Clinical Manifestations and Pathology

The beriberi clinical triad consists of edema and neurological and cardiovascular manifestations. The complex of symptoms resulting from thiamine deficiency, however, has often been confused by the common occurrence of other vitamin deficiencies at the same time. Thus, some of the symptoms that distinguished "dry" beriberi were indicative of riboflavin deficiency. A diet deficient in thiamine would usually be deficient in other B vitamins as well. Some of the differences in the manifestation of thiamine deficiency disease among laboring adults, suckling infants, and alcoholics are due to such complications.

A person with beriberi classically entered the medical system when he or she developed symptoms of the weakness that gave the disease its name. There was malaise, a heaviness in the lower limbs, loss of strength in the knee joint and wrist, and usually some loss of sensation. There was tightness in the chest, palpitations, restlessness, loss of appetite, and often a full feeling in the epigastrium. Infants also vomited, had diarrhea, and had difficulty breathing.

Edema is one of the important signs and is always present in the early stages. Edema, or dropsy, corn-

monly progresses until the lower extremities and the face are swollen. Pain and sensitivity in the calf muscles is an early sign as muscles begin to swell, degenerate, and atrophy. Swelling of the lining of the intestines can also congest them. Edema of the lungs often causes sudden respiratory distress and, with heart failure, death.

Heart palpitations, even at rest, and a diastolic blood pressure below 60 millimeters of mercury are usually diagnostic. There is enlargement of the heart, particularly the right ventricle. A heart murmur may be heard. An EKG may be normal in a mild case but shows abnormal waves of sinus origin in advanced ones.

First the autonomic, then the sensory, and finally the motor nerves are affected. On autopsy, there is proliferation of Schwann's cells in the sciatic nerves. In chronic beriberi, there is progressive degeneration of nerve fibers. There is loss of coordination, sometimes even of the eyes. Sensibility to tactile stimulation, then to pain, and finally to temperature is lost. The motor nerves are next affected, with paralysis beginning in the lower extremities. Then the fingers are affected, the hand drops limp at the wrist, and the fingers contract into a claw hand. Eventually, even the intercostal muscles, diaphragm, and speech control muscles are affected.

Other symptoms that commonly occur include a full sensation or cramping of the epigastrium, heartburn, constipation, and mental confusion. B. Wood and K. J. Breen (1980) define clinical thiamine deficiency to consist of beriberi heart failure and Wernicke's encephalopathy. The latter is a dysfunction of the brain that is characterized by confusion and by a loss of coordination and independent movement of the eyes that is commonly found in alcoholics. Thiamine reverses most of the symptoms, but many patients are left permanently with an inability to form new memories (Korsakoff's psychosis).

In classic beriberi, death results eventually from severe disturbances of the circulatory system and paralysis of the respiratory muscles ending in heart failure.

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