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We report a patient with profound metabolic acidosis that resolved rapidly after thiamine infusion. Thiamine deficiency is common in malnourished patients and is afflicted with high morbidity and mortality if untreated. Intensivists should have an increased awareness of this condition and a low threshold to infuse thiamine in patients at risk, especially before intravenous nutrition with a high percentage of glucose is initiated.

Severe lactic acidosis reversed by thiamine within 24 hours