ビタミンB1(チアミン)欠乏症
ビタミンB1欠乏症の原因
ビタミンB1欠乏症はアルコール依存症・偏食・妊娠悪阻・重労働＋糖質過剰摂取などが原因となって生じることが多い。
アルコール依存症
通常、アルコールは肝臓でアルコール脱水素酵素によってアセトアルデヒドに代謝される。
しかし、大量に飲酒してアルコールを摂取したときにはアルコール脱水素酵素だけでは処理できず、ミクロソーム・エタノール酸化系という別の経路で代謝されてこの際にビタミンB1が消費されてしまう。
つまり、大量に飲酒してアルコールを摂取するとビタミンB1が消費されてしまうということである。
また、一般的にアルコールはビタミン類の吸収を妨げる。
これらの理由に加えて、アルコール依存症の患者は偏食によりそもそもビタミンB1摂取不足なことが多く、非常にビタミンB1欠乏症になりやすい。
偏食
昔の話だと、江戸時代に玄米にかえて精白米を食べるようになってから、米を主食として副食をほとんど摂らないという古来の日本人の食生活が影響して、ビタミンB1欠乏による脚気が多発したといわれている。
精白米とは玄米からビタミンB1が豊富に含まれているヌカを取り除いたものである。
また、明治期に陸軍軍医であった森鴎外が脚気細菌原因説を唱えたのに対して、海軍軍医であった高木兼寛は白米中心の食事が原因であると唱えた。このため、日露戦争において陸軍では脚気による死者が多発したが、海軍ではほとんど脚気による死者が出なかったのは有名な話である。
現代では、スナック菓子やインスタント食品を偏食している人がビタミンB1欠乏症を発症することが多い。
妊娠悪阻
妊娠悪阻とは吐き気・嘔吐・食欲不振といったつわり症状が悪化した結果として食事摂取が困難となり、妊婦が栄養障害や代謝障害をきたして加療を必要とする状態を指す。
食事が摂取できないためにビタミンB1が欠乏することが多い。
妊娠悪阻の輸液ではビタミンB1も一緒に加えて投与することが重要である。
ブドウ糖輸液を単独で行うと糖代謝が回転してさらにビタミンB1が消費されて、ビタミンB1欠乏症が悪化してしまうため禁忌となっている。
重労働＋糖質過剰摂取
重労働をしたり糖質過剰摂取をすると糖代謝が回転する。
このときにビタミンB1が消費されるため、ビタミンB1の需要が増加してビタミンB1欠乏症となることがある。
真夏に工事現場で働いている人などがこのような原因でビタミンB1欠乏症を発症することがある。
ビタミンB1欠乏症の病態
ビタミンB1の生化学
ビタミンB1(別名:チアミン)はピルビン酸デヒドロゲナーゼの補酵素であり、ピルビン酸デヒドロゲナーゼの活性を制御しているためピルビン酸をアセチルCoAに変換させる際に必須因子となる。
ピルビン酸デヒドロゲナーゼとはピルビン酸をアセチルCoAに変換させることによって解糖系とクエン酸回路をつなげている酵素である。
ビタミンB1が不足すると
乳酸アシドーシス
ビタミンB1が欠乏するとピルビン酸はアセチルCoAに変換されなくなり代わりに乳酸に変換されるため、ビタミンB1欠乏症では乳酸アシドーシスが引き起こされることがある。
神経障害
ビタミンB1が欠乏するとエネルギー産生過程が解糖系で止まるため、細胞においてエネルギーが不足するようになる。
エネルギーが不足することで主に神経細胞が障害される。
中枢神経障害(Wernicke脳症・Korsakoff症候群)
中枢神経障害によって、急性期にはWernicke脳症を発症して慢性期にはKorsakoff症候群を発症する。
末梢神経障害(脚気)
末梢神経障害として、全身の多くの末梢神経が同時に障害されて機能不全を起こす多発神経炎が引き起こされる。
感覚神経障害によって、手袋靴下型の表在覚と振動覚が低下する感覚障害が起こる。
下位運動ニューロン障害によって、腱反射が減弱~消失する。
自律神経障害(血管運動神経障害)によって、血管の調節が上手く働かず末梢血管が拡張してしまう。
末梢血管が拡張すると血管内皮細胞と血管内皮細胞の間隙が広がるため、血管透過性が亢進して浮腫が引き起こされる。
また、末梢血管が拡張すると血管抵抗が低下するため高拍出性心不全が引き起こされる。
心臓が組織の隅々まで血液を送り出そうとしているときに血管が拡張して血管抵抗が低下していると、心臓は通常時よりも多くの力で頑張ってしまいやがて疲弊してしまう。
これが拍出量が増えながらも心不全となってしまう高拍出性心不全の機序である。
心臓が拍出量を維持できずに心不全となる低拍出性心不全の方は一般的な心不全であるが、これとは機序が異なることに注意する。
ビタミンB1欠乏によって、多発神経炎と浮腫と高拍出性心不全を呈しているものが脚気である。
参考文献
アルコールとの上手な付き合い方ービタミン摂取の重要性ー:https://alinamin-kenko.jp/yakuhou/backnumber/pdf/vol473_01.pdf
ビタミンB1利用障害による衝心脚気が原因と考えられた著明な全身浮腫に意識障害を併発した症例:https://www.jstage.jst.go.jp/article/shinzo/47/10/47_1213/_pdf/-char/ja
脚気心ーすばやい対応で救命、完治へー:https://www.jstage.jst.go.jp/article/jsicm1994/12/2/12_2_92/_pdf/-char/ja
Wenicke-Korsakoff症候群
アルコール依存症などによるビタミンB1欠乏によって起こる急性期の病態がWernicke脳症である。これに続いてビタミンB1の補充が遅れて不可逆的な神経障害が生じると、後遺症として慢性期の病態であるKorsakoff症候群が起こる。この一連の流れをWernicke-Korsakoff症候群と呼ぶ。
Wernicke脳症
Wernicke脳症の3徴
Wernicke脳症の3徴は以下のように覚えられることが多い。
×Walk→運動失調
小脳機能不全による小脳失調性の運動失調と末梢神経障害による感覚性の運動失調が混ざった状態となる。
歩行がふらついて不安定となる失調性歩行を認める。
×eye→眼球運動障害(眼筋麻痺)
複視や眼振が起きたり、眼の動きに制限が出る眼球運動障害を認める。
脳幹の様々な神経核(動眼神経核や外転神経核など)が障害されることが多い。
×recognize→意識障害
全般的な錯乱状態を認める。著明な見当識障害を呈したり、反応がなく激しい物理的な刺激によってのみ覚醒させることができる昏迷状態となることもある。
見当識障害は広義では意識障害に含まれるものの、Korsakoff症候群でみられる「見当識障害」はWernicke脳症でみられる「意識障害」とは症状の程度の差から区別される。
Wernicke脳症の検査所見
Wernicke脳症では頭部MRIのFLAIR像で脳室周囲に高信号を認める。
これは、脳室周囲では特に代謝が活発であるために障害されやすいからである。
第三脳室周囲の高信号は視床の機能障害を示唆して意識障害につながる。
中脳水道周囲の高信号は脳幹(中脳や橋)の機能障害を示唆して眼球運動障害につながる。
第四脳室周囲の高信号は小脳虫部の機能障害を示唆して小脳性運動失調につながる。
Korsakoff症候群
Wernicke脳症の後遺症としてアルコール依存症を基礎にして発症するのが典型である。臨床的評価によって診断する。
Korsakoff症候群の4徴
Korsakoff症候群は側頭葉内側部に位置して記憶を司る海馬が損傷することで、記憶に関する能力が失われることによって発症する。
記銘力障害
新しく体験する出来事を覚えることが出来なくなる記銘力障害を呈する。
健忘
過去の出来事を思い出せない健忘を呈する。
見当識障害
時間と場所が分からなくなる見当識障害を呈する。
作話
患者は記銘力障害・健忘・見当識障害によって記憶が断片化してしまう。
このため、患者は無意識のうちに断片化した記憶を補完して新たな記憶を作り上げて作話してしまう。
作話をしている患者自身は自分が嘘をついていると意識していない。
作話の検査では患者が「分からないとか覚えていない」と答えるはずの質問を投げかけて、そうではないときに作話と判断する。
例えば、「10年前の今日、2012年10月11日(記事執筆時:2022年10月11日)は一体何をしていましたか?」という問いをする。正常な人であれば、その日がその人にとって何らかしらの特別な日ではない限り、「分かりません」や「覚えていません」と答えるはずである。
しかし、作話をしてしまう患者は何か話を作って「富士山に登っていました」とかいうように話してしまう。これは事実ではない出来事をあたかも現実の出来事であるかのように思い出してしまうために起こるのである。
参考文献
Wernicke-Korsakoff症候群をめぐって:https://journal.jspn.or.jp/jspn/openpdf/1090060509.pdf
Ⅷ.内分泌,代謝疾患と脳神経疾患:https://www.jstage.jst.go.jp/article/naika/101/8/101_2226/_pdf
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{Tôi cực kỳ hài lòng để tìm thấy trang web này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn đánh giá cao từng một phần nó và tôi đã đã lưu vào mục ưa thích để xem những thứ mới trong trang web của bạn.|Tôi có thể chỉ nói rằng thật nhẹ nhõm để khám phá một người mà thực sự biết họ là gì đang nói về trên internet. Bạn chắc chắn nhận ra cách đưa một rắc rối ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa phải kiểm tra điều này và hiểu khía cạnh này câu chuyện của bạn. Tôi đã ngạc nhiên rằng bạn không nổi tiếng hơn cho rằng bạn chắc chắn có món quà.|Tốt bài đăng. Tôi chắc chắn đánh giá cao trang web này. Tiếp tục với nó!|Thật khó tìm những người có học thức về điều này, tuy nhiên, bạn có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên tham gia một cuộc thi dành cho một trang web trên internet tuyệt vời nhất. Tôi sẽ Rất khuyến nghị trang web này!|Một động lực đáng giá bình luận. Không còn nghi ngờ gì nữa rằng bạn cần viết thêm về vấn đề này, nó có thể không là một điều cấm kỵ vấn đề nhưng nói chung mọi người không nói về vấn đề như vậy. Đến phần tiếp theo! Trân trọng!|Xin chào! Tôi chỉ muốn cho bạn một rất to cho thông tin tuyệt vời bạn có ngay tại đây trên bài đăng này. Tôi sẽ là trở lại trang web của bạn để biết thêm thông tin sớm nhất.|Khi tôi ban đầu để lại bình luận tôi có vẻ như đã nhấp hộp kiểm -Thông báo cho tôi khi có bình luận mới- và từ bây giờ mỗi lần được thêm vào tôi nhận được 4 email có cùng nội dung. Có lẽ có một phương pháp dễ dàng bạn có thể xóa tôi khỏi dịch vụ đó không? Cảm ơn rất nhiều.|Lần sau Tôi đọc một blog, Hy vọng rằng nó sẽ không làm tôi thất vọng nhiều như bài này. Rốt cuộc, Tôi biết điều đó là sự lựa chọn của tôi để đọc, nhưng tôi thực sự nghĩ có lẽ có điều gì đó hữu ích để nói về. Tất cả những gì tôi nghe được là một loạt khóc lóc về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi hoàn toàn tin trang web tuyệt vời này cần nhiều hơn nữa sự chú ý.
{Tôi đã rất vui để tìm thấy trang web này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn thích từng một chút nó và tôi cũng đã đã lưu vào mục ưa thích để xem điều mới trên blog của bạn.|Tôi có thể chỉ nói rằng thật thoải mái để khám phá một người mà thực sự biết họ là gì thảo luận trực tuyến. Bạn chắc chắn nhận ra cách đưa một rắc rối ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa thực sự cần kiểm tra điều này và hiểu khía cạnh này của. Tôi đã ngạc nhiên rằng bạn không nổi tiếng hơn vì bạn chắc chắn nhất sở hữu món quà.|Xuất sắc bài đăng. Tôi hoàn toàn yêu thích trang web này. Tiếp tục viết!|Thật khó đến những người có kinh nghiệm trong chủ đề cụ thể này, nhưng bạn có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn cần là một phần của một cuộc thi dành cho một trang web trên internet có chất lượng cao nhất. Tôi sẽ Rất khuyến nghị trang web này!|Một hấp dẫn chắc chắn đáng giá bình luận. Tôi nghĩ rằng bạn nên xuất bản thêm về chủ đề này, nó có thể không là một điều cấm kỵ chủ đề nhưng nói chung mọi người không nói về những chủ đề như vậy. Đến phần tiếp theo! Trân trọng!|Xin chào! Tôi chỉ muốn cho bạn một rất to cho thông tin xuất sắc bạn có ở đây trên bài đăng này. Tôi đang quay lại trang web của bạn để biết thêm thông tin sớm nhất.|Khi tôi ban đầu để lại bình luận tôi có vẻ như đã nhấp vào hộp kiểm -Thông báo cho tôi khi có bình luận mới- và từ bây giờ mỗi lần được thêm vào tôi nhận được 4 email cùng chính xác một bình luận. Có một phương pháp dễ dàng bạn có thể xóa tôi khỏi dịch vụ đó không? Cảm kích.|Lần sau Tôi đọc một blog, Tôi hy vọng rằng nó sẽ không làm tôi thất vọng nhiều như bài này. Rốt cuộc, Vâng, đó là sự lựa chọn của tôi để đọc hết, tuy nhiên tôi thực sự tin bạn sẽ có điều gì đó hữu ích để nói. Tất cả những gì tôi nghe được là một loạt khóc lóc về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi hoàn toàn nghĩ trang web tuyệt vời này cần nhiều hơn nữa sự chú ý.
{Tôi rất vui khám phá trang này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn yêu thích từng một phần nó và tôi cũng đã đã lưu vào mục ưa thích để xem thông tin mới trong trang web của bạn.|Tôi có thể chỉ nói rằng thật nhẹ nhõm để khám phá một người mà thực sự biết họ là gì thảo luận trực tuyến. Bạn chắc chắn nhận ra cách đưa một rắc rối ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn cần phải đọc điều này và hiểu khía cạnh này của. Tôi đã ngạc nhiên bạn không nổi tiếng hơn vì bạn chắc chắn sở hữu món quà.|Rất tốt bài viết. Tôi chắc chắn yêu thích trang web này. Tiếp tục làm tốt!|Thật khó đến những người hiểu biết về điều này, tuy nhiên, bạn nghe có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên là một phần của một cuộc thi dành cho một blog trên mạng hữu ích nhất. Tôi sẽ khuyến nghị trang web này!|Một hấp dẫn chắc chắn đáng giá bình luận. Không còn nghi ngờ gì nữa rằng bạn nên xuất bản thêm về chủ đề này, nó có thể không là một điều cấm kỵ vấn đề nhưng điển hình mọi người không nói về những chủ đề như vậy. Đến phần tiếp theo! Cảm ơn rất nhiều!|Chào buổi sáng! Tôi chỉ muốn đề nghị rất cho thông tin tuyệt vời bạn có ngay tại đây trên bài đăng này. Tôi sẽ là trở lại trang web của bạn để biết thêm thông tin sớm nhất.|Khi tôi ban đầu để lại bình luận tôi có vẻ như đã nhấp hộp kiểm -Thông báo cho tôi khi có bình luận mới- và bây giờ mỗi lần được thêm vào tôi nhận được bốn email cùng chính xác một bình luận. Có một cách bạn có thể xóa tôi khỏi dịch vụ đó không? Chúc mừng.|Lần sau nữa Tôi đọc một blog, Tôi hy vọng rằng nó không thất bại nhiều như bài này. Ý tôi là, Tôi biết điều đó là sự lựa chọn của tôi để đọc hết, dù sao thì tôi thực sự nghĩ bạn sẽ có điều gì đó hữu ích để nói. Tất cả những gì tôi nghe được là một loạt phàn nàn về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi thành thật nghĩ trang web tuyệt vời này cần nhiều hơn nữa sự chú ý.
{Tôi hạnh phúc hơn cả vui để tìm thấy trang web này. Tôi cần cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn yêu thích từng của nó và tôi đã đã lưu vào mục ưa thích để xem điều mới trong trang web của bạn.|Tôi có thể chỉ nói rằng thật thoải mái để tìm thấy một người mà thực sự hiểu họ là gì thảo luận trên internet. Bạn thực sự nhận ra cách đưa một vấn đề ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa cần phải kiểm tra điều này và hiểu khía cạnh này câu chuyện của bạn. Tôi đã ngạc nhiên rằng bạn không nổi tiếng hơn vì bạn chắc chắn có món quà.|Xuất sắc bài viết trên blog. Tôi chắc chắn đánh giá cao trang web này. Tiếp tục với nó!|Thật khó tìm những người có học thức cho điều này, tuy nhiên, bạn có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên là một phần của một cuộc thi dành cho một blog trên mạng có chất lượng cao nhất. Tôi sẽ Rất khuyến nghị trang web này!|Một hấp dẫn đáng giá bình luận. Tôi nghĩ rằng bạn nên viết thêm về chủ đề này, nó có thể không là một điều cấm kỵ chủ đề nhưng điển hình mọi người không nói về chủ đề những điều này. Đến phần tiếp theo! Trân trọng!|Chào buổi sáng! Tôi chỉ muốn đề nghị rất to cho thông tin xuất sắc bạn có ở đây trên bài đăng này. Tôi đang trở lại blog của bạn để biết thêm thông tin sớm nhất.|Sau khi tôi ban đầu để lại bình luận tôi có vẻ như đã nhấp vào hộp kiểm -Thông báo cho tôi khi có bình luận mới- và từ bây giờ mỗi lần được thêm vào tôi nhận được bốn email cùng chính xác một bình luận. Có lẽ có một phương pháp dễ dàng bạn có thể xóa tôi khỏi dịch vụ đó không? Cảm ơn rất nhiều.|Lần sau Tôi đọc một blog, Hy vọng rằng nó không thất bại nhiều như bài này. Rốt cuộc, Tôi biết điều đó là sự lựa chọn của tôi để đọc, nhưng tôi thực sự nghĩ bạn sẽ có điều gì đó hữu ích để nói về. Tất cả những gì tôi nghe được là một loạt rên rỉ về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi thực sự tin trang web này cần nhiều hơn nữa sự chú ý.
May I simply say what a relief to discover someone that actually knows what they’re talking about on the web. You actually realize how to bring an issue to light and make it important. A lot more people have to look at this and understand this side of the story. I was surprised that you are not more popular given that you most certainly have the gift.
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