Wide pulse pressure and Quincke’s pulse in high-output heart failure

A 74-year-old man with a history of chronic alcohol use presented with progressive exertional dyspnoea and weight gain. On physical examination, he was noted to have wide pulse pressure, elevated jugular venous pressure, and alternating flushing and blanching of the nail beds in concert with the cardiac cycle, known as Quincke’s pulse. Transthoracic echocardiography demonstrated normal biventricular systolic function and valvular function, but noted a dilated inferior vena cava. Right heart catheterisation revealed elevated filling pressures, high cardiac output and low systemic vascular resistance, consistent with high-output heart failure. Whole blood concentration of thiamine was low, confirming the diagnosis of wet beriberi. The patient abstained from alcohol use and was started on thiamine replacement therapy, resulting in narrowing of the pulse pressure over time and complete resolution of symptoms without the need for diuretic therapy.