Thiamine (Vitamin B1)

Thiamine was the first B vitamin to be identified and is therefore also referred to as vitamin B1. Thiamine functions in the decarboxylation of alfa-ketoacids, such as pyruvate alfa-ketoglutarate, and branched-chain amino acids and thus is a source of energy generation. In addition, thiamine pyrophosphate acts as a coenzyme for a transketolase reaction that mediates the conversion of hexose and pentose phosphates. It has also been postulated that thiamine plays a role in peripheral nerve conduction, although the exact chemical reactions underlying this function are unknown. Food Sources The median intake of thiamine in the United States from food alone is 2 mg/d. Primary food sources for thiamine include yeast, organ meat, pork, legumes, beef, whole grains, and nuts. Milled rice or grains contain little thiamine, if any. Thiamine deficiency is therefore more common in cultures that rely heavily on a rice-based diet. Tea, coffee (regular and decaffeinated), raw fish, and shellfish contain thiaminases, which can destroy the vitamin. Thus, drinking large amounts of tea or coffee can theoretically lower thiamine body stores. Deficiency Most dietary deficiency of thiamine worldwide is the result of poor dietary intake. In Western countries, the primary causes of thiamine deficiency are alcoholism and chronic illness, such as cancer. Alcohol interferes directly with the absorption of thiamine and with the synthesis of thiamine pyrophosphate. Thiamine should always be replenished when refeeding a patient with alcoholism, as carbohydrate repletion without adequate thiamine can precipitate acute thiamine deficiency. Other at-risk populations are women with prolonged hyperemesis gravidarum and anorexia, patients with an overall poor nutritional status on parenteral glucose, and patients on chronic diuretic therapy due to increased urinary thiamine losses. Maternal thiamine deficiency can lead to infantile beriberi in breast-fed children. Thiamine deficiency should also be considered in the setting of motor vehicle accidents associated with head injury. Thiamine deficiency in its early stage induces anorexia and nonspecific symptoms (e.g., irritability, decrease in short-term memory). Prolonged thiamine deficiency causes beriberi, which is classically categorized as wet or dry, although there is considerable overlap. In either form of beriberi, patients may complain of pain and paresthesia. Wet beriberi presents primarily with cardiovascular symptoms, due to impaired myocardial energy metabolism and dysautonomia, and can occur after 3 months of a thiamine-deficient diet. Patients present with an enlarged heart, tachycardia, high-output congestive heart failure, peripheral edema, and peripheral neuritis. Patients with dry beriberi present with a symmetric peripheral neuropathy of the motor and sensory systems with diminished reflexes. The neuropathy affects the legs most markedly, and patients have difficulty rising from a squatting position. Alcoholic patients with chronic thiamine deficiency may also have central nervous system (CNS) manifestations known as Wernicke's encephalopathy, consisting of horizontal nystagmus, ophthalmoplegia (due to weakness of one or more extraocular muscles), cerebellar ataxia, and mental impairment (Chap. 387). When there is an additional loss of memory and a confabulatory psychosis, the syndrome is known as Wernicke-Korsakoff syndrome. Despite the typical clinical picture and history, Wernicke-Korsakoff syndrome is underdiagnosed. The laboratory diagnosis of thiamine deficiency is usually made by a functional enzymatic assay of transketolase activity measured before and after the addition of thiamine pyrophosphate. A >25% stimulation by the addition of thiamine pyrophosphate (an activity coefficient of 1.25) is taken as abnormal. Thiamine or the phosphorylated esters of thiamine in serum or blood can also be measured by high-performance liquid chromatography (HPLC) to detect deficiency. Thiamine Deficiency: Treatment In acute thiamine deficiency with either cardiovascular or neurologic signs, 100 mg/d of thiamine should be given parenterally for 7 days, followed by 10 mg/d orally until there is complete recovery. Cardiovascular improvement occurs within 24 h, and ophthalmoplegic improvement occurs within 24 h. Other manifestations gradually clear, although psychosis in Wernicke-Korsakoff syndrome may be permanent or persist for several months. Toxicity Although anaphylaxis has been reported after high doses of thiamine, no adverse effects have been recorded from either food or supplements at high doses. Thiamine supplements may be bought over the counter in doses of up to 50 mg/d. Reff: Harrison's Internal Medicine > Chapter 71. Vitamin and Trace Mineral Deficiency and Excess