Atypical presentation of a forgotten disease: refractory hypotension in beriberi

Thiamine deficiency is a treatable disease with an excellent prognosis. However, it is often unrecognized because of the diversity of its clinical presentations. Herein, we report two atypical cases of nonalcoholic thiamine deficiency that presented with refractory hypotension in the absence of lactic acidosis. Case 1 developed recurrent hypotension, right-sided heart failure, and a classic triad of Wernicke’s encephalopathy (WE) after gastrointestinal surgery. Case 2 had decreased dietary intake and diuretic abuse, and had multiple episodes of syncope prior to present admission with refractory hypotension and mental status changes. The diagnosis of both cases was confirmed by undetectable pretreatment serum thiamine and dramatic improvement with thiamine replacement. In this report, we highlight refractory hypotension as a complication of, not only cardiovascular, but also neurologic beriberi. Moreover, thiamine replacement should be considered without delay in hypotensive patients with signs of WE and/or risk factors for beriberi.