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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 178-181

Suspected thiamine deficiency presenting as peripheral neuropathy among peripartum women in a hospital in rural Assam: A neglected public health problem


Department of Internal Medicine, Makunda Christian Leprosy and General Hospital, Karimganj, Assam, India

Date of Web Publication17-Jul-2018

Correspondence Address:
Roshine Mary Koshy
Makunda Christian Leprosy and General Hospital, Bazaricherra, Karimganj - 788 727, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_33_18

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  Abstract 


Context: A single case of thiamine deficiency seen in a population reflects a public health problem which is preventable and easily treatable. Aim: This article describes suspected thiamine deficiency among peripartum women in a rural population in Assam presenting as clinically overt peripheral polyneuropathy. Materials and Methods: A retrospective review of the clinical presentation and electrodiagnostic features of peripartum women presenting with peripheral polyneuropathy during a 6-month period, showing improvement in clinical symptoms after administration of thiamine. Results: The clinical profile of 24 peripartum women described is consistent with features of thiamine deficiency presenting with peripheral polyneuropathy and/or cardiopathy. Of the patients followed up after thiamine supplementation, 90% (18) reported either improvement of neurological deficits or improvement in nerve conduction studies after an average of 10 days. Predominant use of polished rice, thiamine poor diet and habitual use of tea, betel nut, and fermented fish are observed to have precipitated the disease. Limitations of the study include the lack of biochemical measurement of tissue thiamine stores in patients. Conclusions: The observations made among peripartum women in this population assumes public health importance as thiamine deficiency is a preventable and easily treatable illness. There is an urgent need to initiate prospective studies including population surveys to conclusively prove the existence of clinically overt thiamine deficiency in this rural population and its likely causes so that effective public health strategies can be formulated to prevent the morbidity associated with this clinical entity.

Keywords: Dry and wet beriberi, peripartum women, peripheral neuropathy, thiamine deficiency


How to cite this article:
Koshy RM, Ismavel VA, Sharma H, Jacob PM. Suspected thiamine deficiency presenting as peripheral neuropathy among peripartum women in a hospital in rural Assam: A neglected public health problem. CHRISMED J Health Res 2018;5:178-81

How to cite this URL:
Koshy RM, Ismavel VA, Sharma H, Jacob PM. Suspected thiamine deficiency presenting as peripheral neuropathy among peripartum women in a hospital in rural Assam: A neglected public health problem. CHRISMED J Health Res [serial online] 2018 [cited 2018 Oct 23];5:178-81. Available from: http://www.cjhr.org/text.asp?2018/5/3/178/236895




  Introduction Top


The classical syndrome caused primarily by thiamine deficiency in humans is beriberi, presenting as peripheral neuropathy and/or cardiopathy.[1] Thiamine deficiency has been reported by the World Health Organization in epidemic proportions in refugee camps where the predominant diet is polished rice.[2] In addition, a large proportion of patients who are affected are women during their pregnancy or lactation period, wherein the thiamine requirements are higher.[3] The habitual use of betel nut, tea, and raw/fermented fish have also shown to precipitate clinically overt thiamine deficiency in populations who consume a low thiamine diet.[4]

This article describes the clinical presentation and electrodiagnostic features of a group of peripartum women who presented with peripheral neuropathy and/or cardiopathy and who showed clinical improvement after thiamine supplementation.


  Materials and Methods Top


Setting

The Out-patient and In-patient Departments of a rural 150 bedded hospital located in Karimganj District of Assam, bordering Tripura and Mizoram.

Time period of study

This study was conducted from December 1, 2016 to May 31, 2017.

Subjects

Patients are women during pregnancy or within 1 year postpartum who satisfied both of the following criteria.

  1. A clinical diagnosis of peripheral neuropathy made by attending doctor based on any one of the following criteria:


    1. Muscle weakness of upper and/lower limbs less than Grade 5 (Medical Research Council)
    2. Positive sensory symptoms
    3. Objective sensory deficits
    4. Absent or reduced deep tendon reflexes.
  2. An abnormal nerve conduction study suggestive of peripheral neuropathy. Patients with peripheral neuropathy due to diabetes, leprosy, and carpal tunnel syndrome were excluded from the study.


Methods

The data from the medical records of the patients including a neuropathy workup data sheet that had been designed by the physician, were retrospectively reviewed. Results of electrodiagnostic studies done using the ALERON EMG NCV machine and echocardiography using a GE Logiq P5 machine with an adult cardiac probe and continuous Wave Doppler were also included.

Categorical data are presented as percentages and continuous data as mean during analysis.


  Results Top


Of 38,678 adult patients seen by clinicians in the hospital during the 6 months period, 168 patients (0.4%) were referred by clinicians to the neurophysiology department with a clinical diagnosis of peripheral neuropathy. Out of the 112 patients who were confirmed to have a peripheral neuropathy based on electrodiagnostic studies, there were 24 (21.43%) peripartum women with peripheral neuropathy not attributable to known causes, namely diabetes mellitus, Hansen's disease and carpal tunnel syndrome [Figure 1].
Figure 1: Research flow

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Demographic profile and time trend

About 54% of patients were from Karimganj District of Assam, 41% from Northern Tripura and 4% from Mizoram. Nearly 71% of patients belonged to the Muslim community, 17% to the Bengali community, whereas 12% were distributed among other tribal communities [Table 1].
Table 1: Demographic details of participants

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A time trend was noticed in the presentation with all the peripartum women presenting during the months of December (46%), January (33%), and February (21%), which are also the peak months for delivery in the hospital.

Dietary profile

The average calorie intake of patients obtained through a 24 hr dietary recall was 1253 Kcal/day with carbohydrates contributing to 64.32% of the total calories. The average thiamine content of a daily diet was 0.16 mg per 1000 Kcal/day.

All patients had a predominant rice-based diet, with 54% consuming polished rice. None of the patients were purely vegetarian in their diet. All patients consumed either tea (58%), betel nut (71%), or fermented fish (92%) as part of their typical diet with 42% of patients habitually consuming all three food items.

Clinical presentation

Nineteen patients (79%) presented to the hospital within 1 month of onset of symptoms. Twelve patients had their onset of symptoms in the postpartum period, mostly within 2 months of the postpartum period.

The most common symptoms of the patients were paraesthesia associated with weakness of lower limbs alone (10) or both upper and lower limbs (9).

Neurological deficits: Twenty-two patients (92%) had objective clinical evidence of a sensory motor peripheral polyneuropathy. The lowest grade of motor power recorded in any limb was zero seen in six patients (25%). The most frequent sensory deficit recorded was decreased or absent deep tendon reflexes seen in 22 patients (92%) followed by paraesthesia over distal limbs described by 18 patients (75%). One patient was also recorded to have bilateral ptosis.

Electrodiagnostic studies: Of the 24 patients who underwent nerve conduction studies, 23 underwent studies before administration of thiamine supplements. Studies done showed that 18 patients (75%) had a sensory-motor polyneuropathy, five patients (21%) had a pure motor polyneuropathy, whereas one patient (4%) had a pure sensory polyneuropathy. There was evidence of predominant axonal involvement in 23 patients (96%), whereas in one patient, features suggested demyelination.

Cardiovascular involvement

Fourteen patients had baseline echocardiograms at admission, of which six patients (43%) had an abnormal echocardiography. Three patients had cardiac output more than 8 L/min with one of them also having a significant functional mitral regurgitation. Two patients had significant functional regurgitation with preserved ejection fractions while one patient had a low ejection fraction of 28% with poor left ventricular contractility, significant functional mitral and tricuspid regurgitation and moderate pericardial effusion.

Other significant history

Four patients had documented antenatal risk factors, namely pregnancy-induced hypertension and Rh-negative blood group. Nineteen patients had been on Iron and Calcium supplements and two patients had been on Vitamin B complex supplementation during the antenatal period. None of the patients had significant past medical history except for one patient who had a similar neurological complaint 1 year ago. One patient reported a similar neurological disease in her mother which resolved over time. Six patients reported a history of fever in the 2 months previous to onset of complaints, but no details of the febrile illness was available for verification. One patient received Anti-D immunoglobulin injection postpartum, whereas all other patients only reported use of routine antepartum tetanus toxoid vaccinations. None of the patients consumed alcohol in the past. Seven patients reported antecedent use of unspecified allopathic/homeopathic medication.

Other investigations

Other investigations that were done as part of a workup for axonal polyneuropathy and to exclude other coexisting diseases included complete blood count with red blood cell indices, Virology screen for human immunodeficiency virus, Hepatitis B and C virus, VDRL for syphilis, thyroid-stimulating hormone, sodium, pottasium, creatinine, lactates, and liver function tests. Laboratory data obtained was not complete, but prominent abnormalities included macrocytosis (3/19), elevated liver transaminases (5/12), low albumin (7/12), elevated alkaline phosphatase (1/12), elevated serum lactates (12/15), and elevated creatinine (2/16).

Therapy and outcome

All patients were given parenteral (intramuscular or intravenous) thiamine 200 mg per day for an average of 7 days, followed by a capsule of Vitamin B complex, containing 33 mg of thiamine per capsule advised two times a day at discharge until the time of next review.

All patients also received Iron and Calcium supplementation. In addition to the above, 7 patients were also prescribed other medication for the management of associated clinical conditions, namely antibiotics for suspected wound infection, analgesics for pain relief, antifailure medication, antihypertensives, and antipsychotics for postpartum psychosis.

Patients were reassessed by the clinician during admission, at the time of discharge or at the time of review. The outcome of patients who could not be reassessed by the clinician was later reviewed through a telephonic call to the patient.

All 24 patients were followed up by clinicians, but there was no documentation of outcome (either adverse or favorable) in four patients (17%). Of the remaining 20 patients, 18 patients (90%) demonstrated improvement either through clinical assessment or nerve conduction studies after an average of 10 days. The clinical improvement was confirmed by clinicians after an examination at review in 15 patients, whereas in three patients, the improvement was recorded through a telephonic call to the patient. Of the two patients where improvement was not noted, one patient reported only subjective improvement while the other reported a subjective worsening of symptoms and was discharged against medical advice.

Repeat echocardiogram

Of the 6 patients who had an abnormal echocardiogram at admission, only one patient had a repeat study after 1 week of parenteral thiamine, which showed a reduction in cardiac output from 9.2–7.7 L/min and disappearance of the functional mitral regurgitation.

Outcome of pregnancy

Four mothers (17%) had intrauterine death of fetus at presentation to the hospital while one mother had a late neonatal death.


  Discussion Top


Peripartum women with suspected thiamine deficiency constituted 21.43% of patients with peripheral neuropathy confirmed by electrodiagnostic studies.

The constellation of symptoms and signs seen in patients included in the study are characteristic of patients presenting with thiamine deficiency manifesting as peripheral neuropathy or dry beriberi. In addition, 25% of patients also had co-existing features to suggest cardiac involvement or wet beriberi.

The response of patients with beriberi to thiamine supplementation in literature have been remarkable with dramatic responses seen more in wet beriberi than dry beriberi.[1]

The Muslim population appeared to be disproportionately affected (70%).

Four patients had no documentation of clinical outcomes. Of the 20 patients whose outcome was followed up either through examination by a clinician or as reported by patient through telephonic call or through nerve conduction studies, 18 patients (90%) had improvement in neurological deficits. There was a subjective improvement and worsening in complaints in the remaining two patients, respectively.

The patients included in the case series are a population vulnerable to develop clinically overt thiamine deficiency. The recommended thiamine intake for an adult is 0.4 mg/1000 Kcal. The requirements are more, with an additional 0.4 mg/day and 0.5 mg/day for a pregnant and lactating woman, respectively.[2] However, the average thiamine content of a typical daily diet in patients in the study was 0.16 mg/1000 Kcal. All patients had a rice predominant diet with 54% consuming polished rice. All patients habitually ate tea, betel nut, fermented, or raw fish which are known anti-thiamine factors, capable of precipitating clinically overt thiamine deficiency.[4]

All mothers at discharge were counseled on the use of tea, betel nut, and fermented fish as a possible cause for their symptoms and their dietary habits were reviewed at the time of follow-up.

The study is limited by the fact that erythrocyte transketolase activity-thiamine pyrophosphate test,[2] reflecting tissue thiamine stores were not done due to the cost and nonavailability of the test in North East India.

As thiamine deficiency is a preventable and easily treatable illness, addressing this clinical entity will have enormous public health implications. Preventive strategies may include the use of unpolished rice, discouraging use of foods/food habits known to act as antithiamine factors and routine thiamine supplementation in antenatal and postnatal clinics. Creating public health awareness about this disease in the community will lead to early diagnosis and appropriate treatment.

This study provides useful data for public health researchers to initiate further prospective studies including population surveys to conclusively prove the existence of clinically overt thiamine deficiency and its likely causes in this rural population. Preventive strategies could then be employed to produce a major impact on morbidity due to this neglected public health problem.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prakasha SR, Mustafa AS, Baikunje S, Subramanyam K. “Dry” and “wet” beriberi mimicking critical illness polyneuropathy. Annals of Indian Academy of Neurology 2013;16:687-9.  Back to cited text no. 1
    
2.
World Health Organization. Department of Nutrition for Health and Development. Thiamine Deficiency and its Prevention and Control in Major Emergencies. World Health Organization; 1999.  Back to cited text no. 2
    
3.
McGready R, Simpson JA, Cho T, Dubowitz L, Changbumrung S, Böhm V, et al. Postpartum thiamine deficiency in a Karen displaced population. Am J Clin Nutr 2001;74:808-13.  Back to cited text no. 3
    
4.
Stuetz W, Carrara VI, Mc Gready R, Lee SJ, Sriprawat K, Po B, et al. Impact of Food Rations and Supplements on Micronutrient Status by Trimester of Pregnancy: Cross-Sectional Studies in the Maela Refugee Camp in Thailand. Nutrients 2016;8:66.  Back to cited text no. 4
    


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