Transcription:
Treating a Rare Case of Wet Beriberi

Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Dolly Devara. She's a physiatrist at Northwestern Medicine's Marianjoy Rehabilitation Hospital, and she's here to highlight treating a rare case of wet beriberi. Berry. Dr. Devara, thank you for joining us today. Can you tell us about the rare diagnosis of wet beriberi? Berry? What is it? What makes it so rare in the United States and where is it usually found?

Dolly Devara, MD: Thanks, Melanie. Good morning. Beriberi is a disease that's because of thiamine deficiency. So it can be a dry beriberi or wet beriberi. It is rarely seen in modern societies like USA and Europe. It's more commonly seen in Asia, Africa where there's malnutrition and the foods are not enriched in thiamine. Like I said, it's not seen in modern society because most of our foods now are vitamin-enriched. So if you are eating a normal, healthy diet, we should get enough thiamine. And therefore, we don't see many cases in the US. That's why we are talking about this case today, because we did get to see a very rare case of wet beriberi.

Melanie Cole, MS (Host): Well, then tell us about that. What symptoms did the patient present with?

Dolly Devara, MD: So the patient presented with shortness of breath with generalized edema, with difficulty walking and the patient did have an underlying history of increased alcohol consumption and addiction. She presented to our Northwestern Hospital in the suburbs with the symptoms that I described and our colleagues there, including cardiologists and neurologists, did a very thorough examination, ran her through a myriad of tests and was given the diagnosis appropriately of wet beriberi.

Melanie Cole, MS (Host): You mentioned alcohol consumption with this particular patient. Do we know what else caused this patient's condition? Were they somewhere else? Was it their diet? What else was going on?

Dolly Devara, MD: So it was the alcohol consumption, coupled with poor nutritional intake and also some social isolation. So probably they were not getting the vitamin-enriched food that we can easily get from cereals, from bread, from fresh meat, dairy products and fish. So it was a combination of the alcohol consumption, which probably led to some poor appetite, vomiting, and then poor nutrition on top of it.

Melanie Cole, MS (Host): Wow. It's very interesting. So, in what ways uniquely was Marianjoy team able to treat this patient? Tell us what you guys did.

Dolly Devara, MD: We did come up with a multidisciplinary team approach, as we do with any patient, customize it to their needs. So we had the physical therapist, occupational therapist, speech therapist, a psychologist, even a therapeutic recreational therapist and a dietician all as part of our treatment plan, including the nurse and, of course, the physicians. But at Northwestern Medicine Marianjoy, we are unique in the sense we Tellabs Center for neuro rehab which treats patients with severe neurological disorder with this new technology, including robotic exoskeletons. We have zero gravity gait and balance training equipment. So we were able to use all this to promote neuroplasticity in patients with severe neurological conditions. So that was unique when treating this particular patient, because the patient, when first presented to us, needed total assistance. We had to use a lift to get the patient out of bed, so putting the patient through this unique technology was imperative

so with cutting off her alcohol supply and giving her vitamin-enriched diet, it was a slow and steady improvement in strength. And as strength progressed, the patient was referred to our orthotic clinic for ankle and foot brace that was to provide ankle and knee stability when the patient was standing up, so they wouldn't buckle because of the weak quadriceps muscle. We also had the patient go to our wheelchair clinic because, like I said, it was hard to prognosticate how far we could get the patient advanced, you know, in terms of discharge home. So we were preparing the patient for possible wheelchair use. We got a customized wheelchair and a cushion set up for the patient. So those were some ways that we were planning for the patient to customize for the patient's needs and discharge planning

Melanie Cole, MS (Host): Were there any cognitive deficits that you saw with this case of wet beriberi?

Dolly Devara, MD: Thanks for bringing that up, Melanie. Yes, the patient did present with cognitive impairments and that goes along with the thiamine deficiency. Thiamine in its active form, thiamine thyrophospate, is important for metabolic processes, so any deficiency will lead to poor cell replication and cause a lot of not just neurological impairments in terms of weakness, but cognitive impairments as well. So this patient did present initially with cognitive impairments.

When I was describing our multidisciplinary team, we also had a psychologist who played a very important part and an integral part in helping with the cognitive impairments, such as memory, attention, concentration, but also in providing emotional support and education for the patient and the family. The psychologist also provided the patient with appropriate resources at the time of their discharge in terms of, you know, dealing with addiction issues, social isolation, et cetera.

Melanie Cole, MS (Host): So for the most part, Dr. Devara, these deficiencies, whether cognitive or physical or physiological, are not permanent based on the treatments that you were able to provide. Can you speak a little bit about the patient's outcomes?

Dolly Devara, MD: Yes. So wet beriberi at times can be fatal if not treated appropriately and at the right time. But most cases of beriberi are reversible with supplementing the thiamine, which they're deficient in, cutting off their alcohol supply and then treating them with appropriate therapies to increase their strength, endurance, and then have them functionally upgraded to their baseline.

So initially, we had trouble prognosticating the timeframe. It was a very rewarding experience treating this patient for the therapy team, as well as for all of us clinicians. It was a slow and steady, but the patient, like I said, initially came and required total assistance. But by the time the patient was discharged home in about five weeks' time, we were able to discharge the patient ambulatory with a walker. So that was amazing progress.

Melanie Cole, MS (Host): And is this patient still in treatment today?

Dolly Devara, MD: Correct. So the patient was discharged home, but we recommended outpatient therapies, which fortunately the patient decided to come back to Marianjoy for outpatient treatment. So we will still be collaborating with the patient and her treating physicians to make sure the patient gets the optimal benefits.

Melanie Cole, MS (Host): Wow, absolutely fascinating case, Dr. Devara. So as we wrap up, what should physicians keep in mind when treating a patient with a rare diagnosis, such as wet beriberi?

Dolly Devara, MD: It is so rare, Melanie, that we only see them in the aftermath. But like you said, it's such a reversible disease and presentation. So in the forefront, if we pay attention to patient's social history, most patients don't admit to addiction, but a good history-taking will let us know their alcohol intake or about their social life. And it's important to talk about diet in these patients, because really the daily intake of thiamine is like 1.2 milligrams that's required for an adult male or a female, and we get it through the enriched food that's available so readily. So keeping in mind that this is so reversible and can be easily prevented talking to our patients, so we can avoid this long protracted treatment course, is I think the takeaway from seeing patients like this.

Melanie Cole, MS (Host): Wow. That was excellent. Dr. Devara. You and your multidisciplinary team, such a comprehensive treatment approach. Thank you again for joining us. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/rehab to get connected with one of our providers.

And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. For updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole.