Case presentation
Here we report a case of a 20 year-old African American male who
presented with severe depression and lower extremity edema.
Patient suffered from depression after traumatic event. He lost 25
pounds in the month prior to presentation. Patient on examination looked
emaciated and had feeble voice. He had BMI 16kg/m2.
Regular pulse at 140BPM. Blood pressure 120/91mmHg. Patient afebrile and
saturating on room air. He had bilateral calf tenderness. Neurological
exam significant for lower extremities hypersensitivity to light touch.
EKG showed sinus tachycardia. His workup is shown in Table 1and remarkable for Total CK level of 8000 U/L. Hepatitis serology
negative. CT angiogram chest/abdomen/pelvis was significant for
extensive pneumomediastinum with small pleural effusions. Patient was
admitted for further evaluation and was started on fluids for
Rhabdomyolysis. Spontaneous pneumomediastinum was asymptomatic and
likely related to asthma. On day 2, total CK level went up to 41,000U/L
and started to become hypoxic. X-ray showed worsening pleural effusion.
Echocardiogram showed generalized hypokinesis and ejection fraction of
15-20%. AST and ALT elevation felt to be secondary to rhabdomyolysis.
His total CK remained relatively unchanged. B12 and folic acid level
were normal. B1 level was checked and was undetectable. On Day 5,
patient was seen by new attending who suspected Beriberi and patient was
started on Thiamin (500mg IV three times/day). CK level fell from
30,000U/L to 6,000U/L. patient tachycardia resolved. He started to feel
better with more energy on day 7, however, he remained depressed. On day
8, repeat echocardiogram showed significant improvement of ejection
fraction to 45-50%. Patient edema resolved and he was discharged home
on day 9 in stable condition.