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Case Report

Vitamin B1 Deficiency and Perimyocarditis Fulminans: A Case Study of Shoshin Syndrome in a Woman Following an Unbalanced Dietary Pattern Followed by a Literature Review

Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-214 Gdansk, Poland
Department of Noninvasive Cardiac Diagnostics, Medical University of Gdansk, 80-214 Gdansk, Poland
First Department of Cardiology, Medical University of Gdansk, 80-214 Gdansk, Poland
Author to whom correspondence should be addressed.
Life 2023, 13(1), 205;
Submission received: 8 December 2022 / Revised: 7 January 2023 / Accepted: 8 January 2023 / Published: 10 January 2023
(This article belongs to the Special Issue Nutrients and Dietary Supplements in Health and Disease)


(1) Background: vitamin B1 level depletion, known as a beriberi syndrome, can lead to severe cardiovascular complications, from which perimyocarditis fulminans is one of the most severe. (2) Methods: this is a retrospective case study that includes an adult patient with clinical presentations of acute heart failure (HF) symptoms following perimyocarditis on the grounds of thiamine deficiency. (3) Results: A 49-year-old woman presented with acute HF symptoms due to perimyocarditis. The patient suddenly developed refractory cardiogenic shock with metabolic acidosis requiring maximal medical management, including an intra-aortic balloon pump and extracorporeal membrane oxygenation. Due to additional peripheral polyneuropathy, beriberi disease was suspected after excluding other possible causes of the patient’s condition. After administration of vitamin B1, clinical improvement in the patient’s condition and the resolution of metabolic abnormalities were observed, which ultimately confirmed the diagnosis of Shoshin syndrome caused by the implementation of a gluten-free diet without indications for its adherence. (4) Conclusions: Fulminant beriberi disease, although considered rare, is a life-threatening condition and should always be included in the differential diagnosis of critically ill patients, notably those with malnutrition. An unbalanced diet can be detrimental and have severe consequences, i.e., perimyocarditis fulminans. However, treatment with thiamine can significantly improve the patient’s cardiac function and restore hemodynamic and metabolic parameters.

1. Introduction

Thiamine, or aneurine, a small, water-soluble vitamin in the B complex family, plays a crucial role in many cellular processes [1,2]. In its activated form, thiamine pyrophosphate (TPP) acts as an enzymatic cofactor for several reactions during carbohydrate metabolism. The most important aneurine-dependent biocatalysts are pyruvate dehydrogenase (PDH) and 2-oxoglutarate dehydrogenase (OGDH), which enable pyruvate, a product of glycolysis, to enter the citric acid cycle, and, therewith, promote aerobic metabolism and adenosine triphosphate (ATP) production [1,2]. The reactions mentioned above are known as the central metabolic pathway which provides cells with their energetic requirements. Consequently, the importance of thiamine is predominantly noticed in organs with the highest metabolic activity, including those in the cardiovascular, nervous, and musculoskeletal systems [1,2,3].
A depletion in vitamin B1 levels is called beriberi syndrome. The two main manifestations of this disease affect either the neuromuscular system (a dry form of beriberi) or the cardiovascular system (a wet form of beriberi) [4]. Rarely, a fulminant version called Shoshin syndrome may be seen [5,6,7,8,9]. It is characterized by low cardiac output and hemodynamic collapse. Severe cardiac dysfunction and lactic acidosis are observed [6,7,8,9]. The course of this form of the disease can be fulminant, and when untreated, it can be fatal [10]. Due to complex clinical presentation, non-specific symptoms, and a lack of clinically approved diagnostic tests, Shoshin syndrome can be easily misdiagnosed [10].
The current paper aims to present the case of a 49-year-old woman who suddenly developed perimyocarditis fulminans complicated by cardiogenic shock due to thiamine deficiency. Difficulties in the differential diagnosis, the importance of a thorough medical history, and the effect of optimal medical treatment, including mechanical circulation support and intravenous vitamin B1 administration are described. We highlight the practical implications of the study, and, finally, a summary review of the available literature on Shoshin syndrome is provided.

2. Materials and Methods

This is a single-center, observational case study of fulminant perimyocarditis during beriberi syndrome. We retrospectively identified patients between the periods of January 2016 and December 2020, who were admitted to the Clinical Centre of Cardiology of the University Clinical Centre in Gdańsk, Poland, with the symptoms of new-onset heart failure (HF) and had the features of perimyocarditis resulting from vitamin B1 deficiency confirmed either by laboratory tests or by showing clinical improvement after thiamine administration. Additionally, other distinguishable causes of perimyocarditis among patients were excluded. Patients with normal thiamine levels were not included. Physical examination, laboratory data, echocardiography results, cardiac magnetic resonance imaging, and endomyocardial biopsy results were taken into consideration for further analysis. As part of the literature review, the PubMed database was searched for the literature, clinical trials, and databases from 1978 to December 2022. The keywords were “Shoshin syndrome” or “fulminant beriberi”. Case reports were mostly found.

3. Case Presentation

A 49-year-old female with a short history of previous de novo HF based on perimyocarditis requiring hospitalization (Figure 1) was re-hospitalized due to HF exacerbation.
At the time of admission, the patient was hemodynamically stable but complained of dyspnea, nausea, and weakness. On physical examination, mild lower limb edema and pale skin color were noticeable. In a 12-lead electrocardiogram, a sinus rhythm of 110 beats per minute (BPM) was observed with unspecific ST-T segment changes (Figure 2).
The patient’s condition suddenly deteriorated to cardiogenic shock within a few hours. Pronounced lactic acidosis with a pH of 6.6 and lactate level of 19 mmol/L was identified (Table 1).
Myocardial injury markers were slightly elevated in the laboratory assays. Troponin I (TnI) was 1.01 ng/mL, creatinine kinase-MB mass (CK-MB mass) was 27.6 ng/mL), and brain natriuretic peptide (BNP) was significantly increased—up to 1800 pg/mL (Table 1). A transthoracic echocardiography (TTE) revealed severe biventricular dilatation and failure (left ventricular ejection fraction (LVEF) of 10% without regional wall motion disturbances and tricuspid annular plane systolic excursion of 8 mm). Furthermore, moderate tricuspid and mitral regurgitations and a hemodynamically insignificant amount of pericardial fluid with dilated non-collapsible with inspiration inferior vena cava were observed. Due to progressive respiratory failure, the patient was intubated, and mechanical ventilation was initiated. Despite intensive pharmacological treatment (including fluid administration and high doses of vasopressors, such as adrenaline, noradrenaline, and dobutamine), no increase in blood pressure was obtained, with maximum values reaching 50/30 mmHg. An intra-aortic balloon pump (IABP) was implanted, and further, due to its inefficacy, an emergency venoarterial extracorporeal membrane oxygenation (VA-ECMO) supply was implemented. The procedure was complicated by bleeding into the soft tissue of the right lower limb (with the hemoglobin level decreasing to 6.4 g/dL); therefore, repeated blood transfusions were performed with a slight consequent increase in the hemoglobin level rising up to 8.4 g/dL (Table 2).
Repeated CXR examinations revealed persistent, severe pulmonary edema, notably in the hilar regions of both lungs, despite maintaining negative fluid balance.
In the meantime, there was an incidence of flaccid paraparesis observed, notably involving both feet. Neurological examination revealed symmetrical impairment of motor, sensory, and reflex functions of lower limbs without any neurological deficit in the upper limbs, so the neuropathy–myopathy of the critical state was suspected, and supplementation of coenzyme Q10, selenium, and D3 vitamin was started along with parenteral nutrition.
In the following days of hospitalization, the features of acute kidney injury were observed: creatinine was 3.37 mg/dL, blood urea nitrogen (BUN) was 101.1 mg/dL, and the estimated glomerular filtration rate (eGFR) was 15 mL/min/1.73 m2 (Table 1), and despite diuresis being present, continuous renal replacement therapy with continuous venovenous hemofiltration (CRRT—CVVHF) was initiated. Due to later ventilator-associated pneumonia, targeted antibiotic therapy (with meropenem) was used with sound clinical effects. Various laboratory data derived from the patient are presented in Table 2.
With time, significant improvement in clinical status was observed (Table 1) with gradual improvement in LVEF (eventually up to 60%); therefore, CRRT—CVVHF and VA-ECMO were decannulated, and subsequently, the patient was successfully extubated. For optimal HF treatment, an angiotensin receptor blocker, beta blocker, mineralocorticoid receptor antagonist, and loop diuretic were continued. Moreover, due to neurological deficits, tailored physical rehabilitation was provided along with an easily digested balanced diet and supplementation of polyunsaturated fatty acids, selenium, and vitamins.
Further, an extensive panel of additional studies was made to determine the leading cause of perimyocarditis fulminans (Table 3).
Despite a wide range of diagnostic tests, an unambiguous cause of disease could not be determined. An electroneurography assay, requested due to persistent flaccid paraparesis, revealed marked, symmetrical, axonal demyelinating polyneuropathy of both lower limbs, suggesting beriberi disease. The diagnosis was made based on coexisting peripheral neuropathy and cardiovascular failure with severe lactate acidosis. Additionally, due to the thorough medical history obtained, the patient was following a long-lasting imbalanced gluten-free diet, adopted without medical consultation, due to an unconfirmed celiac disease. Even though the thiamine blood level was not obtained in the presented case, based on the specific clinical picture, intramuscular thiamine replacement therapy was empirically initiated (50 mg once daily) with an adequate clinical response. The patient’s cardiovascular and renal functions quickly and markedly improved (LVEF raised to 70%, creatinine was 0.73 mg/dL, and eGFR was >90 mL/min/1.73 m2) with lower limb polyneuropathic symptoms markedly mitigated.
After a nutritional consultation, the patient was discharged home in good general condition. The lady was informed about the negative consequences of an unbalanced gluten-free diet, which is harmful in people without confirmed celiac disease. Within a year, the lady saw an improvement in exercise tolerance, allowing her to return to physical activity.

4. Discussion

The main finding of our study reveals that vitamin B1 deficiency can be a life-threatening condition, and therapy with thiamine results in a significantly favorable clinical response.
In the absence of thiamine, pyruvate cannot be an input for a Krebs cycle and is converted into lactate following an anaerobic process [1,2]. A less efficient anaerobic respiration resulting in ATP depletion does not meet energetic organ demand and leads to a decrease in function, i.e., myocardial contraction, which, over time, can manifest as cardiogenic shock, as seen in our patient. Moreover, with lactate accumulation, metabolic acidosis usually presents, which we noticed during the hospitalization of our lady. A long-term decrease in the thiamine level caused by its insufficient consumption by following an unbalanced dietary pattern eventually led to decompensation of the cardiovascular system manifesting itself as refractory circulatory collapse, resistance to standard HF therapy, and the need for medical management, even with mechanical circulation support. Subsequently, acute HF caused multiorgan failure (particularly noted within the renal, gastrointestinal, and neural systems—Table 1) which significantly complicated the hospitalization course and was potentially fatal.
Currently, Shoshin syndrome is considered rare in developed countries. However, its exact incidence remains unknown [11]. The most common causes include excessive alcohol consumption, liver disease and malnutrition [1,2,4,8,9,10]. Therefore, an unbalanced diet, including a gluten-free diet, which has become increasingly popular in recent decades, should be seriously considered in the diagnostic algorithm for this pathology as demonstrated in the presented patient. Since the human body cannot synthesize thiamine, it requires dietary supplementation. The most common nutritional sources are whole grains, bread, and pulses, while fruits and vegetables, the fundamentals of the gluten-free regimen, are less valuable [1,2]. Thus, a human’s dietary habits are of great importance and can be remarkably detrimental if left unbalanced, as observed in our patient [12]. The patient had adopted a gluten-free diet, depleted of micronutrients, including vitamin B1, without any medical consultation or medically proven gluten-related disease, which resulted in cardiogenic shock on the grounds of perimyocarditis in the course of fulminant beriberi disease. Nowadays, it is considered that gluten could be harmful for the human body. However, available scientific data deny this hypothesis as it is proven that gluten restriction may have severe adverse effects, as were present in our patient [13,14].
Due to low awareness of Shoshin syndrome among physicians, unrevealing symptoms involving multiple systems, and a lack of specific, widely obtainable laboratory assays, the diagnosis of fulminant beriberi disease is extremely challenging [10]. In the literature, many cases of wet beriberi are described [4,5,6,7,8,9,11]. However, the symptoms are non-specific and include, among others, acute right-sided HF, biventricular failure, diffuse ST-segment elevation, or T wave inversion [4,5,6,8,9,15]. Likewise, in our case, none of the symptoms in the initially collected anamnesis (no liver disease or excessive alcohol intake) was suggestive of beriberi disease, which delayed the final diagnosis. On admission, our patient was hemodynamically stable, presented the symptoms of acute biventricular failure, hypotension, and metabolic acidosis of unknown cause in a few hours.
In the diagnostic process of Shoshin syndrome, laboratory blood tests are beneficial and allow confirmation of the disease with certainty. These tests include red blood cell transketolase activity, measurement of the pyrophosphatase effect, and the plasma and intraerythrocytic thiamine levels [16]. However, all of them are only performed in highly specialized centers, and the measurement is time-consuming, complicated, and thereby, infrequent [17,18]. Since obtaining a result is a lengthy procedure, the tests are clinically inefficient, particularly in life-threatening clinical conditions as presented in our patient. However, available data indicate that while suspecting its deficiency, treatment with vitamin B1 is considered safe and beneficial for the diagnosis and final confirmation of cardiovascular beriberi disease [19]. The therapy is outstandingly efficient in Shoshin syndrome and can quickly improve the patient’s condition even after one dose of thiamine [5,6,7,8,9,19]. Therefore, thiamin administration was initiated in our patient based on the presented clinical picture, notably cardiogenic shock with lactic acidosis and neurological features, which resulted in a pronounced clinical improvement with LVEF restoration and subsidence of peripheral neuropathy and finally confirmed the diagnosis of fulminant beriberi disease. The patient was discharged home in good general condition, and, in a follow-up, it was reported she had returned to regular daily activities, including intensive physical activity.

5. Practical Implications

With our article, we aimed to hopefully raise awareness of beriberi disease among practicing clinicians, expand the knowledge about thiamine relevance, and show potential therapeutic options. Although considered rare, vitamin B1 deficiency should always be included in the differential diagnosis of critically ill patients as the condition can be fatal if left misdiagnosed or untreated. Treatment with vitamin B1 is considered safe and generally accepted in patients suspected of its deficiency. Available data indicate that this method could be useful in the treatment of wet beriberi and is confirmed in our study. Hopefully, our experience will contribute to a further understanding of beriberi disease and the impact of thiamine on human health.

6. Review of the Literature

To further support of our findings, we performed an extensive literature search of articles published from 1978 up to December 2022. The reference lists of all the included studies were manually searched for other potential eligible studies. We identified 41 papers, from which the majority were case reports (32 papers) and case series. Two original research studies were found. Data include reports from countries all over the world, and the studied population was aged from pre-term infants to the elderly (87 years old). The background of thiamine deficiency varies; however, the clinical picture is identical. All of the patients developed sudden cardiogenic shock with lactic acidosis, and a pronounced improvement of HF after thiamine administration was observed in all of the cases. In one study, patients died due to non-implementation of the proper (thiamine) therapy [10]. A summary is presented in Table 4.

7. Conclusions

Although considered rare in developed countries, fulminant beriberi disease is a life-threatening condition. It should always be included in the differential diagnosis of critically ill patients, notably those with malnutrition. An unbalanced diet, i.e., gluten-free, lacking essential microelements can have severe consequences, including perimyocarditis fulminans, which can be fatal if left untreated. However, targeted therapy with thiamine can significantly improve the patient’s cardiac function and restore hemodynamic and metabolic parameters.

Author Contributions

Conceptualization, J.R., W.B., and L.D.-S.; methodology, J.R. and L.D.-S.; software, J.R., K.M. and K.D.; validation, L.D.-S. and K.D.; formal analysis, L.D.-S. and K.D.; investigation, W.B., G.R., M.G. and K.D.; resources, K.D., K.M., M.G. and G.R.; data curation, J.R. and W.B.; writing—original draft preparation, J.R.; writing—review and editing, L.D.-S. and K.D.; visualization, J.R. and K.M.; supervision, L.D.-S.; project administration, J.R. and K.M. All authors have read and agreed to the published version of the manuscript.


This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Medical University of Gdansk (protocol code NKBBN/624/2022 on 14 October 2022).

Informed Consent Statement

Patient consent was waived by the Ethics Committee of the Medical University of Gdansk due to the retrospective, observational character of the study.

Data Availability Statement

Upon reasonable request, data presented in this study will be provided by emailing the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest. The company had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.


  1. Hrubša, M.; Siatka, T.; Nejmanová, I.; Vopršalová, M.; Kujovská Krčmová, L.; Matoušová, K.; Javorská, L.; Macáková, K.; Mercolini, L.; Remião, F.; et al. Biological Properties of Vitamins of the B-Complex, Part 1: Vitamins B1, B2, B3, and B5. Nutrients 2022, 14, 484. [Google Scholar] [CrossRef]
  2. Lonsdale, D. A review of the biochemistry, metabolism and clinical benefits of thiamin(e) and its derivatives. Evid. Based Complement. Alternat. Med. 2006, 3, 49–59. [Google Scholar] [CrossRef] [Green Version]
  3. Ahmed, M.; Azizi-Namini, P.; Yan, A.T.; Keith, M. Thiamin deficiency and heart failure: The current knowledge and gaps in literature. Heart Fail Rev. 2015, 20, 1–11. [Google Scholar] [CrossRef]
  4. Gubbay, E.R. Beri-Beri heart disease. Can. Med. Assoc. J. 1966, 95, 21–27. [Google Scholar]
  5. Kim, J.; Park, S.; Kim, J.H.; Kim, S.W.; Kang, W.C.; Kim, S.J. A case of shoshin beriberi presenting as cardiogenic shock with diffuse ST-segment elevation, which dramatically improved after a single dose of thiamine. Cardiovasc. J. Afr. 2014, 25, e1–e55. [Google Scholar] [CrossRef]
  6. Attas, M.; Hanley, H.G.; Stultz, D.; Jones, M.R.; McAllister, R.G. Fulminant beriberi heart disease with lactic acidosis: Presentation of a case with evaluation of left ventricular function and review of pathophysiologic mechanisms. Circulation 1978, 8 Pt 1, 566–572. [Google Scholar] [CrossRef] [Green Version]
  7. Cottini, M.; Ranucci, M.; Facciolo, C.; Satriano, A.; Kandill, H.; Bettini, F.; De Vincentis, C.; Cotza, M.; Ballotta, A. An unusual case of cardiogenic shock in which thiamine administration led to reversal of lactic acidosis and heart function recovery: Shoshin beriberi in an adolescent. Int. J. Cardiol. 2016, 222, 401–403. [Google Scholar] [CrossRef]
  8. Kountchev, J.; Bijuklic, K.; Bellmann, R.; Joannidis, M. A patient with severe lactic acidosis and rapidly evolving multiple organ failure: A case of shoshin beri-beri. Intensive Care Med. 2005, 31, 1004. [Google Scholar] [CrossRef]
  9. Dabar, G.; Harmouche, C.; Habr, B.; Riachi, M.; Jaber, B. Shoshin Beriberi in Critically-Ill patients: Case series. Nutr. J. 2015, 14, 51. [Google Scholar] [CrossRef] [Green Version]
  10. Bello, S.; Neri, M.; Riezzo, I.; Othman, M.S.; Turillazzi, E.; Fineschi, V. Cardiac beriberi: Morphological findings in two fatal cases. Diagn. Pathol. 2011, 6, 8. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  11. Pang, J.A.; Yardumian, A.; Davies, R.; Patterson, D.L.H. Shoshin beriberi: An underdiagnosed condition? Intensive Care Med. 1986, 12, 380–382. [Google Scholar] [CrossRef] [PubMed]
  12. Kaya, Z.; Bicer, A.; Yalcin, F.; Er, A.; Camuzcuoglu, A.; Korkmaz, N.; Sezen, Y. Impaired global and segmental myocardial deformation assessed by two-dimensional speckle tracking echocardiography in patients with vitamin B12 deficiency. Cardiol. J. 2014, 21, 60–66. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  13. Niland, B.; Cash, B.D. Health Benefits and Adverse Effects of a Gluten-Free Diet in Non-Celiac Disease Patients. Gastroenterol. Hepatol. 2018, 14, 82–91. [Google Scholar]
  14. Diez-Sampedro, A.; Olenick, M.; Maltseva, T.; Flowers, M. A Gluten-Free Diet, Not an Appropriate Choice without a Medical Diagnosis. J. Nutr. Metab. 2019, 2019, 2438934. [Google Scholar] [CrossRef]
  15. Hathirat, S.; Jumbala, B. Giant T inversion in cardiac beriberi. J. Med. Assoc. Thail. 1975, 58, 636–641. [Google Scholar]
  16. Meurin, P. Shoshin beriberi. A rapidly curable hemodynamic disaster. Presse Med. 1996, 25, 1115–1118. [Google Scholar]
  17. Whitfield, K.C.; Bourassa, M.W.; Adamolekun, B.; Bergeron, G.; Bettendorff, L.; Brown, K.H.; Cox, L.; Fattal-Valevski, A.; Fischer, P.R.; Frank, E.L.; et al. Thiamine deficiency disorders: Diagnosis, prevalence, and a roadmap for global control programs. Ann. N. Y. Acad. Sci. 2018, 1430, 3–43. [Google Scholar] [CrossRef]
  18. Smith, T.J.; Johnson, C.R.; Koshy, R.; Hess, S.Y.; Qureshi, U.A.; Mynak, M.L.; Fischer, P.R. Thiamine deficiency disorders: A clinical perspective. Ann. N. Y. Acad. Sci. 2021, 1498, 9–28. [Google Scholar] [CrossRef]
  19. Lei, Y.; Zheng, M.H.; Huang, W.; Zhang, J.; Lu, Y. Wet beriberi with multiple organ failure remarkably reversed by thiamine administration: A case report and literature review. Medicine 2018, 97, e0010. [Google Scholar] [CrossRef]
  20. Barennes, H.; Sengkhamyong, K.; Rene, J.P.; Phimmasane, M. Beriberi (thiamine deficiency) and high infant mortality in northern Laos. PLoS Negl. Trop. Dis. 2015, 9, e0003581. [Google Scholar] [CrossRef] [Green Version]
  21. Bhat, J.I.; Rather, H.A.; Ahangar, A.A.; Qureshi, U.A.; Dar, P.; Ahmed, Q.I.; Charoo, B.A.; Ali, S.W. Shoshin beriberi-thiamine responsive pulmonary hypertension in exclusively breastfed infants: A study from northern India. Indian Heart J. 2017, 69, 24–27. [Google Scholar] [CrossRef] [Green Version]
  22. Thomas, L.; Fay, D.; Moraillon, X.; Delubac, G.; Berthet, P.; Demingeon, G. Lactic acidosis treated with thiamine. 3 cases. Presse Med. 1985, 14, 1871–1875. [Google Scholar] [PubMed]
  23. Shivalkar, B.; Engelmann, I.; Carp, L.; De Raedt, H.; Daelemans, R. Shoshin syndrome: Two case reports representing opposite ends of the same disease spectrum. Acta Cardiol. 1998, 53, 195–199. [Google Scholar] [PubMed]
  24. Saya, R.P.; Baikunje, S.; Prakash, P.S.; Subramanyam, K.; Patil, V. Clinical correlates and outcome of shoshin beriberi. N. Am. J. Med. Sci. 2012, 4, 503–506. [Google Scholar] [CrossRef] [PubMed]
  25. Salvatori, G.; Mondi, V.; Piersigilli, F.; Capolupo, I.; Pannone, V.; Vici, C.D.; Rizzo, C.; Dotta, A. Thiamine Deficiency in a Developed Country: Acute Lactic Acidosis in Two Neonates Due to Unsupplemented Parenteral Nutrition. JPEN J. Parenter. Enteral Nutr. 2016, 40, 886–889. [Google Scholar] [CrossRef] [PubMed]
  26. Delorme, N.; Cornette, A.; Maurin, P.; Polu, J.M.; Sadoul, P. Shoshin beriberi with hyponatremia in a beer drinker. Presse Med. 1986, 15, 2005–2009. [Google Scholar] [PubMed]
  27. Naidoo, D.P.; Singh, B.; Haffejee, A.; Aitcheson, J.; Barker, E.M. Acute pernicious beriberi in a patient receiving parenteral nutrition. A case report. S. Afr. Med. J. 1989, 75, 546–548. [Google Scholar]
  28. Cage, J.B.; Wall, B.M. Shoshin beriberi in an AIDS patient with end-stage renal disease. Clin. Cardiol. 1992, 15, 862–865. [Google Scholar] [CrossRef]
  29. Debuse, P.J. Shoshin beriberi in an infant of a thiamine-deficient mother. Acta Paediatr. 1992, 81, 723–724. [Google Scholar] [CrossRef]
  30. Fujita, I.; Sata, T.; Gondo, K.; Fukazawa, M.; Kukita, J.; Zaitsu, A.; Yoshitake, J.; Ueda, K. Cardiac beriberi (shoshin beriberi) caused by excessive intake of isotonic drink. Acta Paediatr. Jpn. 1992, 34, 466–468. [Google Scholar] [CrossRef]
  31. Smith, S.W. Severe acidosis and hyperdynamic circulation in a 39-year-old alcoholic. J. Emerg. Med. 1998, 16, 587–591. [Google Scholar] [CrossRef]
  32. López Gastón, O.D.; Malvino, E.R.; McLoughlin, D.; Osatnik, J.; Chávez Zambrano, M.A.; Pino, C. Acute cardiovascular beriberi (shoshin-beriberi). Medicina 2002, 62, 331–334. [Google Scholar]
  33. Groeneveld, J.H.; Geelhoed-Duijvestijn, P.H.; Veldkamp, R.F.; Baur, H.J. Shoshin beriberi provoked by the inhalation of salbutamol. Ned. Tijdschr. Geneeskd. 2003, 147, 1601–1603. [Google Scholar] [PubMed]
  34. Goto, Y.; Awata, M.; Uematsu, M.; Yano, M.; Morozumi, T.; Kotani, J.; Watanabe, T.; Onishi, T.; Iida, O.; Sera, F.; et al. Shoshin beriberi complicating severe pulmonary hypertension: A case report. J. Cardiol. 2007, 49, 361–365. [Google Scholar] [PubMed]
  35. Daly, M.J.; Dixon, L.J. A case of ST-elevation and nystagmus—When coronary thrombosis is not to blame. QJM Int. J. Med. 2009, 102, 737–739. [Google Scholar] [CrossRef] [PubMed]
  36. Greenspon, J.; Perrone, E.E.; Alaish, S.M. Shoshin beriberi mimicking central line sepsis in a child with short bowel syndrome. World J. Pediatr. 2010, 6, 366–368. [Google Scholar] [CrossRef]
  37. Loma-Osorio, P.; Pe√Īafiel, P.; Doltra, A.; Sionis, A.; Bosch, X. Shoshin beriberi mimicking a high-risk non-ST-segment elevation acute coronary syndrome with cardiogenic shock: When the arteries are not guilty. J. Emerg. Med. 2011, 41, e73–e77. [Google Scholar] [CrossRef]
  38. Reinhardt, D.; Giambarba, C.; Raimondi, S. Alcohol, acid, vitamins and heart. Praxis 2011, 100, 733–736. [Google Scholar] [CrossRef] [PubMed]
  39. Brown, T.M. A case of Shoshin Beriberi: Lessons old and new for the psychiatrist. Psychosomatics. 2013, 54, 175–180. [Google Scholar] [CrossRef]
  40. Kuno, T.; Nakamura, H.; Endo, Y.; Saito, K.; Yamazaki, H.; Motoda, H.; Numasawa, Y.; Shimizu, K.; Takahashi, T. Clinical history and colliquative myocytolysis are keys to the diagnosis of shoshin beriberi. Case Rep. Pathol. 2014, 2014, 506072. [Google Scholar] [CrossRef] [Green Version]
  41. Misumida, N.; Umeda, H.; Iwase, M. Shoshin beriberi induced by long-term administration of diuretics: A case report. Case Rep. Pathol. 2014, 2014, 878915. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  42. Moulin, P.; Cinq-Frais, C.; Gangloff, C.; Peyre, M.; Seguela, P.E.; Charpentier, S.; Cascarigny, F.; Alcouffe, F.; Periquet, B.; Dulac, Y.; et al. Thiamine deficiency in infants: A case report. Arch. Pediatr. Organe Off. Soc. Fr. Pediatr. 2014, 21, 392–395. [Google Scholar] [CrossRef] [PubMed]
  43. Tejedor, A.; Solé, M.; Prieto-González, S.; Alba, M.A.; Grau, J.M.; Cid, M.C.; Hernández-Rodriguez, J. Acute dilated cardiomyopathy in a patient with beriberi and cryoglobulinaemic vasculitis: An unusual potential complication of two rare disorders. Clin. Exp. Rheumatol. 2014, 32 (Suppl. 82), S66–S69. [Google Scholar] [PubMed]
  44. Imamura, T.; Kinugawa, K. Shoshin Beriberi With Low Cardiac Output and Hemodynamic Deterioration Treated Dramatically by Thiamine Administration. Int. Heart J. 2015, 56, 568–570. [Google Scholar] [CrossRef] [Green Version]
  45. Shah, A.; Patel, S.; Kothari, S.; Denk, J. Beriberi Induced Cardiomyopathy Requiring Salvage Venoarterial Extracorporeal Membrane Oxygenation. Case Rep. Crit. Care 2016, 2016, 5043818. [Google Scholar] [CrossRef]
  46. Elias, I.M.; Sinclair, G.; Blydt-Hansen, T.D. Acute Shoshin beriberi syndrome immediately post-kidney transplant with rapid recovery after thiamine administration. Pediatr. Transplant. 2019, 23, e13493. [Google Scholar] [CrossRef]
  47. Vicinanza, A.; De Laet, C.; Rooze, S.; Willems, A.; Beretta-Piccoli, X.; Vens, D.; Voglet, C.; Jacquemart, C.; Massin, M.; Biarent, D. Shoshin Beriberi and Severe Accidental Hypothermia as Causes of Heart Failure in a 6-Year-Old Child: A Case Report and Brief Review of Literature. Front. Pediatr. 2019, 7, 119. [Google Scholar] [CrossRef] [Green Version]
  48. Didisheim, C.; Ballhausen, D.; Choucair, M.L.; Longchamp, D.; Natterer, J.; Ferry, T.; Perez, M.H.; Amiet, V. Severe Lactic Acidosis in a Critically Ill Child: Think About Thiamine! A Case Report. J. Pediatr. Intensive Care 2020, 10, 307–310. [Google Scholar] [CrossRef]
  49. Hodgkinson, L.M.; Shah, A.; Bae, G.H.; Novoa, R.; Kwong, B.Y. Shoshin beriberi in a patient with oral and cutaneous graft-versus-host disease. JAAD Case Rep. 2020, 6, 420–421. [Google Scholar] [CrossRef]
  50. Lim, M.S.; Win, W.; Von Essen, A.; Gannon, D.; Ramali, M. Lessons of the month 1: Shoshin beriberi: A case report of fulminant cardiovascular collapse, intractable hyperlactatemia and deteriorating consciousness. Clin. Med. 2021, 21, e670–e672. [Google Scholar] [CrossRef]
  51. Tamaki, H.; Tsushima, H.; Kachi, N.; Jimura, F. Cardiac Dysfunction Due to Thiamine Deficiency after Hemodialysis for Biguanide-related Lactic Acidosis. Intern. Med. 2022, 61, 2905–2909. [Google Scholar] [CrossRef] [PubMed]
  52. Tanné, C.; Nguyen, J.; Blondé, R. Shoshin beriberi and thiamine-responsive right heart failure: A case report in Mayotte Recognition and management of infant Shoshin beriberi. Arch. Pediatr. Organe Off. Soc. Fr. Pediatr. 2022, 29, 624–625. [Google Scholar] [CrossRef] [PubMed]
Figure 1. Cardiac magnetic resonance findings in the patient during the previous hospitalization: (a) Features of myocardial edema (significant hyperintensity of the myocardium), consistent with ongoing inflammation, can be noted in the short tau inversion recovery T2-weighted (T2STIR) image. The signal intensity (SI) ratio of the myocardium to the skeletal muscle SI is greater than 2, as shown by the red dashed line ROIs. An asterisk marks a small pericardial effusion. (b) Subepicardial and intramural streaks of late gadolinium enhancement, pointing out areas of predominantly irreversible damage (arrows) in the inversion recovery images, and possibly related to healed myocarditis. A white dashed line marks an artifact.
Figure 1. Cardiac magnetic resonance findings in the patient during the previous hospitalization: (a) Features of myocardial edema (significant hyperintensity of the myocardium), consistent with ongoing inflammation, can be noted in the short tau inversion recovery T2-weighted (T2STIR) image. The signal intensity (SI) ratio of the myocardium to the skeletal muscle SI is greater than 2, as shown by the red dashed line ROIs. An asterisk marks a small pericardial effusion. (b) Subepicardial and intramural streaks of late gadolinium enhancement, pointing out areas of predominantly irreversible damage (arrows) in the inversion recovery images, and possibly related to healed myocarditis. A white dashed line marks an artifact.
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Figure 2. 12-lead electrocardiogram of the patient. Sinus tachycardia (110 bpm) with unspecific ST-T segment changes are seen.
Figure 2. 12-lead electrocardiogram of the patient. Sinus tachycardia (110 bpm) with unspecific ST-T segment changes are seen.
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Table 1. Time course of basic laboratory assays.
Table 1. Time course of basic laboratory assays.
On AdmissionDay 2Day 5After 2 Weeks
(normal: 7.37–7.45)
Lac; mmol/L
(normal: 0.5–2.2)
HCO3; mmol/L
(normal: 22–28)
4 pCO2; mmHg
(normal: 31–43)
BE; mmol/L
(normal: −2.0–3.0)
TnI; ng/mL
(normal: 0–0.1)
CK-MB mass; ng/mL
(normal: 0.0–6.6)
creatinine; mg/dL
(normal: 0.55–1.02)
ml/min/1.73 m2
CRP; mg/L
(normal: 0.0–5.0)
PCT; ng/mL
(normal: 0.0–0.5)
WBC; ×109/L
(normal: 4–10)
Abbreviations: BE—base excess; CK-MB mass—creatine kinase-MB; CRP—C-reactive protein; eGFR—estimated glomerular filtration rate; HCO3—bicarbonate; ICU—intensive care unit; Lac—lactate; pCO2—partial pressure of carbon dioxide; PCT—procalcitonin; TnI—troponin I; WBC—white blood cells.
Table 2. Further laboratory data derived from the patient.
Table 2. Further laboratory data derived from the patient.
Hb; g/dL (normal: 12–16)
on admission12.5
the outermost value6.4
iron; ug/dL (normal: 50–170)38
ferritin; ng/mL (normal: 4.63–204)588
transferrin; G/L (normal: 1.8–3.82)1.29
transferrin saturation; % (normal: 15–45)20.9
ALT; U/L (normal: 0–55)
on admission31
the outermost value495
AST; U/L (normal: 0–35)
on admission21
the outermost value555
serum albumin; G/L (normal: 35–50)18
Abbreviations: ALT—alanine transaminase; APTT—activated partial thromboplastin time; AST—aspartate transaminase; Hb—hemoglobin; INR—international normalized ratio; PT—prothrombin time.
Table 3. Further studies performed to establish the final diagnosis.
Table 3. Further studies performed to establish the final diagnosis.
Endomyocardial BiopsyCardiac Fragments within Normal Limits
anti-beta2GPI antibodies IgG (normal 0–5)0.27
anti-beta2GPI antibodies IgM (normal 0–5)0.00
aPS antibodies IgG (normal 0–10)3.48
aPS antibodies IGM (normal 0–10)0.00
dRVVT—LA1 (screening); sec (normal 31–44)27
anti-cardiac muscle antibodies (normal 0–1)1:10
anti-striated muscle antibodies (normal 0–1)1:10
ANCA (normal 0–1)0
HLA B27 antigenpositive
anti-CMV antibodies IgG; U/ml26.8
anti-CMV antibodies IgM; U/ml<5
anti-borelia burgdorferi antibodies IgM and IgGnegative
Chlamydophilia pneumoniae IgA, IgM and IgGnegative
Mycoplasma pneumoniae IgA, IgM and IgGnegative
Clostridium difficile toxins (A, B, GDH)negative
Pneumocystis carinii trophozoitsnegative
adenoviruses and rotavirusesnegative
eosinophil count; ×109/L (normal 0.02–0.5)0.17
eosinophil count; ×109/L (normal 0.02–0.5)2.3
TSH; uU/mL (normal 0.34–4.94)5.25
fT4; pmol/L (normal 9.01–19.05)15.17
fT3; pmol/L (normal 2.63–5.7)3.49
anti-tTg IgA; RU/mL (normal 0–20)11.55
anti-tTg IgG0.05
total IgA; G/L (normal 0.65–4.21)2.02
total IgM; G/L (normal 0.33–2.93)14.92
total IgG; G/L (normal 5.52–16.31)0.96
serum proteins electrophoresis:
albumin; % (normal 55.8–66.1)53.2
albumin; G/L (35–50)28
alpha-1-globulins; % (normal 2.9–4.9)4.2
alpha-2-globulins; % (normal 7.1–11.8)7.7
beta-2-globulins; % (normal 3.2–6.5)6.0
beta-1-globulins; % (normal 4.7–7.2)6.2
gamma-globulins; % (normal 11.1–18.8)22.7
total protein G/L (normal 64–83)66
Abbreviations: ANCA—anti-neutrophil cytoplasmic antibodies; anti-beta2GPI—anti-beta 2 glycoprotein I; anti-tTg—anti-tissue transglutaminase; aPS—anti-antiphosphatidylserine; dRRVT—dilute Russell’s viper venom time; fT3—free triiodothyronine; fT4—free thyroxine; IgA—immunoglobulin A; IgG—immunoglobulin G; IgM—immunoglobulin M; LA—lupus anticoagulant; TSH—thyroid stimulating hormone.
Table 4. Available literature findings of Shoshin beriberi.
Table 4. Available literature findings of Shoshin beriberi.
AuthorDate and Country of the StudyPatient’s AgeCause of Thiamine DeficiencyClinical Presentation
Original research
Barennes, H.; et al. [20]Laos, 20151–6 months oldbreastfed infant of thiamine-deficient mother (dietary insufficiency—excessive consumption of polished rice)acute heart failure (AHF) and lactic acidosis
Bhat J.I., et al. [21]India, 201778.45 ± 30.7 daysbreastfed infants of thiamine-deficient mothers (due to customary dietary restrictions)cardiogenic shock and renal failure
Case series
Thomas, L.; et al. [22]France, 19853 adult patients, 1 had Shoshin beriberiexcessive alcohol intakecardiogenic shock and lactic acidosis
Pang, J. A.; et al. [11]United Kingdom (UK), 19862 adult patientsdietary deficiencyAHF with renal failure and severe metabolic acidosis
Shivalkar, B.; et al. [23]Belgium, 19982 adult patientsexcessive alcohol intakeone with high-output heart failure (HF) and the other with low-output HF and cardiovascular collapse
Bello, S.; et al. [10]Italy, 20112 patients, 47 and 43 years old1. gastric resection
2. total parenteral nutrition (TPN)
cardiac arrest and lactic acidosis
Saya, R.P.; et al. [24]India, 20126 patients, 20–36 years oldfive were non-alcoholics and none had signs of overt malnutritioncardiogenic shock, severe metabolic acidosis, and multiorgan failure (MOF)
Dabar, G.; et al. [9]Lebanon, 20154 patients, 23–60 years oldcritically ill non-septic non-alcoholic patients
1. gastric surgery
2. pancreatic cancer
3. type-1 glycogen storage disease
4. peritonitis
severe lactic acidosis and refractory cardio-circulatory collapse
Salvatori, G., et al. [25]Italy, 20162 pre-term infantsprolonged TPNAHF with MOF and lactic acidosis
Case reports
Attas, M.; et al. [6]United States of America (USA), 197836 years oldexcessive alcohol intakeAHF with lactic acidosis and dyspnea
Delorme, N.; et al. [26]France, 1986age not precise, adultexcessive alcohol intakecardiogenic shock with lactic acidosis and severe hyponatremia
Naidoo, D.P.; et al. [27]Republic of South Africa, 1989age not precise, adultTPN and protracted vomiting from intestinal obstructionrefractory cardiogenic shock and lactic acidosis
Cage, J. B.; et al. [28]USA, 199229 years oldend-stage kidney failure on continuous peritoneal dialysiscardiogenic shock with fulminant pulmonary edema
Debuse, P. J.; et al. [29]Australia, 19923 months oldbreastfed infant of thiamine-deficient mothercardiogenic shock with lactic acidosis
Fujita, I.; et al. [30]Japan, 199221 months oldexcessive isotonic sports drink intakecardiogenic shock with lactic acidosis
Smith, S. W. [31]USA, 199839 years oldexcessive alcohol intakeunexplained lactic acidosis and high output HF
López Gastón, O. D.; et al. [32]Argentina, 200258 years oldexcessive alcohol intakedyspnea, oliguria, edema, high output HF, metabolic acidosis, and renal tubular dysfunction
Groeneveld, J.H.; et al. [33]The Netherlands, 200345 years oldexcessive alcohol intake, dietary deficiency, and inhalation of salbutamolcardiogenic shock, severe dyspnea, and lactic acidosis
Kountchev, J.; et al. [8]Austria, 200550 years old excessive alcohol intakeAHF, dyspnea, and lactic acidosis
Goto, Y.; et al. [34]Japan, 200744 years olddietary deficiencycardiogenic shock and pulmonary hypertension
Daly, M.J.; et al. [35]UK, 2009post-menopausal womanprolonged vomiting and diarrheacardiogenic shock
Greenspon, J.; et al. [36]USA, 2010pediatric patient, age not preciseshort bowel syndromecardiogenic shock and lactic acidosis
Loma-Osorio, P.; et al. [37]Spain, 201135 years old not precisecardiogenic shock and an electrocardiographic pattern of severe myocardial ischemia suggesting left main coronary artery obstruction
Reinhardt, D.; et al. [38]Switzerland, 201167 years oldexcessive alcohol intakeacute dyspnea, AHF, and severe lactic acidosis
Brown, T.M.; et al. [39]USA, 201355 years oldexcessive alcohol intake and dietary deficiencyAHF and lactic acidosis
Kim, J.; et al. [5]South Korea, 201487 years oldTPNCardiogenic shock with diffuse ST-segment elevation (inferior and anterior wall)
Kuno, T.; et al. [40] Japan, 201466 years olddietary deficiencyAHF, colliquative myocytolysis, and lactic acidosis
Misumida, N.; et al. [41]Japan, 201461 years oldlong-term diuretics therapyAHF
Moulin, P.; et al. [42]France, 201410 weeks oldbreastfed infant of thiamine-deficient mother due to high consumption of polished ricediarrhea, vomiting, lactic acidosis and AHF
Tejedor, A.; et al. [43]Spain, 201445 years oldexcessive alcohol intake and dietary deficiencyAHF and dilated cardiomyopathy
Imamura, T.; et al. [44]Japan, 201540 years oldexcessive alcohol intakeAHF and lactic acidosis
Cottini, M.; et al. [7]Italy, 201617 years oldnot precisecardiogenic shock and lactic acidosis
Shah, A.; et al. [45]USA, 201633 years oldmalnutrition (restrictive, unbalanced diet)cardiogenic shock and lactic acidosis
Lei, Y.; et al. [19]China, 201839 years oldexcessive alcohol intakeAHF, MOF, and lactic acidosis
Elias, I. M.; et al. [46]Canada, 201914 years oldend-stage kidney failureAHF and lactic acidosis
Vicinanza, A.; et al. [47]Belgium, 20196 years oldMalnutrition and refeeding syndromecardiogenic shock with cardiac arrest and severe accidental hypothermia
Didisheim, C.; et al. [48]Switzerland, 202013 years oldTPNrefractory cardiogenic shock and lactic acidosis
Hodgkinson, L. M.; et al. [49]USA, 202068 years oldoral and cutaneous graft-versus-host disease after allogeneic hematopoietic cell transplant (reduced intestinal absorption)AHF, renal failure, and lactic acidosis
Lim, M. S.; et al. [50]UK, 202157 years oldexcessive alcohol intakecardiogenic shock and lactic acidosis
Tamaki, H.; et al. [51]Japan, 202282 years oldhemodialysis and biguanide therapyAHF and lactic acidosis
Tanné C.; et al. [52]Mayotte, 20222 months oldbreastfed infant of thiamine-deficient mother due to high consumption of polished riceAHF and lactic acidosis
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Rohun, J.; Dorniak, K.; Młodziński, K.; Bachorski, W.; Gruchała, M.; Raczak, G.; Daniłowicz-Szymanowicz, L. Vitamin B1 Deficiency and Perimyocarditis Fulminans: A Case Study of Shoshin Syndrome in a Woman Following an Unbalanced Dietary Pattern Followed by a Literature Review. Life 2023, 13, 205.

AMA Style

Rohun J, Dorniak K, Młodziński K, Bachorski W, Gruchała M, Raczak G, Daniłowicz-Szymanowicz L. Vitamin B1 Deficiency and Perimyocarditis Fulminans: A Case Study of Shoshin Syndrome in a Woman Following an Unbalanced Dietary Pattern Followed by a Literature Review. Life. 2023; 13(1):205.

Chicago/Turabian Style

Rohun, Justyna, Karolina Dorniak, Krzysztof Młodziński, Witold Bachorski, Marcin Gruchała, Grzegorz Raczak, and Ludmiła Daniłowicz-Szymanowicz. 2023. "Vitamin B1 Deficiency and Perimyocarditis Fulminans: A Case Study of Shoshin Syndrome in a Woman Following an Unbalanced Dietary Pattern Followed by a Literature Review" Life 13, no. 1: 205.

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