Acute pernicious beriberi in a patient receiving parenteral nutrition. A case report

Parenteral nutrition is being used increasingly in the treatment of the critically ill patient but it causes complications and metabolic derangement. A patient receiving parenteral nutrition in whom protracted vomiting from intestinal obstruction led to the development of acute cardiovascular beriberi (Shoshin) with severe metabolic acidosis--probably lactic--is described. The acidosis was refractory to bicarbonate infusion and inotropic support but the administration of intravenous thiamine 100 mg resulted in a dramatic recovery. Biochemical confirmation of thiamine deficiency was obtained by the measurement of an elevated thiamine pyrophosphate level (24.4%). The patient received thiamine 2.4 mg weekly, a dose that proved insufficient. Thiamine deficiency should be considered when patients receiving parenteral nutrition develop metabolic acidosis with a wide anion gap, even if vitamin supplementation appears adequate.