Case Reports
A Nervous Recipient of a “Tongue Lashing”
A veteran with a history of mental illness and drug and alcohol misuse developed a bleeding lesion on his tongue, which raised concerns of self-...
Reem Al Shabeeb is a Medical Student at the School of Medicine and Health Sciences at George Washington University. Caroline Trevisan is a Rheumatology Fellow and Amy Safadi is a Neurology Resident in the Departments of Internal Medicine and Neurology, both at MedStar Georgetown University Hospital, all in Washington, DC. Raj Singaraju is an Assistant Professor in the Department of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Correspondence: Raj Singaraju (raj.singaraju@usuhs.edu)
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Gastrointestinal beriberi has been reported in chronic cannabis users who present with nausea, vomiting, epigastric pain, leukocytosis, and lactic acidosis; all these symptoms rapidly improve after thiamine administration.5,6 The patient’s dietary change also eliminated her intake of vitamin B12, which compounded her condition. Thiamine deficiency produces lactic acidosis by disrupting pyruvate metabolism.7 Bradycardia also can be a sign of thiamine deficiency, although the patient’s use of clonidine for migraines is a confounder.8
Chronically ill patients are prone to nutritional deficiencies, including deficiencies of thiamine.7,9 Many patients with chronic illnesses also use cannabis to ameliorate physical and neuropsychiatric symptoms.2 Recent reports suggest cannabis users are prone to gastrointestinal beriberi and Wernicke encephalopathy.5,10 Treating gastrointestinal symptoms in these patients can be challenging to diagnose because gastrointestinal beriberi and CHS share many clinical manifestations.
The patient’s presentation is likely multifactorial resulting from the combination of gastrointestinal beriberi and CHS. However, thiamine deficiency seems to play the dominant role.
There is no standard treatment regimen for thiamine deficiency with neurologic deficits, and patients only retain about 10 to 15% of intramuscular (IM) injections of cyanocobalamin.11,12 The British Committee for Standards in Haematology recommends IM injections of 1,000 mcg of cyanocobalamin 3 times a week for 2 weeks and then reassess the need for continued treatment.13 The British Columbia guidelines also recommend IM injections of 1,000 mcg daily for 1 to 5 days before transitioning to oral repletion.14 European Neurology guidelines for the treatment of Wernicke encephalopathy recommend IV cyanocobalamin 200 mg 3 times daily.15 Low-level evidence with observational studies informs these decisions and is why there is variation.
The patient’s serum lactate and leukocytosis normalized 1 day after the administration of thiamine. Thiamine deficiency classically causes Wernicke encephalopathy and wet beriberi.16 The patient did not present with Wernicke encephalopathy’s triad: ophthalmoplegia, ataxia, or confusion. She also was euvolemic without signs or symptoms of wet beriberi.
Thiamine deficiency is principally a clinical diagnosis. Thiamine laboratory testing may not be readily available in all medical centers, and confirming a diagnosis of thiamine deficiency should not delay treatment when thiamine deficiency is suspected. This patient’s thiamine levels resulted a week after collection. The administration of thiamine before sampling also can alter the result as it did in this case. Additionally, laboratories may offer whole blood and serum testing. Whole blood testing is more accurate because most bioactive thiamine is found in red blood cells.17
A veteran with a history of mental illness and drug and alcohol misuse developed a bleeding lesion on his tongue, which raised concerns of self-...
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