1981, British Journal of Radiology, 54, 1102-1104

Case reports
visceral herniation into the chest (Fataar and Schulman, 1979). The absence of any previous trauma
favoured congenital pleuroperitoneal fistulation as
the cause in our patient.
Unilateral and bilateral small holes have been
found in the diaphragm at autopsy and laparotomy
and may be solitary or multiple (Smith, 1943;
Nayak and Lawrence, 1976; Bradley and Fielding,
1972; Liebermann et ah, 1966). These congenital
fistulae are small which may account for them being
missed at autopsy in our patient when they were not
specifically sought. These defects also allow fluid
transit across the diaphragm and accounted for 5.5%
of Liebermann et al.'s cirrhotic patients with ascites
having hydrothoraces. Finn and Jowett (1970) recorded an acute hydrothorax repeatedly complicating every attempt at peritoneal dialysis in one
patient.
In our patient the spontaneous pneumothorax was
probably due to the subpleural blebs, the commonest
cause of spontaneous pneumothorax which recurs
ipsilaterally in 30% (Felson and Wiot, 1973; Greene
et al., 1977). It is unlikely that the pneumoperitoneum preceded the pneumothorax, as the symptoms
were thoracic only with a clinically normal abdomen
and normal abdominal viscera found at autopsy,
when the blebs seen in the partially collapsed lung on
the chest radiographs were confirmed.
ACKNOWLEDGMENTS

We thank Miss B. Neumann for secretarial assistance and

Mrs. J. Tuft for the photography.
REFERENCES
BRADLEY, J. W. P. and FIELDING, L. P., 1972. Hydro-

pneumothorax complicating perforated peptic ulcer.

British Journal of Radiology, 59, 72-73.

HENDREN, W. H., 1972. Pneumoperitoneum secondary to

pulmonary air leak. Journal of Pediatrics, 81, 797-800.

FATAAR, S. and SCHULMAN, A., 1979. Diagnosis of dia-

phragmatic tears. British Journal of Radiology, 52, 375381.

FELSON, B. and WIOT, J. F., 1973. Another look at pneumo-

peritoneum. Seminars in Roentgenology, 8, 437-443.

FINN, R. and JOWETT, E. W., 1970. Acute hydrothorax

complicating peritoneal dialysis. British Medical Journal,

ii, 94.
GANTT, C. B., DANIEL, W. D. and HALLENBECK, G. A., 1977.

Nonsurgical pneumoperitoneum. American Journal of

Surgery, 134,\\\-A\\.

GLANZ, S., RAVIN, C. E. and DEREN, M. M., 1978. Benign

pneumoperitoneum following median sternotomy incision

American Journal of Roentgenology, 131, 267269.
GLAUSER, F. L. and BARTLETT, R. H., 1974. Pneumoperit-

oneum in association with pneumothorax. Chest, 66, 536

540.
GREENE, R., MCLOND, T. C. and STARK, P., 1977. Pneumo-

thorax. Seminars in Roentgenology, 12, 313-325.

KRAUSZ, M. and MANNY, J., 1977. Pneumoperitoneum

associated with pneumothorax: a surgical dilemma in the

post-traumatic patient. Journal of Trauma, 17, 238-240.
LIEBERMANN, F. L., HIDEMURA, R., PETERS, R. L. and
REYNOLDS, T. B., 1966. Pathogenesis and treatment of

hydrothorax complicating cirrhosis with ascites. Annals of

Internal Medicine, 64, 341-351.
MACKLIN, M. T. and MACKLIN, C. C , 1944. Malignant

interstitial emphysema of the lungs and mediastinum as

an important occult complication in many respiratory
diseases and other conditions: an interpretation of the
clinical literature in the light of laboratory experiment.
Medicine, 23, 281-358.
NAYAK, I. N. and LAWRENCE, D., 1976. Tension pneumo-

thorax from a perforated gastric ulcer. British Journal of

Surgery, 63, 245-247.
SCHULMAN, A., FATAAR, S., VAN DER SPUY, J. W., MORTON,

P. C. G. and CROZIER, J., 1981. Air in funny places: some

causes and ramifications of pneumomediastinum (submitted to Clinical Radiology).
SELTZER, R. A., 1976. Pneumothorax complicating pelvic
pneumography. British Journal of Radiology, 49, 892.
SMITH, C. N., 1943. Induced pneumoperitoneum: a fatal
case. British Medical Journal', ii, 404.
WOLLOCK, Y., DINTSMAN, M. and WEISS, A., 1972. Pneuma-

tosis cystoides intestinalis of adulthood. Archives of

Surgery, 105, 723-726.

DONAHOE, P. K., STEWART, D. R., OSMOND, J. D. and

latrogenic (self-induced) wet beri-beri

By R. W. Saleh, D.M., D.M.R.E., M.D.
Itobba Hospital, Cairo, Egypt
N. G. Ghaly, M.B., B.Ch., D.M. and M. H. Aziz, M.B., B.Ch.
The American Hospital, Tanta, Egypt
{Received May 1981)

Beri-beri used to be a common disease in tropical

and sub-tropical areas as well as in the crews of ships
on the high seas (Wilcocks and Manson-Bahr, 1972).
Nowadays, however, it is uncommon and the wet
type even rare. In western countries the dry type is
Reprint requests: Dr. M. H. Aziz, Department of Radiology, The American Hospital, Tanta, Egypt.

rarely encountered and is invariably associated with

chronic alcoholism. It is thus identified as a conditioned deficiency disease (Scott, 1978). Generally,
however, beri-beri in both childhood and adulthood
is present in association with protein-calorie malnutrition (Moran and Greene, 1979).
Beri-beri is caused by deficiency of vitamin Bi

1102

DECEMBER

1981

Case reports
(aneurin or thiamine). The pyrophosphate ester of
thiamine is a co-carboxylase which catalyses the decarboxylation and oxidation of pyruvic acid in
living matter, and is thus involved in the metabolism

of carbohydrates in the Krebs citric acid cycle

(Wilcocks and Manson-Bahr, 1972). In deficiency of
vitamin Bi, the tissues which use glucose in large
amounts as a primary source of energy are most
markedly affected. Thus the nervous tissues and
heart bear the main brunt of the disease. In nervous
tissues, degenerative changes ranging from slight
medullary changes to complete destruction of the
nerve may occur. In heart muscle, water retention
leads to loss of contractility which is reflected
clinically as high output cardiac failure (Scott, 1978;
Wilcocks and Manson-Bahr, 1972). The right side of
the heart is more affected than the left. Oliguria of
high specific gravity with no albumin, and generalized oedema are common features. Pleural effusions,
unilateral or bilateral are also common.
CASE REPORT

A 16-year-old male presented with loss of 30 kg bodyweight within one year, oedema most marked in the lower
limbs, dyspnoea on exertion, orthopnoea and skin pigmentation. One year before he presented to us, he suffered an
attack of diarrhoea and vomiting which was diagnosed as

I
FIG. 1.
Bilateral pleural effusions.

FIG. 2.
Pleural effusions resolved. Enlarged heart and pulmonary
oedema are still seen.

FIG. 3.
Normal chest and heart. Two weeks after starting treatment
with vitamin Bi.

1103

1981, British Journal of Radiology, 54, 1104-1107

Case reports
enterocolitis, and was treated with intestinal antibacterial
and antiamoebic drugs and controlled diet. Relapse of
diarrhoea occurred, which the patient treated himself by
abandoning the prescribed balanced diet and continuing to
eat white bread, boiled polished rice and boiled vegetables
only. Six months later he began to notice oedema of his legs
and dyspnoea on exertion, as well as brownish discoloration
of the skin.
On presentation, his pulse rate was 130/min and BP was
110/90. Pellagric rash, pitting oedema, marked pallor and
emaciation were present. There were bilateral pleural
effusions, ascites, enlarged soft spleen and liver and congested, pulsating neck veins. Oliguria without albumin or
casts was noted and there was marked anaemia (9g 46%)
hypoproteinaemia (3 g% total proteins). The ESR and
stools were normal. Chest radiography confirmed the
presence of bilateral pleural effusions (Fig. 1), and a barium
follow-through examination showed normal findings. He
was treated by high protein diet, oral iron, folic acid,
nicotinic acid, vitamin B complex and vitamin C, as well as
four transfusions of packed red cells and diuretics.
Three weeks later, anaemia and hypoproteinaemia were
improved and the oedema had disappeared but the patient
was still dyspnoeic and orthopnoeic. A chest radiograph
showed absorption of the pleural effusions, but a markedly
enlarged heart and interstitial pulmonary oedema were seen
(Fig. 2). Thus the possibility of beri-beri of the wet type
was suggested. Diuretics were then stopped and vitamin Bi
100 mg tds started and vitamin B complex and vitamin C
and iron were continued. Marked clinical improvement was
noticed within one week. A chest X-ray two weeks after
initiation of vitamin Bi treatment was normal (Fig. 3). Three
days later the patient was discharged from hospital.

DISCUSSION

The full picture of wet beri-beri is seen in this

case. It is believed to be self-induced, resulting from
prolonged abstention from proteins, fresh vegetables
and fruits. The association of thiamine deficiency
with low protein-calorie diet is known (Moran and
Greene, 1979), as well as the association of poor
intestinal absorption of thiamine with folate depletion (Thompson and Leevy, 1971).
The marked rapid improvement resulting from
the use of vitamin Bi treatment alone confirmed the
aetiology of the condition.
REFERENCES
MORAN, J. R. and GREENE, H. L., 1979. The B vitamins and

vitamin C in human nutrition. I. General considerations

and obligatory B vitamins. II. Conditional B vitamins
and vitamin C. American Journal of Diseases of Children,
133, 192-199, 308-314.
SCOTT, SIR RONALD BODLEY, 1978. Beri-beri heart disease.

In Heart diseases in various systematic diseases: Price's

Text Book of The Practice of Medicine. 13th edit. (Oxford
University Press, London), p. 779.
THOMPSON, A. D. and LEEVY, C. M., 1972. Observations on

the mechanism of thiamine hydrochloride absorption in

man. Clinical Science, 43, 1 53-163.
WILCOCKS, C. and MANSON-BAHR, P. E. C , 1972. Vitamin

deficiencies: beri-beri. In Manson's Tropical Diseases.

17th edit. (Bailliere Tindall, London), pp. 763-770.

Technetium 99m-diethyl-IDA hepatobiliary scintigraphy in the

pre-operative diagnosis of choledochal cyst
By M. Paramsothy, M.B., B.S., M.R.C.P. (UK) and
K. Somasundram, M.B., B.S., F.R.C.S. (Edin. & Eng.), F.R.A.C.S.
Departments of Radiology and Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
(Received April 1981)

Choledochal cyst, first described by Vater (1728),

is a localized cystic dilation of the common bile duct
and may extend upwards to involve the hepatic ducts.
The disease is relatively rare and affects orientals
more frequently than any other race (Han et al.,
1969). Early diagnosis and treatment can prevent the
complications of ascending cholangitis, calculus formation, spontaneous or traumatic rupture, biliary
cirrhosis, portal hypertension, varices, carcinoma of
the cyst wall and death (Barlow et al., 1976). The
clinical triad of abdominal pain, jaundice and
abdominal mass is present in only about 20% of the
cases and unless the index of suspicion is high the
diagnosis will be missed (Alonso-Lej et al., 1959).
Request for reprints: Dr. M. Paramsothy, Department of
Radiology, University of Malaya, Kuala Lumpur, Malaysia.

Intravenous cholangiogram may be diagnostic in the

absence of jaundice (Alonso-Lej et al., 1959), and
ultrasonogram could be helpful in demonstrating
the presence of a cyst, although it is not always
diagnostic (Barlow et al., 1976). After Williams et al.
(1970) first reported a choledochal cyst diagnosed by
hepatoscintigraphy, iodine 131 Rose Bengal liver scan
appeared to be the only consistent investigation of
diagnostic value (Barlow et al., 1976). The physical
characteristics of 131 I are not optimal for imaging
and its relatively long half-life and its fi emissions
result in a relatively high radiation dose to the bowel
mucosa which finally prevented its widespread use.
Iodine 123 overcomes this limitation but is expensive
and, because of its physical half-life of 13 hours, not
practical for unscheduled emergency examinations.
Technetium 99m, because of its excellent physical

1104