thiamine deficiency
- Formula-fed young infant if formula does not contain adequate thiamine 16
- Child dependent on parenteral nutrition receiving thiamine-inadequate nutritional fluid
- Infant with thiamine-insufficient diet
- Children and adults (in boarding schools, monasteries, military camps) with thiamine-deficient diet 17
- Children and adults with obesity and/or disordered eating 12
- Decreased absorption 1
- Altered thiamine absorption seen with alcohol overuse 18
- Thiamine inactivated by ingested thiaminases (such as those in betel nuts in some parts of Asia) 6
- Altered absorption following bariatric surgery
- Decreased intake
- Increased thiamine need due to intercurrent illness with fever, hypoxia, and/or increased metabolic demand
- Iatrogenic loss of thiamine 15
- Hemodialysis or peritoneal dialysis 19
- Loop diuretic use 20
Risk factors and/or associations
Gender
- Differences likely relate to the relative risks of the underlying conditions leading to thiamine deficiency
- Thiamine deficiency related to alcohol use disorder is more common in males 1
- Thiamine deficiency related to bariatric surgery is more common in females 1
Genetics
- Tribal/ethnic differences in the risk of thiamine deficiency in some parts of Southeast Asia likely due to lifestyle factors affecting diet 18
- Some genetic conditions related to dysfunction of thiamine, such as thiamine-biotin-basal ganglia disease. Relevant genes: 21
- TPK1 (thiamine pyrophosphokinase 1)
- SLC25A19 (TPC), SLC19A2 (THTR1), and SLC19A3 (THTR2) (various thiamine transporters)
How is thiamine deficiency diagnosed?
Primary diagnostic tools
- Presumptive diagnosis is based on clinical suspicion; treatment with thiamine not to be delayed while waiting for confirmatory test results 22
- Whether coincidental or due to increased metabolic demands, thiamine deficiency can present during and/or complicate recovery from other illnesses
- In an area of endemic thiamine deficiency, presumptive treatment, with thiamine administered to all children with: 522
- Respiratory distress 23
- Heart failure
- Encephalopathy
- Peripheral neuropathy
- In an area of endemic thiamine deficiency, presumptive treatment, with thiamine administered to all individuals with peripheral neuropathy and/or encephalopathy 1
- A clinical diagnosis of Wernicke-Korsakoff syndrome can be made in the presence of 2 or more of the following: 1
- Nutritional deficiency (eg, evidence of malnutrition, low BMI, grossly impaired nutritional intake, abnormal thiamine status on laboratory testing)
- Oculomotor abnormalities
- Cerebellar dysfunction
- Altered mental status or mild memory impairment 1
- Immediately give IV thiamine to all patients with symptoms and signs suggestive of thiamine deficiency, as delay can lead to permanent disability or death 1
- Deficiency is confirmed if oculomotor symptoms (when present) abate within a few hours of thiamine replacement; however, be aware thiamine deficiency could be just one of several reasons for a patient’s condition 1
- Obtain laboratory tests for drugs and other metabolic conditions that cause clinical presentation similar to that of thiamine deficiency syndromes
- Draw blood before thiamine administration, but do not delay treatment of presumptive thiamine deficiency while awaiting laboratory test results
- Serum thiamine levels may not accurately indicate thiamine status, and a level within reference range does not exclude Wernicke encephalopathy 1
- Appropriate testing includes serum glucose, electrolyte, calcium, and creatinine levels, as well as CBC, arterial blood gas levels, blood and urine toxicology, urinalysis, and therapeutic drug levels
- Neuroimaging may be required for some patients, primarily to exclude other conditions 22
- MRI is the most useful modality for detecting changes associated with Wernicke encephalopathy
Laboratory
- Either of 2 different tests can be used to confirm thiamine deficiency 1622
- Whole blood thiamine diphosphate (the bioactive form of thiamine) level
- Reference range, usually considered 70 to 180 nmol/L 7
- Cardiac disease in infants usually associated with levels of less than 30 nmol/L
- Erythrocyte transketolase activity (the function of thiamine in red blood cells)
- Reported as a ratio of activity in red blood cells after addition of thiamine diphosphate to baseline activity
- A reference range usually considered to be less than 1.25
- Whole blood thiamine diphosphate (the bioactive form of thiamine) level
- Test results not always correlated with the extent of symptoms 22
- Test results unable to either confirm or rule out thiamine deficiency as a cause of specific clinical findings
Imaging
- Echocardiography: to evaluate for right and left heart dysfunction, pulmonary hypertension 24 25
- Brain imaging: MRI most definitive; CT and ultrasonography also useful 2526
- May be used to support the diagnosis of acute Wernicke encephalopathy, exclude other conditions, and monitor recovery
- Nonhomogeneity of basal ganglia is the key feature
- Findings are highly variable; lesions in mammillary bodies, thalamus, and periaqueductal areas are seen in 58% of patients 27
- High specificity of 93%, but sensitivity is only 53% 25
Differential Diagnosis
Guiding principles
- Thiamine deficiency can present acutely and can also persist chronically
- Presence of thiamine deficiency does exclude an overlapping concurrent disorder, and finding a different diagnosis does not exclude thiamine deficiency
Most common
- For sick infant with signs suggestive of thiamine deficiency:
- Viral infection: respiratory, gastrointestinal, meningoencephalitic, or systemic 28
- Bacterial infection: sepsis, pneumonia, meningitis
- Differentiated based on full clinical presentation, inflammatory markers, microbiologic testing
- For infant with respiratory distress
- Congenital cardiovascular malformation
- Congenital pulmonary malformation
- Heart failure due to viral infection, metabolic disorder, anemia, or hyperthyroidism
- Differentiated by full clinical presentation, imaging, echocardiography, laboratory testing
- For child with encephalopathy
- Metabolic disorder, possibly with hypoglycemia
- Toxic ingestion
- Meningoencephalitis: infectious or autoimmune
- Seizure disorder with postictal state
- Differentiated by details of clinical presentation, blood testing, toxicology screens, spinal fluid analysis, EEG
- For child or adult with dysesthesias and/or weakness
- Toxic exposure, Guillain-Barré syndrome, transverse myelitis
- Differentiated by details of clinical presentation, toxicology screening, imaging studies, spinal fluid analysis, electrodiagnostic studies
- For child or adult with heart failure
- Myocardial infarction
- Cardiomyopathy: congenital, viral, metabolic
- Alcoholic cardiomyopathy: dilated cardiomyopathy associated with long-term excessive alcohol use 29
- Cardiac manifestations are similar to those of thiamine deficiency, but condition does not improve with thiamine administration
- Differentiated by thorough review of clinical presentation, echocardiography
- Differential diagnosis of Wernicke-Korsakoff syndrome with encephalopathy
- Delirium tremens 28
- Late-stage alcohol withdrawal presenting with disorientation, impaired attention, visual or auditory hallucinations, and/or seizures; typically also associated with shaking or shivering
- History of recent alcohol cessation, which may not be the case in thiamine deficiency
- Diagnosis is based on history and exclusion of alternative diagnoses
- Neurosyphilis 3031
- Late neurologic manifestations of infection with the spirochete Treponema pallidum can present with paresthesias and difficulties in gait, coordination, and balance
- Oculomotor defects and confusion are absent, while these are typical of Wernicke encephalopathy
- Definitive diagnosis is based on serologic testing
- Metabolic disorders
- Hypoglycemia, hypercalcemic uremia, diabetic ketoacidosis, or hepatic encephalopathy
- Differentiated on basis of history and laboratory testing
- Electrolyte disturbances
- Dehydration, hyponatremia, or hypernatremia
- Differentiated on basis of laboratory testing
- Delirium tremens 28
Treatment Goals
- Correction of thiamine deficiency
- Supportive care of persisting deficits (especially neurologic deficits)
Admission criteria
- Admit all patients with significant respiratory distress and/or encephalopathy for parenteral thiamine replacement
- In resource-limited areas, daily outpatient follow-up may be considered for less severely affected individuals, possibly with initial intramuscular thiamine administration
Recommendations for specialist referral
- Specialist consultation or referral indicated for evaluation and management of underlying cause of thiamine deficiency (such as excessive alcohol use, eating disorder, post–gastrointestinal surgery complications)
- Referral to a nutritionist warranted for patients with thiamine deficiency caused by poor dietary intake
- Referral to a cardiologist possibly indicated for patients with cardiac manifestations of thiamine deficiency
- Referral for neurodevelopmental and physical therapy care should be considered for children with persisting neurologic deficits
Treatment Options
Thiamine deficiency with cardiorespiratory and/or encephalopathic symptoms is a medical emergency 3 5
- Treatment should be given immediately, without waiting for laboratory test results confirming biochemical thiamine deficiency 3
Route of administration and dose of thiamine depends on clinical scenario
- Ideal thiamine dosing has not been studied thoroughly, however, thiamine is safe, even in large doses
Concurrent treatment
- Correct any other nutritional deficits
- Magnesium deficiency exacerbates the effects of thiamine deficiency; consider magnesium supplementation in addition to thiamine replacement
- Use of general vitamin supplements is reasonable for individuals with a predisposition for inadequate dietary intake
Drug therapy
- Infantile thiamine deficiency
- Infantile thiamine deficiency with severe heart failure, convulsions or coma
- IV/IM dosage
- Vitamin B1 (Thiamine Hydrochloride) Solution for injection; Infants: 25 to 50 mg IV as a single dose, then 10 mg IM once daily for 10 days, and followed by oral thiamine for at least 6 weeks.
- Oral dosage
- Vitamin B1 (Thiamine) Oral tablet; Infants: 3 to 5 mg PO once daily for at least 6 weeks after initial parenteral therapy.
- IV/IM dosage
- Thiamine deficiency in infants and children with heart failure due to the deficiency
- IV/IM dosage
- Vitamin B1 (Thiamine Hydrochloride) Solution for injection; Infants and Children: 25 mg IV and 25 mg IM concurrently as single doses, then 25 mg IV/IM once daily until the child can eat, and followed by oral thiamine for 2 to 3 weeks.
- Oral dosage
- Vitamin B1 (Thiamine) Oral tablet; Infants and Children: 10 mg PO once daily for 2 to 3 weeks after initial parenteral therapy.
- Vitamin B1 (Thiamine) Oral tablet; Breast-feeding Persons: 100 mg PO twice daily for 1 month until the mother can eat a more diverse diet.
- Treat the mother if infant is breastfed
- IV/IM dosage
- Infantile thiamine deficiency with severe heart failure, convulsions or coma
- Wernicke-Korsakoff syndrome
- Vitamin B1 (Thiamine Hydrochloride) Solution for injection; Adults: 200 to 500 mg IV every 8 hours for at least 3 days.
- Thiamine deficiency with critical illness
- IV dosage
- Vitamin B1 (Thiamine Hydrochloride) Solution for injection; Adults: 50 to 100 mg IV as a single dose, followed by oral thiamine for at least 6 weeks.
- Oral dosage
- Vitamin B1 (Thiamine) Oral tablet; Adults: 3 to 5 mg PO once daily for at least 6 weeks after initial parenteral therapy.
- IV dosage
- Thiamine deficiency after bariatric surgery
- IV dosage
- Vitamin B1 (Thiamine Hydrochloride) Solution for injection; Adults: 200 mg IV 3 times daily to 500 mg IV once or twice daily for 3 to 5 days, then 250 mg IV once daily for 3 to 5 days or until symptoms resolve. Consider treatment with oral thiamine indefinitely or until risk factors have been resolved.
- IM dosage
- Vitamin B1 (Thiamine Hydrochloride) Solution for injection; Adults: 250 mg IM once daily for 3 to 5 days or 100 to 250 mg IM once monthly.
- Oral dosage
- Vitamin B1 (Thiamine) Oral tablet; Adults: 100 mg PO 2 to 3 times daily until symptoms resolve.
- IV dosage
- Mild thiamine deficiency states (including lactating women at risk of inadequate intake)
- Vitamin B1 (Thiamine) Oral tablet; Infants, Children, and Adolescents: 10 mg PO once daily for 1 week, then 3 to 5 mg PO once daily for 6 weeks.
- Vitamin B1 (Thiamine) Oral tablet; Adults: 10 mg PO once daily for 1 week, then 3 to 5 mg PO once daily for 6 weeks.
- Thiamine supplementation recommended dietary allowance
- Vitamin B1 (Thiamine) Oral tablet; Neonates: 0.2 mg/day PO.
- Vitamin B1 (Thiamine) Oral tablet; Infants 1 to 6 months: 0.2 mg/day PO.
- Vitamin B1 (Thiamine) Oral tablet; Infants 7 to 11 months: 0.3 mg/day PO.
- Vitamin B1 (Thiamine) Oral tablet; Children 1 to 3 years: 0.5 mg/day PO.
- Vitamin B1 (Thiamine) Oral tablet; Children 4 to 8 years: 0.6 mg/day PO.
- Vitamin B1 (Thiamine) Oral tablet; Children 9 to 13 years: 0.9 mg/day PO.
- Vitamin B1 (Thiamine) Oral tablet; Adolescent Females 14 to 17 years: 1 mg/day PO.
- Vitamin B1 (Thiamine) Oral tablet; Adolescent Males 14 to 17 years: 1.2 mg/day PO.
- Vitamin B1 (Thiamine) Oral tablet; Pregnant or Lactating Persons: 1.4 mg/day PO.
- Vitamin B1 (Thiamine) Oral tablet; Adult Females: 1.1 mg/day PO.
- Vitamin B1 (Thiamine) Oral tablet; Adult Males: 1.2 mg/day PO.
- Thiamine supplementation after bariatric surgery
- Vitamin B1 (Thiamine) Oral tablet; Adults: 12 mg or more PO once daily; preferably 50 to 100 mg PO once daily.
Special populations
- Patients who have had bariatric surgery 32
- Routine thiamine screening may be considered after bariatric procedures 32
- Thiamine supplementation should routinely be given as part of routine multivitamin with mineral preparation 32
- Consider postprocedure screening for thiamine deficiency and/or empiric thiamine supplementation for high-risk patients, such as those with protracted vomiting, parenteral nutrition, excessive alcohol use, neuropathy, encephalopathy, heart failure, gastrointestinal symptoms, or small-bowel bacterial overgrowth 32
- In recalcitrant or recurrent cases of thiamine deficiency without any of the aforementioned risks, consider addition of antibiotics to address small-bowel bacterial overgrowth 32
Monitoring
- Determine frequency of monitoring according to severity of condition and comorbidities
- Serial evaluation and MRI of brain may help with assessment of progress
Complications
- Children inadvertently deprived of thiamine can have persistent neurologic compromise 16
- Initial encephalopathy (formerly referred to as Wernicke encephalopathy) can progress to chronic amnesic encephalopathy (formerly referred to as Korsakoff syndrome) if untreated
Prognosis
- For infants with thiamine deficiency–induced heart failure, symptomatic improvement begins within an hour of initiating treatment and can be dramatic 33
- In infantile beriberi, echocardiographic abnormalities resolve with 1 to 7 days of treatment 5
- In infants, basal ganglia abnormalities resolve slowly, to some degree
- In children and adults, peripheral neuropathy resolves within days, and strengthening follows
- In adults overusing alcohol, initial encephalopathy can resolve fully with treatment, but amnesic encephalopathy can be irreversible
Screening and Prevention
Prevention
- US recommended dietary allowance for thiamine for different life-stage groups: 34
- Children: 0.5 to 0.9 mg/day
- Adult males: 1.2 mg/day
- Adult females (nonpregnant): 1.1 mg/day
- Ideally recommended dietary allowance is obtained via an adequate dietary intake of thiamine 27
- Food sources include whole grain, meat, legumes and fortified breads and cereals
- For individuals at risk for dietary insufficiency of thiamine, thiamine supplementation is warranted 235
- This can be provided as part of a multivitamin preparation
- In settings where diets are often thiamine insufficient, food fortification is being tested 32 35
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