Case Report
Metabolic Acidosis and Thiamine Deficiency

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We describe a 19-year-old patient who was receiving home parenteral nutrition in whom lactic acidosis developed. A review of her home parenteral nutrition formula revealed the absence of multivitamins, most significantly thiamine. After thiamine administration, the acidosis resolved, and the patient experienced pronounced clinical improvement. Clinicians must be aware that thiamine is essential for normal glucose metabolism and that thiamine deficiency can lead to lactic acidosis. Thiamine deficiency should be included in the differential diagnosis of lactic acidosis. The recent shortage of intravenous multivitamin preparations has led to documented cases of lactic acidosis as a result of thiamine deficiency, and a previous shortage led to several deaths due to lactic acidosis as a consequence of thiamine deficiency. All patients receiving parenteral nutrition must also receive adequate vitamin supplementation.

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REPORT OF CASE

A 19-year-old woman sought medical advice from her local physician because of a 3-year history of episodic nausea, vomiting, diarrhea, and abdominal pain. Initially, the symptoms had occurred only with her menses and lasted 3 to 5 days. Subsequently, however, the frequency and severity of her symptoms increased to the point that they were almost continuous, and multiple hospitalizations were necessary. Cholecystectomy was performed after a hepatic iminodiacetic acid scan revealed delayed

DISCUSSION

Lactic acidosis is one of the most common causes of an anion gap metabolic acidosis in critically ill patients. It is defined as an acid-base disorder, resulting from the accumulation of lactic acid in body fluids. The diagnosis is made by measurement of the serum or plasma lactate concentration in a patient with an increased anion gap. A plasma lactate concentration of 5 mmol/L or greater is diagnostic. The lactate concentration directly correlates with the severity of illness and the

SUMMARY

Thiamine deficiency can cause significant morbidity and even mortality. Administration of thiamine has an extremely low risk of adverse effects. Health-care providers must have a high index of suspicion and err on the side of thiamine supplementation in order to prevent the complications of deficiency. This case report illustrates three important points: (1) thiamine deficiency should be included in the differential diagnosis of lactic acidosis, (2) patients receiving parenteral nutrition must

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