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.