A Case of Cardiac Beriberi: A Forgotten but Memorable Disease
A 72-year-old female presented at our emergency department with 1-week febrile sense, progressive dyspnea, and generalized edema. A few days prior to this presentation, she had experienced several loose stools with intermittent abdominal pain localized to the right upper quadrant for four months.\nShe denied smoking or using illicit drug use, but confessed excessive and protracted alcohol consumption and a dietary pattern restricted to intake of only carbohydrates; specifically, eating only cookies without any intake of essential nutrients.\nOn admission, she appeared to be chronically ill-looking, but alert with mild hyperventilation. Her vital signs were a blood pressure of 134/95 mm Hg, heart rate of 83 beats/min, and body temperature of 36.5℃. Peripheral oxygen saturation was approximately 100% without oxygen supplementation despite subjective dyspneic complaint. She had icteric sclera without evidence of anemia on physical examination. Her neck veins were not distended, and irregular heartbeats without a murmur were auscultated. A normal breathing sound was heard on whole lung field. There was a tender, enlarged and palpable liver below the right costal margin, but shifting dullness or visualized distended veins on the abdominal wall were not observed. The spleen was not palpable. Both lower extremities were warm to touch and showed minimal edema in a symmetrical fashion. Neurologic examination revealed no abnormalities. Electrocardiography demonstrated revealed premature atrial contraction with nonspecific ST-T segment change (). Her chest X-ray showed cardiomegaly with mild pulmonary congestion and pleural effusion (). Laboratory parameters included mild elevations in the level of liver enzymes, total bilirubin, and high sensitive-C reactive protein (hs-CRP); aspartate transaminase (AST) 44 IU/L (0-40), alanine transaminase (ALT) 64 IU/L (0-40), total bilirubin 1.7 mg/dL (0.2-1.2), and hs-CRP 0.7 mg/dL (<0.5). Results of the initial arterial blood gas analysis, electrolyte levels, thyroid function test and cardiac enzymes like creatinine kinase (CK), CK-MB, and troponin-I were all within the normal range. For further cardiac evaluation, echocardiogram and cardiac magnetic resonance imaging (CMR) were performed. Transthoracic echocardiography showed LV global hypokinesia with severe reduction in LV systolic function (as demonstrated by an LV ejection fraction of 20%), and dilated LV cavity (as shown by an LV end-diastolic dimension of 70 mm). In addition, functional mitral/tricuspid regurgitation in association with a moderate degree of pulmonary hypertension (estimated systolic pulmonary artery pressure of 60 mm Hg), and small amount of pericardial effusion were noted (). The CMR result allowed the exclusion of ischemic cardiomyopathy on the basis of the absence of myocardial delayed enhancement () and the lack of evidence of myocardial perfusion abnormality.\nBased on the patient's history of excessive alcohol consumption in combination with nutritional insufficiency, as well as cardiac imaging findings suggestive of dilated cardiomyopathy, cardiac beriberi was highly suspected. Intravenous thiamine administration was initiated for the next seven days, which was subsequently switched to oral vitamin B complex. With thiamine supplementation, the patient's condition steadily and gradually improved. Liver enzymes and total bilirubin were restored to normal levels a week later, and she was given permission to leave hospital two weeks after admission.\nFollow-up echocardiography performed six months later revealed that her cardiac condition had dramatically improved: LV end-diastolic dimension decreased from 70 mm to 61 mm with a concomitant increase in LV ejection fraction to 43%, systolic pulmonary artery pressure was significantly decreased to 38 mm Hg, and the pericardial effusion that was present before the initiation of treatment was gone (). The patient's subjective complaints of dyspnea and generalized edema were also no longer present.