Table 1.

Nonalcoholic, adult cases of thiamine deficiency reported in high‐income countries

Source	Country, year(s) of data collection	Number of cases and institution or type of setting (e.g., hospital and community)	Overall characteristics: age, gender, and underlying condition(s)	Likely cause of thiamine deficiency	Laboratory confirmation	Symptoms and clinical presentation	Treatment: supplementation dose and effect on symptoms (resolution)	Other notes (including the presence or absence of infection)
Alligier et al.12 (Published article) “A series of severe neurologic complications after bariatric surgery in France: the NEUROBAR Study”	France, 2010–2018	38 cases with neurologic complications after bariatric surgery, of which 14 had confirmed thiamine deficiency	34 females, 4 males; median age = 39 years; median BMI = 43 kg/m2; 34% received gastric bypass and 45% sleeve gastrectomy, with neurologic complications observed 6 months (median) after surgery	Gastrointestinal symptoms and surgical complications after bariatric surgery (e.g., vomiting and limited oral energy intake)	Thiamine deficiency was confirmed in 14 cases (values not provided)	10 cases had encephalopathy, 15 had peripheral neuropathy, 12 had both, and 1 had a pyramidal syndrome	15 patients received IV, and 2 received oral thiamine supplementation; neurologic symptoms were completely resolved in 9 cases; 2 patients died	No reported infection
Kohnke and Meek18 (Published article) “Don't seek, don't find: the diagnostic challenge of Wernicke's encephalopathy”	United Kingdom, 2020	One case admitted to hospital (department of surgery)	26‐year‐old woman had bariatric surgery 6 weeks before	Persistent vomiting for 6 weeks after gastric sleeve surgery	Not known (“inconclusive biochemistry” assessed after onset of treatment)	Presented with nystagmus, imbalance, and gait disturbance, interfering with activities of daily living	250 mg IV thiamine (3×/day), later raised to 500 mg (3×/day) for several weeks, resulting in a marked improvement of symptoms	No reported infection
Zafar30 (Published article) “Wernicke's encephalopathy following Roux‐en‐Y gastric bypass surgery”	Saudi Arabia, 2015	One case admitted to hospital	40‐year‐old male had Roux‐en‐Y gastric bypass surgery (for weight loss) 3 months before and reported repeated vomiting since then	Repeated vomiting (and likely little oral food intake) following weight loss surgery	No	Presented with confusion and difficulty in maintaining balance while walking; assessment: nystagmus and ataxic gait (Wernicke encephalopathy)	500 mg IV thiamine (3×/day), then 250 mg/day, resulted in improved symptoms (“almost completely normal” on 3‐month follow‐up visit)	No reported infection
Isenberg‐Grzeda et al.15 (Published article) “Nonalcoholic Thiamine‐Related Encephalopathy (Wernicke–Korsakoff Syndrome) Among Inpatients With Cancer: A Series of 18 Cases”	U.S., 2013–2014	18 cancer inpatients with Wernicke–Korsakoff syndrome referred to psychiatry service	Median age = 65 years; 33% women; 61% with solid tumors and 39% with hematologic malignancies	Disease‐related malnutrition: decreased availability/intake (e.g., nausea), accelerated usage (e.g., infection and fever), impaired use (e.g., fluorouracil and metronidazole), and excessive loss of thiamine	Yes, in 89% of patients: serum thiamine was <7 nmol/L (normal: 9–14 nmol/L)	Presented with cognitive signs and symptoms; for example, altered mental status (100%), cerebellar signs and symptoms (39%), and ocular signs and symptoms (17%). No/little vitamins B9 and B12 deficiency	Most received 500 mg IV thiamine (3×/day), initiated on average 18 days after symptom onset; 17% had complete resolution of symptoms, and 83% had residual symptoms at the time of last follow‐up	50% of patients had an infection
Cui and Qiu2 (Published article) “Thiamine Deficiency (Beriberi) Induced Polyneuropathy and Cardiomyopathy: Case Report and Review of the Literature”	U.S., 2014	One case admitted to the ER	20‐year‐old female with papillary thyroid carcinoma and dysphagia caused by radiation injury; low body weight	Significantly decreased oral intake due to dysphagia	Yes, thiamine was 7 nmol/L (normal 9–14 nmol/L)	Presented with bilateral lower extremity weakness and paresthesia, inability to walk, chest palpitations, and shortness of breath; assessment: ptosis, nystagmus, tachycardia, and lactic acidosis	IV thiamine supplementation for 5 days and tube feeding after hospital discharge resulted in the improvement of all symptoms at 3‐month follow‐up visit	No reported infection
Jung et al.11 (Published article) “Wernicke's Encephalopathy in Advanced Gastric Cancer”	Korea, 2009	Two cases admitted to hospital	Case 1: 48‐year‐old woman with advanced GC, receiving intermittent home parenteral nutrition (HPN), suffered a 20‐kg weight loss over 2 months Case 2: 58‐year‐old woman with advanced GC and a 15‐kg weight loss over 2 months	Case 1: disease‐related malnutrition (with marked weight loss after chemotherapy) Case 2: disease‐related malnutrition (with marked weight loss after chemotherapy)	Case 1: No Case 2: No	Case 1: presented with dizziness and diplopia; assessment: nystagmus and gaze disturbance (Wernicke encephalopathy) Case 2: presented with sudden disorientation, confusion; assessment: gaze limitation and mild ataxia (Wernicke encephalopathy)	Case 1: daily parenteral injection of thiamine 100 mg for 17 days resulted in improved symptoms Case 2: parenteral injection of thiamine (100 mg for 4 days), but patient had recurrent seizure attack and aggravation, resulting in death on hospital day 6	Case 1: no reported infection Case 2: no reported infection. Thiamine replacement started 3 days after neurologic symptoms and was ineffective
Helali et al.31 (Published article) “Thiamine and Heart Failure: Challenging Cases of Modern‐Day Cardiac Beriberi”	U.S., 2018	Two cases admitted to the ER	Case 1: 68‐year‐old homeless obese man (BMI = 33 kg/m2) Case 2: 63‐year‐old obese man (BMI = 39 kg/m2) was severely limiting caloric intake to encourage weight loss	Case 1: food insecurity Case 2: restrictive diet (less than 1 meal/day, mostly convenience foods)	Case 1: Yes, a random nonfasting level of 12 nmol/L, a few days after admission (normal: 8–30 nmol/L) Case 2: Yes, undetectable	Case 1: presented with progressive dyspnea and swollen legs; assessment: cardiomegaly and anemia; multiple hospital visits in the following 3 months, with new neurocognitive deficits and bilateral cranial nerve 6 palsies Case 2: presented with dyspnea and altered mental status; assessment: tachycardia, tachypnea, and severe heart failure	Case 1: 100 mg oral thiamine/day improved cardiac and cognitive function after 16 days Case 2: heart failure improved significantly after 14 days of IV thiamine	Both cases: no reported infection. Authors suggest that patients who present with an unexplained cardiomyopathy should be evaluated for thiamine deficiency
Misumida et al.32 (Published article) “Shoshin Beriberi Induced by Long‐Term Administration of Diuretics: A Case Report”	U.S., 2014	One case admitted to the ER; Transferred to ICU on second day	61‐year‐old man with a history of heart failure (receiving furosemide and trichlormethiazide therapy for 6 months), diabetes and stage 3 chronic kidney disease. BMI = 29 kg/m2	Chronic diuretic therapy	Yes, plasma thiamine concentration of 11 mg/dL (normal range: 20–50 mg/dL)	Presented with dyspnea; assessment: edema in legs, cardiomegaly, pulmonary vascular congestion, and severe metabolic acidosis	IV thiamine supplementation (100 mg/day) resolved all symptoms and patient was discharged on day 15 (on “oral vitamin pills”)	No reported infection (absence of fever and leukocytosis, and negative results of serial blood cultures)
Romanski and McMahon33 (Published article) “Metabolic Acidosis and Thiamine Deficiency”	U.S., 1999	One case admitted to medical center	19‐year‐old woman, BMI = 13 kg/m2, with persistent, unexplained GI symptoms and receiving HPN	Absence of multivitamins, most significantly thiamine, in HPN formula (no multivitamins or trace elements were provided for 19 days)	No, test was ordered but not completed; reason not provided	Presented with nausea, vomiting, diarrhea, and abdominal pain; assessment: very low BMI, hyperglycemia, and metabolic acidosis	IV thiamine supplementation (100 mg daily for 2 days), followed by daily administration of 50 mg orally for the next 14 weeks, resulted in a dramatic clinical improvement	No reported infection
Koike et al.34 (Published article) “Myopathy in thiamine deficiency: analysis of a case”	Japan, 2006	One case admitted to hospital	26‐year‐old woman with a particular dietary pattern (ate mostly white rice and drank coffee, disliked meat and vegetables); BMI = 24.5 kg/m2	Monotonous diet	Yes, total thiamine in whole blood was 16 ng/mL (normal, 20–50 ng/mL)	Presented with walking difficulties, leg edema, and myalgia; assessment: moderate cardiomegaly with pulmonary congestion and axonal neuropathy	75 mg oral dose of fursultiamine (daily) resulted in dramatic decrease in cardiomegaly, pleural effusions, and edema in the legs, followed by improvement of neurologic symptoms, muscle strength, and myalgia	No reported infection
Shible et al.13 (Published article) “Dry Beriberi Due to Thiamine Deficiency Associated with Peripheral Neuropathy and Wernicke's Encephalopathy Mimicking Guillain–Barré syndrome: A Case Report and Review of the Literature”	U.S., 2019	One case admitted to hospital and transferred to intensive care unit	56‐year‐old woman with history of gallstone pancreatitis and malnutrition; on HPN until 6 months prior to admission, then returned to normal diet. BMI unknown	Underlying severe protein‐calorie malnutrition and duration of critical illness	Yes, but measured after four doses of thiamine therapy (serum level: 104 nmol/L, reference range: 70–180 nmol/L)	Presented with paresthesia of the lower limbs, arms and neck; assessment: unresponsive to verbal stimuli, Hb 9.4 g/dL, and Wernicke encephalopathy	High‐dose IV thiamine (500 mg every 8 h) resulted in mental status improvement within 48 hours	Reported infection (septic state). Initial diagnosis was Guillain–Barré syndrome (symptoms and signs of dry beriberi can mimic those of the Guillain–Barré syndrome)
Koike et al.17 (Published article) “Rapidly developing weakness mimicking Guillain–Barré syndrome in beriberi neuropathy: two case reports”	Japan, 2007	Two cases admitted to hospital	Case 1: 46‐year‐old man had a gastrectomy 3 years ago to treat cancer Case 2: 33‐year‐old man with a particular dietary pattern (did not like meat or vegetables, preferring white rice and noodles with no side dishes); heavy outdoor work	Case 1: disease‐related malnutrition (BMI or weight loss not reported) Case 2: monotonous diet	Case 1: Yes, total thiamine in whole blood was 15 ng/mL (normal: 20–50 ng/mL) Case 2: Yes, total thiamine in whole blood was 7 ng/mL (normal: 20–50 ng/mL)	Case 1: presented with weakness in lower extremities; assessment: axonal neuropathy; later developed progressive weakness, lactic acidosis, and heart failure Case 2: presented with weakness of limbs (unable to walk); assessment: severe sensory deficits in legs and mild sensory loss in hands	Case 1: 100 mg IV thiamine resulted in gradual improvement of all symptoms Case 2: 100 mg IV thiamine resulted in gradual improvement of all symptoms	Both cases: no reported infection and symptoms mimicked Guillain–Barré syndrome (which was initially considered as a diagnosis)
Solorzano and Guha14 (Published article) “Wernicke's Encephalopathy: Under Our Radar More Than it Should Be?”	U.S., 2016	One case admitted to hospital	30‐year‐old woman with abdominal sepsis due to choledocholithiasis, on parenteral nutrition due to poor oral intake (caused by nausea, vomiting, and abdominal pain)	Thiamine was not included in the parenteral nutrition formulation	Yes, low levels (values not provided)	Presented with deteriorated mental status; assessment: miotic pupils and roving eye movements, and Wernicke encephalopathy	500 mg IV thiamine, 3×/day for 3 days, then oral 50 mg/day resulted in symptom improvement, although ataxia and memory issues persisted 2 months later	Reported complex intra‐abdominal infections
Ruiz et al.35 (Conference abstract) “Acute polyneuropathy and Wernicke encephalopathy due to thiamine deficiency”	Italy, 2019	One case admitted to the ER	59‐year‐old woman with cancer (adenocarcinoma of the extrahepatic biliary tree)	Disease‐related malnutrition	Yes, low serum thiamine level (34 nmol/L, normal values 66–200)	Admission: subacute onset of confusion, amnesia for recent events and confabulation. Later: nystagmus, hypoesthesia, and severe flaccid quadriparesis	200 mg of IV thiamine hydrochloride/day, for 3 weeks Strength improvement, distal lower limb paresthesia, reduced reflexes at upper limbs and areflexia at lower limbs. Amnestic‐confabulatory syndrome persisted	No reported infection
Murase et al.36 (Conference abstract) “Shoshin beriberi in a young man living on Japanese rice balls”	Japan, year not reported	One case admitted to ER	24‐year‐old single man, living alone, no underlying conditions (BMI = 17.4 kg/m2)	Food insecurity (subsisting on balls of polished rice in preceding 4 years) due to financial problems	Yes, 17 ng/mL (normal: 24–66 ng/mL)	Presented with chest pain and shortness of breath; assessment: systemic edema, central cyanosis, hyporeflexia, lactic acidosis, and moderate cardiomegaly	Hemodynamic parameters improved dramatically in only 3 h after thiamine administration (dose not reported)	No reported infection
Bruera et al.37 (Clinical communication to the editor) “The Malnourished Heart: An Unusual Case of Heart Failure”	U.S., 2017	One case admitted to hospital	66‐year‐old woman with no past medical history, but relied on a diet “of processed cheese chips and vanilla cake” for 2 years; BMI = 17 kg/m2	Monotonous diet that led to multiple nutritional deficiencies	Yes, low levels (values not provided)	Presented with worsening dyspnea, lower extremity edema, and orthopnea; assessment: heart failure, periodontal disease, patchy hair loss, low HB (10.3 g/dL), deficient for vitamins B1, B6, C, and D	After injections of thiamine and other vitamins + multivitamin tablets, the heart failure symptoms resolved completely and periodontal disease improved	No reported infection
Mates (2020) (Personal communication, unpublished dataa from Dr. Elisabeth Mates, MD, attending hospitalist physician at the VA Sierra Nevada Healthcare System)	USA, 2018–2020	33 cases admitted to hospital	Veteran patients (mean age = 75 years old) from the greater Reno area, Nevada, with wide range of underlying acute and chronic illnesses	Disease‐related malnutrition (illnesses or conditions that led to reduced appetite and nutritional intake, e.g., cancer, cholecystitis, and pancreatitis)	Yes, all patients had a plasma thiamine level ≤7 nmol/L (normal: 8–30 nmol/L); note: takes 7–10 days to obtain test result	Wide‐ranging symptoms; no single symptom stands out other than many had weakness and “hospital delirium”	Treated patients (<50%) had demonstrable improvement in the neurologic symptoms and general weakness; some went from needing nursing home level of care to be discharged home after treatment	Pending subsequent prospective study (n = 400) to determine the prevalence of thiamine deficiency in hospitalized patients

BMI, body mass index; ER, emergency room; GC, gastric cancer; GI, gastrointestinal; HPN, home parenteral nutrition; ICU, intensive care unit; IV, intravenous; WB, whole blood.

^a Manuscript in preparation for peer review; data included in this table reflect the information provided by Elisabeth Mates, MD, an attending hospitalist physician at the VA Sierra Nevada Healthcare System.