Keshan’s disease

What is Keshan’s disease

Keshan’s disease is a condition which occurs when there is a deficiency of selenium intake. It is named for the region in China where it was first discovered in the children and young women of the area, where the soil is deficient in selenium (normal soil contains adequate amounts of selenium so normally prevents this condition from occurring).

Keshan’s disease causes an abnormality of the heart muscles that causes it to function abnormally. Many children and young women in China (not just in the Keshan region) died because of the lack of selenium causing this condition.

Normally selenium intake protects against developing Keshan’s disease, but it cannot reverse damage to the heart muscle once it occurs., although some studies do show that once selenium supplementation occurs, the damage can be reversed in some people, depending on how far the condition has progressed and how damaged the heart muscle has become.

Facts about Keshan’s disease

• Ensure to get enough selenium in your diet to prevent deficiency
• A regular blood test can determine if deficiency of any nutrient, especially if there are any symptoms associated with deficiency
• Children and young adults should especially get adequate intake of selenium in the diet
• Brazil nuts are high in selenium that is easily absorbed by the body
• Hazelnuts are high in selenium that is easily absorbed by the body
• Selenomethionine is more bioavailable (easily absorbed) by the body than selenium selenite, so it is the preferable supplement type
• Some experts believe that a virus is at least partly responsible for the cause of Keshan’s disease
• Some studies show that selenium supplementation can reverse damage to the heart muscle in some people with Keshan’s disease

Symptoms of Keshan’s disease

General symptoms of Keshan’s disease

• Arrhythmia
• Cardiac insufficiency
• Heart enlargement – this can lead to heart failure
• Loss of heart tissue

If Keshan’s disease is not diagnosed and treated, then it can result in heart failure due to the selenium deficiency.

Viral cause of Keshan’s disease symptoms

It has also been suggested that Keshan’s disease may be, at least partly due to infection by a virus (coxsackievirus B3 – CVB3/0), which would initially present with the typical viral infection symptoms such as:

• Diarrhoea
• Fever
• Lethargy
• Malaise
• Vomiting

Causes of Keshan’s disease

Keshan’ disease is thought to be caused by the following:

Selenium deficiency

Keshan’s disease is believed to be mainly caused by a deficiency of the mineral selenium.

Keshan’s disease occurs in areas where there is a lack of selenium in the soil. Plant foods absorb the selenium from the soil and if there is a deficiency, then the plant food will also not have adequate levels.

Enterovirus infection

While selenium deficiency plays a large role in development of Keshan’s disease, it is also thought that due to the seasonal and annual variation in its occurrence, this could mean that bacterial or viral infection may also be involved and studies on the Keshan area have determined that an enterovirus may be responsible, such as coxsackievirus.

Studies show that enteroviruses are mainly responsible for viral myocarditis and possibly also cardiomyopathy, two very serious complications of Keshan’s disease, which can both result in heart failure if not promptly treated.

Prevention of Keshan’s disease

Non-preventable risk factors

Keshan’s disease may be unpreventable in certain circumstances:

• Living in an area with little selenium in the soil – it is impossible, without testing the soil, to determine if there is enough selenium in it
• Viral or bacterial infection – while selenium deficiency plays a large role in development of Keshan’s disease, it is also thought that due to the seasonal and annual variation in its occurrence, this could mean that bacterial or viral infection may also be involved. Studies on the Keshan area have determined that an enterovirus may be responsible, such as coxsackievirus

Preventable risk factors

There are ways to prevent Keshan’s disease from occurring:

• Eat foods rich in selenium – people who ensure they have a diet that includes foods rich in selenium have protection against developing Keshan’s disease and have very little risk for this condition. Foods rich in selenium are: Brazil nuts, eggs, onions, garlic
• Supplements – people who live in an area with known selenium-deficient soil should be taking selenium supplements to prevent deficiency and prevent Keshan’s disease from occurring. A blood test can determine if there is a selenium deficiency in the body

Complications of Keshan’s disease

There are a number of major complications that can arise from untreated and undiagnosed Keshan’s disease:

• Cardiomyopathy – the most common complication of Keshan’s disease is cardiomyopathy, where the heart muscle starts to get larger, thicker or more stiff over time and this interferes with the heart’s ability to pump blood around the body
• Myocarditis – another complications of Keshan’s disease is the heart condition myocarditis, which is characterised by inflammation of the heart muscle and this is caused mainly by a viral infection (and the enterovirus coxsackievirus is thought to be responsible), but it can also be caused by an underlying health condition, certain medications or parasitic infestation
• Heart failure – the single most severe and life-threatening complication of Keshan’s disease is heart failure, where the heart is no longer able to pump blood around the body and it dies

It is really important for anyone who may not be getting an adequate intake of selenium in their diet and who has any of the symptoms of Keshan’s disease to visit their doctor and have a blood test to determine if their selenium blood levels are normal. If they are too low, or in the lower end of the normal scale, selenium supplements will be recommended together with another blood test to monitor the treatment.

The earlier any deficiency of selenium is treated, the quicker any adverse effects can be reversed.

When to see a doctor about Keshan’s disease

People who have any of the symptoms of Keshan’s disease need to see their doctor to have a blood test to rule out this condition or to confirm it and have appropriate treatment to reverse symptoms and improve health. Keshan’s disease is relatively rare outside the Keshan region in China, but moderate selenium deficiency is not rare outside this region.

People with an existing condition (already diagnosed with Keshan’s disease due to deficiency of selenium in the diet) need to visit their doctor on a regular basis to monitor their condition to determine if there is improvement and to also ensure that symptoms do not worsen. If symptoms worsen, seek immediate medical attention.

Diagnosis of Keshan’s disease

Keshan’s disease is initially diagnosed through the following methods:

• Medical history – the doctor will ask a series of questions about the severity and duration of symptoms, your diet, when they started and how often they occur
• Physical examination – a doctor will examine the person with suspected Keshan’s disease to see if an obvious cause can be determined through the physical examination, especially of the heart
• Blood test – a blood test will be requested to measure levels of selenium and other functions

Further diagnostic tests

If the initial diagnosis is not conclusive, or if the symptoms are affecting the heart, the following further tests will be requested:

• Echocardiogram – a special ultrasound machine called an echocardiogram is used in a similar way as a regular ultrasound machine. A special rod (covered in some gel to help it roll over the chest area) is used to get a picture of the heart – the atria, ventricles and other parts – to determine if there are any structural problems of the heart, including blockages, that may be causing the arrhythmia
• Resting ECG – this ECG test is usually performed when a person is resting and lasts only a few minutes. A number of attachments from an ECG machine are put on various parts of the body to do a quick, preliminary test of the electrical activity of the heart
• Holter ECG monitor – a special ECG monitor which has electrical leads that are attached (glued) to various parts of the body is worn under clothing for 24 hours to record heart rhythm while a person just goes about their normal daily acclivities. The person also needs to record their activities of the day. This is one of the best ways to determine the cause of arrhythmia as it gives a very good indication on any triggers of the arrhythmia
• Stress ECG – an ECG machine is used to determine the heart’s activity during exercise (usually while a person is on a tread mill or exercise bike). A set of leads are attached to certain part of the body and the person is required to run on a treadmill (or ride an exercise bike) for a specified amount of time to increase heart rate by putting pressure on it through exercise, to determine if there are any problems with the heart and if these problems can be viewed on the electrical activity of the heart on the ECG

Conventional treatment of Keshan’s disease

Conventional treatment of Keshan’s disease includes the following treatment strategies:

• Medication – a number of medications are used to help treat the symptoms of Keshan’s disease, namely the heart muscle problems that arise from this condition:
  • ACE inhibitors – angiotensin converting enzyme (ACE) inhibitors are used in the case where the heart is enlarged (dilated cardiomyopathy) or if there is heart failure
  • Beta blockers – these drugs block specific nerve signals to the heart to reduce heart rate and force, which means the heart does not have to exert as much force to pump out blood and this reduces pressure on a heart that is not functioning properly. These medications are used in the case where the heart is enlarged (dilated cardiomyopathy) or if there is heart failure
  • Corticosteroids – these medications may be used to reduce inflammation in the heart muscle and reduce symptoms of myocarditis, cardiomyopathy or heart failure. These medications are immune suppressants so they may cause a number of side effects that need to be treated too. Examples of corticosteroids used: Prednisilone, Prednisone
  • Diuretics – these drugs flush out and remove sodium and water from the body, which reduces the amount of fluid in the body, reduces pressure on blood vessels and helps to dilate blood vessels back to a normal size and allow blood to flow more freely and reduce pressure on the heart

• Fluids – if the damage to the heart muscle is not very severe and symptoms of Keshan’s disease (especially myocarditis) are mild, without any major cardiomyopathy or heart failure, the doctor will recommend drinking adequate fluids such as water, diluted natural fruit juice and herbal tea (such as peppermint, chamomile or rosehip)
• Rest – if the damage to the heart muscle is not very severe and symptoms of Keshan’s disease (especially myocarditis) are mild, without any major cardiomyopathy or heart failure, the doctor will recommend complete rest, to give the body the best chance to remove the virus through the function of the immune system
• Supplements – selenium, in the bioavailable form selenomethionine will be given, either intravenously or in a high dose supplement (up to the tolerable upper limit) until symptoms of Keshan’s disease are reversed. This is the main form of treatment for this condition
• Surgery (heart transplant) – in very serious cases, where there is heart failure from myocarditis or cardiomyopathy (serious complications of severe Keshan’s disease) and the patient is a candidate, a heart transplant can be performed to replace the diseased heart with a new, donor heart and restore health

Alternative / complementary treatment of Keshan’s disease

Never try to self-treat or self-diagnose Keshan’s disease or selenium deficiency, as it could be potentially fatal, especially in infants or people with any other health conditions

Always seek medical attention if you think you have any of the symptoms of Keshan’s disease or if you think you are deficient in selenium. If you have Keshan’s disease, do not try any alternative treatments unless they have been approved by your doctor (and selenium supplementation will be advised but at a very specific level and it needs to be monitored).

Herbs

There are no herbs which are recommended to help treat Keshan’s disease.

Vitamins

There are no vitamins which are recommended to help treat Keshan’s disease.

Minerals

There are only one mineral which is recommended to help treat Keshan’s disease

• Selenium – if you have been diagnosed with Keshan’s disease your doctor will recommend you take a selenium supplement, either intravenously or in a supplement (usually selenomethionine as that is better tolerated and better absorbed by the body) at a very specific dosage and your health will be closely monitored. If you have lowered selenium blood levels, but do not have Keshan’s disease, your doctor will recommend a a selenium supplement (usually selenomethionine as that is better tolerated and absorbed by the body) at a very specific dosage and your blood levels of selenium will be again monitored after a week of treatment

Other nutrients

There are no other nutrients which are recommended to help treat Keshan’s disease.

Dietary modifications

There are a number of dietary modification strategies which are recommended to help treat Keshan’s disease:

• Eat foods rich in selenium – in addition to the selenium supplements (intravenously or in tablet form), your doctor will also recommend you eat more foods rich in selenium to help increase levels of selenium in your body. Foods rich in selenium are: Brazil nuts, hazelnuts, eggs, onion, garlic
• Reduce fat intake – if your heart is not functioning properly, then excessive fat intake will only increase the burden on it, so reduce intake of foods high in fat, such as: full fat dairy, high fat red meats, junk foods, processed (packaged) foods

Lifestyle modifications

There are no lifestyle modifications which are recommended to help treat Keshan’s disease.

Alternative treatments

There are no other alternative treatments which are recommended to help treat Keshan’s disease.

Always ensure that you notify your medical practitioner of any supplements that you want to take – it may interfere with other medication or conditions you have. Confirm with your doctor it is safe to take before you try it.

Living with Keshan’s disease

Self care strategies

There are a number of strategies which are recommended to help you better deal with Keshan’s disease:

• Advise your doctor if symptoms get worse – it is of utmost importance to visit your doctor for further evaluation if your symptoms get worse, to prevent any major complications of this condition
• Avoid alcohol – it is really important that you avoid all alcohol during the duration of of your illness, as alcohol just puts more pressure on an already malfunctioning heart (and body) and can make your symptoms worse
• Foods rich in selenium – ensure that your diet consists of adequate foods rich in selenium to help your heart heal more quickly (in addition to any supplements you may also be taking). Foods rich in selenium include: Brazil nuts, eggs, onions, garlic
• Healthier diet – ensure the diet you consume consists of healthy fresh, unprocessed foods, with lots of vegetables, fruits, legumes, nuts, seeds and some fish and lean meat to provide more vitamins, minerals, amino acids and antioxidants which can all help your heart. A diet lower in saturated fats and processed (junk) foods is advisable
• Monitor your side effects to medications – if you are prescribed any type of medication(s), it may be helpful if you can monitor any side effects you have (if they are present) and see your doctor if the side effects are more than just the mildly common ones
• Rest – it is really important that you rest as much as possible, because your heart is not functioning as well as normal and your body needs all its energy to get healthy. In the case of mild Keshan’s disease caused by a viral agent, your doctor will advise you to have complete rest (and adequate fluids) for a specific period to help your body’s immune system fight the viral infection and heal
• Supplements – you will most likely be prescribed selenium supplements (in the form of selenomethionine) or have injections of this mineral, so it would be helpful if you can take your supplements at the same time each day, to prevent forgetting a dose
• Surgery – if surgery has been advised (implants, stents or full heart transplant) your cardiac specialist will advise you about the pre- and post-operative care that you will need to undergo and how to best take care of yourself during this time, to avoid complications or worsening of any symptoms or health

Caring for someone with Keshan’s disease

Partner

There are a number of strategies to help a partner deal with Keshan’s disease:

• Allow your partner to rest – it is really important that your partner is allowed to rest as much as possible, because their heart is not functioning as well as normal and their body needs all its energy to get healthy. In the case of mild Keshan’s disease caused by a viral agent, your partner’s doctor will advise complete rest (and adequate fluids) for a specific period to help their body fight the viral infection and heal. It is also important to allow your partner to rest if they have had any type of surgery, as their body needs this time to heal properly from the invasive surgical procedure that need to be performed
• Avoid alcohol – it is really important that your partner avoids all alcohol during the duration of their illness, as alcohol just puts more pressure on an already malfunctioning heart (and body) and can only make your partner’s symptoms worse
• Foods rich in selenium – ensure that your partner is eating adequate foods rich in selenium to help their heart heal more quickly (in addition to any supplements they may also be taking). Foods rich in selenium include: Brazil nuts, eggs, onions, garlic
• Healthy food – ensure the diet you and your partner consume consists of healthy fresh, unprocessed foods, with lots of vegetables, fruits, legumes, nuts, seeds and some fish and lean meat to provide more vitamins, minerals, amino acids and antioxidants which can all help your partner’s heart (and yours). A diet lower in saturated fats and processed (junk) foods is advisable
• Monitor medications – if your partner is prescribed any type of medication(s), it may be helpful if you can monitor any side effects they have (if they are present) and encourage your partner to see their doctor if the side effects are more than just the mildly common ones
• Supplements – your partner will most likely be prescribed selenium supplements (in the form of selenomethionine) or have injections of this mineral, so it would be helpful if you can remind or encourage your partner to take their supplements at the same time each day, to prevent them forgetting a dose

Friends

There are a number of strategies to help a friend deal with Keshan’s disease:

• Avoid alcohol – ensure that your social interactions with your friend do not involve alcohol, as it could (a) adversely interact with their medications and (b) their heart cannot tolerate any alcohol if they are so sick
• Healthy food – ensure any food you provide (if you provide any) to your friend is healthy, low fat and unprocessed, to help their heart (and yours)

Parents

There are a number of strategies to help a child deal with Keshan’s disease:

• Allow your child to rest – it is really important your child is allowed to rest as much as possible, because their heart is not functioning as well as normal and their body needs all its energy to get healthy. In the case of mild Keshan’s disease caused by a viral agent, your child’s doctor will advise complete rest (and adequate fluids) for a specific period to help their body fight the viral infection and heal
• Foods rich in selenium – ensure that your child is eating foods rich in selenium to help their heart heal more quickly (in addition to supplements they may be taking). Foods rich in selenium include: Brazil nuts, eggs, onions, garlic
• Healthy food – ensure the diet you and your family consume consists of healthy fresh, unprocessed foods, with lots of vegetables, fruits, legumes, nuts, seeds and some fish and lean meat to provide more vitamins, minerals, amino acids and antioxidants which can all help your child’s heart (and yours). A diet lower in saturated fats and processed (junk) foods is advisable
• Monitor medications – if your child is prescribed any type of medication(s), it may be helpful if you can monitor any side effects they have (if they are present) and take your child to see their doctor if the side effects are more than just the mildly common ones
• Supplements – your child will most likely be prescribed selenium supplements (in the form of selenomethionine) or have injections of this mineral, so it would be helpful if you can remind or encourage your child to take their supplements at the same time each day, to prevent them forgetting a dose

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Last reviewed and updated: 14 May 2024