Case Report: Severe Edema and Marked Weight Gain Induced by Marginal Thiamine Deficiency in a Patient With Alcohol Dependency and Type 2 Diabetes Mellitus

Abstract

Background: Patients with alcohol use disorder (AUD) may develop peripheral edema due to alcohol-related liver, renal, or heart disease. Thiamine deficiency is reported to occur in AUD and type 2 diabetes mellitus (T2DM). Thiamine deficiency may also cause peripheral edema. Thiamine is essential for optimal glucose metabolism through its role as an essential co-factor for key enzymes in intermediary metabolism. Since glucose metabolism worsens under diabetic conditions, it seems that a relative shortage of thiamine may occur more easily in patients with diabetes mellitus. Case Presentation: A 59-year-old Japanese man was admitted to the hospital with severe peripheral edema. His background history included alcohol liver disease (ALD), chronic renal failure (CRF), and T2DM. His body mass index (BMI) at admission was 37.7 kg/m² and this represented a 30 kg increase in body weight over 2 months. Laboratory investigations showed anemia, liver and renal injury, hyperglycemia, and marginal hypothyroidism. The plasma thiamine diphosphate concentration was 20 ng/mL (reference range: 24-66 ng/mL). Diet therapy of 1,600 kcal/day and intravenous fursultiamine hydrochloride therapy (50 mg/once a day, seven days) was commenced in combination with intravenous diuretics. After one week, the plasma thiamine concentration was 853 ng/mL, and the patient's body weight had reduced by 18 kg. Conclusions: Patients with T2DM and AUD may develop severe peripheral edema in the context of marginal thiamine deficiency. Fursultiamine hydrochloride (50 mg/once a day, seven days) restored normal plasma thiamine concentrations and may have contributed to the rapid resolution of severe peripheral edema in this case. Empirical treatment with thiamine should be considered in patients with severe peripheral edema in the context of AUD and T2DM.

Keywords: alcohol dependency; thiamine deficiency; type 2 diabetes mellitus; weight gain; whole body edema.

Figure 1

Total body CT: Chest CT showed a marginal pleural effusion and cardiomegaly. Abdominal CT revealed early liver cirrhosis together with fatty change, surface nodularity, and a small amount of ascites. Limb CT revealed severe subcutaneous edema mainly in the lower limb.

Figure 2

Magnetic resonance imaging (MRI) and ultrasonography showed lower limb edema.

Figure 3

Time course of clinical parameters in this patient. We continued 20 mg/day of furosemide and 25 g/day of spironolactone treatment for edema. He was treated with diet therapy of 1,600 kcal/day and a restriction of 6 g of salt after admission. In addition, we started 50 mg/day of fursultiamine hydrochloride. Plasma vitamin B1 concentration was increased from 20 to 853 ng/mL. His body weight was decreased by 18 kg only after two weeks and it was 83.2 kg at discharge. BW, body weight; BUN, blood urea nitrogen; AST, aspartate aminotransferase; ALT, alanine aminotransferase.