If you had asked me about beriberi twelve months ago, when I was on holiday in Burma, I would have been reminded of Sir Alec Guinness, in the film, “Bridge over the River Kwai”. Most of the allied prisoners of war, who were used as slave labour to build the notorious Death Railway, suffered from malnutrition, especially thiamine (vitamin B1) deficiency. So did this three year old girl.
NOTE: I have deliberately cropped the photograph to protect her confidentiality.
Beriberi is a bit like sandpaper; it comes in wet and dry forms. Thiamine deficiency can cause heart failure, with shortness of breath, rapid pulse and swollen ankles – wet beriberi. However, this little lass had dry beriberi, when the nervous system is affected.
Her mother said that the problem began two weeks ago, when her daughter felt weak and tired. Within a few days, she couldn’t walk and was finding it difficult to stand up. Now her hands and arms were weak. She also had problems talking and she looked exhausted.
I examined her with one of the nurses. She was slumped on her mother’s lap, chin on her chest as though it was an effort to hold her head up. She had a convergent squint (cross-eyed) but her mum said she’d always had this. She was able to keep her eyes open, there was no ptosis, and although she looked washed out, she was not anaemic.
Her pulse was rapid, just over 100 beats per minute, with occasional dropped beats. The lungs sounded clear although she was not able to breathe deeply. I could feel and enlarged liver in her abdomen, but no other signs. Her arms and legs were very floppy. Lying on the examination couch, she could not bring herself to a sitting position without help.
Examining the neurological system of a small child is difficult. The nurse claimed he could elicit a patellar reflex (knee jerk), but this was just the leg bouncing back after he had hit it. There was no twitch in the quadriceps. I couldn’t elicit any peripheral reflexes.
She claimed to be able to feel the touch of a whisp of cotton wool on her legs, even when I hadn’t touched her. I used the cold metal of the tuning fork to test her sensation of temperature, but again, she was unreliable with her response. She did claim to feel the buzzing of the tuning fork, suggesting that vibration sense was preserved.
The treatment is simple – vitamin B1 by intramuscular injection. Our protocol is to give 50mg thrice daily. Even though she couldn’t cry loudly, it was obvious that she could still perceive pain!
The prisoners of war had beriberi because of their appalling diet, deficient in many vitamins, not just thiamine and niacin. The outer covering of rice grains contains thiamine, but this is lost when the rice is milled and polished. Other popular local foods such as raw and smoked fish, contain enzymes which destroy thiamine. Cassava contains a tiny amount of thiamine, but digesting it consumes more than it provides. Although this girl didn’t chew betel nut, her mother did, and this can reduce thiamine levels in breast milk.
Within 24 hours, the transformation was amazing; she was completely better. She could walk, talk, eat and play. Result! Discharged with six weeks B vitamin oral supplements and dietary advice for mum. It’s not often that a treatment has such immediate and dramatic results. But it’s great when it happens.