Zinc deficiency manifested by dermatitis and visual dysfunction in a patient with Crohn's disease

Zinc Deficiency and Therapeutic Value of Zinc Supplementation in Pediatric Gastrointestinal Diseases

The benefits of zinc in treating certain gastrointestinal (GI) diseases have been recognized for over two decades. This review aims to explore zinc deficiency (ZD) and the potential therapeutic value and safety of zinc supplementation in pediatric GI diseases. A systematic review of published articles on ZD and zinc as adjuvant treatments for GI diseases was conducted using various databases. Children with inflammatory bowel disease (IBD), celiac disease, and those receiving long-term proton pump inhibitor treatments are particularly susceptible to ZD. ZD in children with celiac disease and IBD is attributed to insufficient intake, reduced absorption, and increased intestinal loss as a result of the inflammatory process. Zinc plays a crucial role in maintaining the integrity of the gastric mucosa and exerts a gastroprotective action against gastric lesions. Although considerable evidence supports the use of zinc as adjuvant therapy for certain GI diseases in adults, its use is unspecified in children except for infectious diarrhea. Current evidence suggests that zinc supplementation with well-documented dosages helps reduce the duration of diarrhea in children with acute or persistent diarrhea, while there are no specific guidelines for zinc supplementation in children with IBD and celiac disease. Zinc supplementation appears to be beneficial in peptic ulcer disease or gastroesophageal reflux disease. The available evidence highlights the need for intervention programs to enhance zinc status and reduce the morbidity of certain GI diseases in children.

Zinc and gut microbiota in health and gastrointestinal disease under the COVID-19 suggestion

Microelements represent an emerging resource for medicine and its preventive branch. Zinc is the second most abundant element in our organism with peculiar physiologic functions and pathophysiologic implications in systemic and gastrointestinal (GI) diseases. It interacts very often with gut microbiota (GM) and can affect natural course of GI diseases through a bidirectional relationship with intestinal bugs. We aimed to review literature data regarding zinc chemistry, role in health, and GI diseases in man with a special focus on its interaction with GM. We conducted a search on the main medical databases for original articles, reviews, meta-analyses, randomized clinical trials and case series using the following keywords and acronyms and their associations: zinc, microelements, gut microbiota, gut health, and COVID-19. Zinc has a rapid and simple metabolism and limited storage within our body. Its efficacy on immune system modulation reflects on improved response to pathogens, reduced inflammatory response, and improved atopic/allergic reactions. Zinc is also involved in cell cycle regulation (namely, apoptosis) with potential anti-cancerogenic effects. All these effects are in a "symbiotic" relationship with GM. Finally, zinc shows preliminary viral antireplicative effects. Zinc seems to gain more and more evidences on its efficacy in allergic, atopic and infectious diseases treatment, and prevention. COVID-19 can be the booster for research on future applications of zinc as perfect "postbiotic" in medicine.

Improvement of body composition and bone mineral density after enteral nutrition in pediatric Crohn disease

BACKGROUND

The relationship between exclusive enteral nutrition (EEN) and bone status is poorly defined in pediatric Crohn disease (CD).

AIMS

The aim of this study was to investigate the impact of EEN on body composition, nutritional status, and bone mineral density (BMD) in an incident CD cohort.

METHODS

18 newly diagnosed CD children starting EEN for 8 weeks were prospectively enrolled and evaluated at baseline and after 8 (T8), 26 (T26) and 52 weeks (T52) from diagnosis. The Fat Free Mass (FFM) and the Resting Energy Expenditure (REE) were measured through Bioelectrical Impedance (BIA) and the BMD was assessed by dual-energy X-ray (DXA). We compared DXA data of IBD patients to the data obtained in 15 healthy controls.

RESULTS

CD children had a significant lower BMD compared to healthy control both at baseline (p<0.0001), and after EEN therapy at T52 (p=0.0004); although at this latest time point CD children had a significant increase of BMD compared to baseline (p=0.0015). The BIA analysis showed a significant increase at T26 and T52 of FFM and REE. T52. FFM measured by BIA and BMD measured by DXA were significantly correlated.

CONCLUSION

EEN improves nutritional status and bone mineral composition.

Zinc Levels Modulate Lifespan through Multiple Longevity Pathways in Caenorhabditis elegans

Zinc is an essential trace metal that has integral roles in numerous biological processes, including enzymatic function, protein structure, and cell signaling pathways. Both excess and deficiency of zinc can lead to detrimental effects on development and metabolism, resulting in abnormalities and disease. We altered the zinc balance within Caenorhabditis elegans to examine how changes in zinc burden affect longevity and healthspan in an invertebrate animal model. We found that increasing zinc levels in vivo with excess dietary zinc supplementation decreased the mean and maximum lifespan, whereas reducing zinc levels in vivo with a zinc-selective chelator increased the mean and maximum lifespan in C. elegans. We determined that the lifespan shortening effects of excess zinc required expression of DAF-16, HSF-1 and SKN-1 proteins, whereas the lifespan lengthening effects of the reduced zinc may be partially dependent upon this set of proteins. Furthermore, reducing zinc levels led to greater nuclear localization of DAF-16 and enhanced dauer formation compared to controls, suggesting that the lifespan effects of zinc are mediated in part by the insulin/IGF-1 pathway. Additionally, zinc status correlated with several markers of healthspan in worms, including proteostasis, locomotion and thermotolerance, with reduced zinc levels always associated with improvements in function. Taken together, these data support a role for zinc in regulating both development and lifespan in C. elegans, and that suggest that regulation of zinc homeostasis in the worm may be an example of antagonistic pleiotropy.

Cutaneous Manifestations of Crohn Disease

Awareness of the extraintestinal manifestations of Crohn disease is increasing in dermatology and gastroenterology, with enhanced identification of entities that range from granulomatous diseases recapitulating the underlying inflammatory bowel disease to reactive conditions and associated dermatoses. In this review, the underlying etiopathology of Crohn disease is discussed, and how this mirrors certain skin manifestations that present in a subset of patients is explored. The array of extraintestinal manifestations that do not share a similar pathology, but which are often seen in association with inflammatory bowel disease, is also discussed. Treatment and pathogenetic mechanisms, where available, are discussed.

Serum zinc levels in patients with iron deficiency anemia and its association with symptoms of iron deficiency anemia

Iron deficiency anemia (IDA) is a major public health problem especially in underdeveloped and developing countries. Zinc is the co-factor of several enzymes and plays a role in iron metabolism, so zinc deficiency is associated with IDA. In this study, it was aimed to investigate the relationship of symptoms of IDA and zinc deficiency in adult IDA patients. The study included 43 IDA patients and 43 healthy control subjects. All patients were asked to provide a detailed history and were subjected to a physical examination. The hematological parameters evaluated included hemoglobin (Hb); hematocrit (Ht); red blood cell (erythrocyte) count (RBC); and red cell indices mean corpuscular volume (MCV), mean corpuscular hemoglobin (МСН), mean corpuscular hemoglobin concentration (МСНС), and red cell distribution width (RDW). Anemia was defined according to the criteria defined by the World Health Organization (WHO). Serum zinc levels were measured in the flame unit of atomic absorption spectrophotometer. Symptoms attributed to iron deficiency or depletion, defined as fatigue, cardiopulmonary symptoms, mental manifestations, epithelial manifestations, and neuromuscular symptoms, were also recorded and categorized. Serum zinc levels were lower in anemic patients (103.51 ± 34.64 μ/dL) than in the control subjects (256.92 ± 88.54 μ/dL; <0.001). Patients with zinc level <99 μ/dL had significantly more frequent mental manifestations (p < 0.001), cardiopulmonary symptoms (p = 0.004), restless leg syndrome (p = 0.016), and epithelial manifestations (p < 0.001) than patients with zinc level > 100 μ/dL. When the serum zinc level was compared with pica, no statistically significant correlation was found (p = 0.742). Zinc is a trace element that functions in several processes in the body, and zinc deficiency aggravates IDA symptoms. Measurement of zinc levels and supplementation if necessary should be considered for IDA patients.

Zinc and gastrointestinal disease

This review is a current summary of the role that both zinc deficiency and zinc supplementation can play in the etiology and therapy of a wide range of gastrointestinal diseases. The recent literature describing zinc action on gastrointestinal epithelial tight junctions and epithelial barrier function is described. Zinc enhancement of gastrointestinal epithelial barrier function may figure prominently in its potential therapeutic action in several gastrointestinal diseases.

Zinc, its biological role and use in dermatology

This literature review detines the biological role ot zinc in the human body, immune homeostasis and skin physiology as well as pathophysiology ot skin diseases. It describes the current range ot systemic and topical zinc preparations and their pharmacological characteristics. The review also describes skin diseases that may be treated with the use ot zinc preparations on a grounded basis, and discloses the clinical experience ot the use ot these drugs described in the world literature. It sets out certain recommendations tor using zinc preparations in clinical practice.

Alteration of plasma trace elements in patients undergoing open heart surgery

Trace elements may contribute to myocardial dysfunction and susceptibility of the phospholipid cell membrane to free-radical damage and oxidative changes. We studied the concentration of trace elements copper, zinc, and magnesium in cardiac surgery. Fifty-four consecutive patients for elective coronary artery bypass grafting (n = 30) and valve replacement (n = 24) were studied. Blood samples were collected every 30 min (T1-T5) during cardiopulmonary bypass and postoperatively (T6-T9). Plasma concentrations of copper, zinc, and magnesium were measured with flame atomic absorption spectrophotometry. The concentrations of copper, zinc, and magnesium were significantly different during and after cardiopulmonary bypass (p < 0.01). The zinc concentration at T7 and T8 (p < 0.01) and the copper concentration at T1, T9 (p < 0.05) were significantly different between two groups. However, the magnesium concentration had no significant differences between the two groups (p > 0.05). In patients undergoing valve replacement or coronary artery bypass grafting, the concentrations of copper and zinc decreased significantly during cardiopulmonary bypass. Our study suggests that the current cardiopulmonary bypass protocol is adequate in the maintenance of c magnesium. However, the low copper and zinc concentrations found in the present study may suggest that in the future, supplementation particularly of copper and zinc may become a necessary procedure in cardiac surgery with cardiopulmonary bypass.

Impact of exclusive enteral nutrition on body composition and circulating micronutrients in plasma and erythrocytes of children with active Crohn's disease

BACKGROUND

Nutritional therapy is the primary treatment for active pediatric Crohn's disease (CD) in the UK/Europe, improving disease activity and anthropometry. This study assessed changes in micronutrient status during exclusive enteral nutrition (EEN).

METHODS

Seventeen children (male/female: 8/9; median age: 12.7 years) with active CD were treated exclusively for 6-8 weeks on a polymeric feed (Modulen IBD; Nestle, UK). Body impedance was measured at baseline, during EEN, and posttreatment on normal diet and converted to z-scores of fat and lean mass. Blood samples for nutrient analysis were collected from 13 children at baseline, end of EEN, and posttreatment.

RESULTS

Lean but not fat mass improved at the end of EEN (initiation vs. end of EEN; fat mass [z-score]: -0.5 vs. -0.3; P = 0.141; lean mass [z-score]: -2.1 vs. -0.8; P < 0.0001). At baseline several children presented with suboptimal concentrations of carotenoids, trace elements, vitamin C, B6, and folate in plasma but not in erythrocytes. EEN improved concentrations for several nutrients, but more than 90% of patients had depleted concentrations of all carotenoids. The latter improved on normal diet but other micronutrients, which improved during EEN, returned toward pretreatment concentrations.

CONCLUSIONS

Lean but not fat mass improved at the end of EEN. Median concentrations for several plasma micronutrients improved on EEN but carotenoids were depleted. These findings may have implications for clinical practice and producers of enteral feeds. As plasma concentrations for many micronutrients can be affected by the acute phase response, measurements in erythrocytes may be a better marker of actual body stores.

Zinc and copper levels in severe heart failure and the effects of atrial fibrillation on the zinc and copper status

Oxidative stress is involved in the pathogenesis of congestive heart failure (CHF). Some trace elements serve as antioxidant defenses. The purpose of this study was to analyze the effect of atrial fibrillation (AF) on zinc (Zn) and copper (Cu) levels in patients with advanced CHF. In this prospective study, serum Zn and Cu levels in 78 patients with clinically advanced CHF, i.e., New York Heart Association (NYHA) functional class III or IV (40 patients with AF and 38 in sinus rhythm) were measured using atomic absorption spectrophotometry. All patients also had a left ventricular ejection fraction (EF) of <35%. We recruited 40 volunteers with nearly the same age and weight as control. They had normal EF. There was no significant difference between patients with AF and those with sinus rhythm regarding serum Zn and Cu levels. However, both groups showed significant hypozincemia (p < 0.000) and a decreased Zn/Cu ratio (p < 0.03) compared with control group. Serum Cu levels were similar in the two groups and did not differ significantly from the control group. In patients with advanced CHF, irrespective of the rhythm, profound hypozincemia, and a decreased Zn/Cu ratio were present, which could be secondary to the activation of the renin-angiotensin-aldosterone system and CHF medications. The results suggest the need for more studies focusing on possible benefits with Zn nutriceutical replacement in patients with advanced CHF.

The aetiology and impact of malnutrition in paediatric inflammatory bowel disease

Disease-associated undernutrition of all types is very common in paediatric inflammatory bowel disease (IBD). Recent weight loss remains one of the triad of clinical manifestations and a cornerstone for the diagnosis of Crohn's disease (CD), although significantly fewer patients now present as being underweight. Recent evidence suggests that the introduction of medical treatment will quickly restore body weight, although this does not reflect concomitant changes in body composition. CD children present with features of nutritional cachexia with normal fat stores but depleted lean mass. Poor bone health, delayed puberty and growth failure are additional features that further complicate clinical management. Suboptimal nutritional intake is a main determinant of undernutrition, although activation of the immune system and secretion of pro-inflammatory cytokines exert additional independent effects. Biochemically low concentrations of plasma micronutrients are commonly reported in IBD patients, although their interpretation is difficult in the presence of an acute phase response and other indices of body stores adequacy are needed. Anaemia is a common extraintestinal manifestation of the IBD child. Iron-deficient anaemia is the predominant type, with anaemia of chronic disease second. Decreased dietary intake, as a result of decreased appetite and food aversion, is the major cause of undernutrition in paediatric IBD. Altered energy and nutrient requirements, malabsorption and increased gastrointestinal losses are additional factors, although their contribution to undernutrition in paediatric CD needs to be studied further.

Implications of abnormal pathology in fulminating colitis on the outcome of surgery

BACKGROUND

The severe relapse of the diseases in patients with Crohn's disease or ulcerative colitis is associated with high morbidity and mortality. Early prediction for the failure of aggressive medical treatment and consequently, early surgical interference in cases with severe colitis and severe Crohn's colitis are supposed to be effective means for reducing these high rates.

METHODS

Patients who presented at the Accident & Emergency Department with severe colitis and severe Crohn's colitis and on whom emergency colectomy was operated were identified and they formed the basis of this study.

RESULTS

Patients (n=34) with acute fulminating colitis and their condition required emergency colectomy were seen over a period of 5 years. A strategy of early detection of cases of toxic dilatation and/or perforation proved efficient in reducing morbidity and mortality in cases of severe colitis. The mortality in the presented series was zero and the morbidity occurred mainly in such cases that presented with fulminant distal colitis, which was complicated by proximal faecal loading.

CONCLUSION

Diagnosis of proximal faecal loading in cases with fulminant colitis is likely to be an indication for surgery. Further studies are required for confirming this conclusion.

[Neurological complications of inflammatory bowel disease]

Although ulcerative colitis and Crohn's disease have traditionally been considered to be inflammatory diseases limited to the gastrointestinal tract, it has been shown that both pathologies are frequently accompanied by various extraintestinal disorders. There is an increasing evidence that they may also manifest in the nervous system, including the peripheral and the central parts. Although some of these neurological complications have been known for a long time, such as cerebrovascular disease, vasculitis and autoinmune processes including neuropathies and cerebral demyelination, others have been recently described. With the exception of some of this complications such as the thromboembolism, evidence for a casual relationship relies merely on single case reports or case series. In this article, we try to review the existing evidence on neurological manifestations of both variants of inflammatory bowel disease.

Nutritional deficiencies in morbidly obese patients: a new form of malnutrition? Part B: minerals

Even though in the Western world there is almost no limitation to a wide variety of food supply, nutritional deficiencies can be found in both normal-weight population and in the obese population. In this review, we examine the prevalence and manifestations of various mineral deficiencies in obese patients.

Acrodermatitis enteropathica–like eruption and failure to thrive as presenting signs of cystic fibrosis

We describe a female infant with an acrodermatitis enteropathica-like eruption as the presenting sign of rapidly fatal cystic fibrosis. The patient had growth retardation, developed an erythematous eruption unresponsive to oral zinc, and finally a generalized erosive dermatitis with associated edema, anemia and hypoproteinemia.

Zinc in wound healing: theoretical, experimental, and clinical aspects

Zinc is an essential trace element in the human body and its importance in health and disease is appreciated. It serves as a cofactor in numerous transcription factors and enzyme systems including zinc-dependent matrix metalloproteinases that augment autodebridement and keratinocyte migration during wound repair. Zinc confers resistance to epithelial apoptosis through cytoprotection against reactive oxygen species and bacterial toxins possibly through antioxidant activity of the cysteine-rich metallothioneins. Zinc deficiency of hereditary or dietary cause can lead to pathological changes and delayed wound healing. Oral zinc supplementation may be beneficial in treating zinc-deficient leg ulcer patients, but its therapeutic place in surgical patients needs further clarification. Topical administration of zinc appears to be superior to oral therapy due to its action in reducing superinfections and necrotic material via enhanced local defense systems and collagenolytic activity, and the sustained release of zinc ions that stimulates epithelialization of wounds in normozincemic individuals. Zinc oxide in paste bandages (Unna boot) protects and soothes inflamed peri-ulcer skin. Zinc is transported through the skin from these formulations, although the systemic effects seem insignificant. We present here the first comprehensive account of zinc in wound management in relation to current concepts of wound bed preparation and the wound-healing cascade. This review article suggests that topical zinc therapy is underappreciated even though clinical evidence emphasizes its importance in autodebridement, anti-infective action, and promotion of epithelialization.

Acquired acrodermatitis enteropathica: case report of an atypical presentation

Acrodermatitis enteropathica (ADE) is a rare genetic or acquired disorder of hypozincemia. It can be caused by impaired intestinal absorption of zinc or by poor consumption of the mineral. It is characterized by skin lesions on acral and periorificial areas and may be associated to alopecia, diarrhea and increased frequency of infections. We present an atypical presentation of ADE in a 33-year-old women with a history of mental retardation and psoriasis that presented with lesions on the periorificial areas and extremities, and low plasma zinc levels.

Zinc metabolism in adolescents with Crohn's disease

Low serum zinc concentrations have been reported in Crohn's disease (CD) and overt zinc deficiency has been described, but little is known about the effect of CD on zinc metabolism in adolescents. The aim of this study was to measure zinc absorption, endogenous fecal zinc excretion, urinary zinc excretion, and zinc balance in children with stable CD and in matched controls. Subjects were 15 children, ages 8-18 y, with stable CD, and 15 healthy matched controls. Subjects were adapted to diets providing 12 mg/d elemental zinc for 2 wk, and then admitted for a 6-d metabolic study. Stable zinc isotopes were given intravenously and orally, and urine and feces collected for 6 d. Fractional zinc absorption, endogenous fecal zinc excretion, and zinc balance were calculated using established stable isotope methods. In subjects with CD, zinc absorption (10.9% +/- 6.1 versus 23.4 +/- 15.8, p = 0.008) and plasma zinc concentration (0.85 mg/dL +/- 0.15 versus 1.25 +/- 0.35, p = 0.004) were significantly reduced, compared with controls. Despite this, there were no significant differences in endogenous fecal zinc excretion (2.0 mg +/- 1.5 versus 1.5 +/- 1.5, p = 0.34) or urinary zinc excretion (0.9 mg +/- 0.7 versus 1.0 +/- 0.7, p = 0.47). Zinc balance was significantly lower in CD (-1.5 mg +/- 1.5) than in controls (+0.6 mg +/- 3.1, p < 0.0001). In conclusion, adolescents with CD have significantly reduced zinc absorption. Despite this, they were unable to reduce endogenous fecal zinc excretion to restore normal zinc balance and had a significantly worse zinc balance and lower plasma zinc concentration than controls.

Nutrition support for pediatric patients with inflammatory bowel disease: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology And Nutrition

Impairment of growth and malnutrition are significant complications of inflammatory bowel disease (IBD) in pediatric patients. Since this topic was last reviewed in these pages (), a number of studies have further explored the epidemiology and pathogenesis of these nutritional complications of IBD in an effort to provide more effective interventions to prevent the long-term consequences of chronic nutrient deficiencies in childhood. In addition, during the past 15 years, the use of selected nutrients and microorganisms (probiotics) as primary or adjunctive therapy for the treatment of IBD has become an emerging area of great interest. The following is a Clinical Report from the Nutrition and Inflammatory Bowel Disease Committees of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

Optic nerve changes in zinc-deficient rats

In this study the optic nerve changes in zinc (Zn)-deficient rats are examined. Zinc is one of the essential trace elements and is known to be related to optic nerve diseases such as ethambutol neuropathy. However, the effect of Zn on the optic nerve has not been studied experimentally in animals. We used 3 week old weanling male Wistar Kyoto rats weighing 40-50 g. Rats were fed a Zn-deficient diet containing 0.007 mg of Zn per 100 g, all other nutrients and distilled and deionized water. The same water supplemented with 3 mg Zn per 100 g was given to the control group. After 4 or 7 weeks on a Zn-deficient diet, the optic nerve was examined with an electron microscope. A recovery group was fed a Zn-containing diet for 5 weeks after 7 weeks on the Zn-deficient diet. The serum Zn levels of the deficient group were significantly decreased at both 4 and 7 weeks. Most of the Zn-deficient rats showed hair loss around the eyes and on the extremities. Ultrastructural findings were as follows. The number of myelinated axons of Zn-deficient rats at 4 and 7 weeks were significantly decreased and the myelin sheaths were significantly thinner in the Zn-deficient groups and in the recovery group. Unmyelinated axons were more numerous than in the control rats. Destruction of myelin and proliferation of glial cells were found in the optic nerves of Zn-deficient rats. This study suggests that the optic nerve needs Zn for the maintenance of its cell structure and even if Zn is supplied to the Zn-deficient rats, destruction of the myelin structure may continue. Zn-deficiency induce a decrease of myelinated nerve fibers, and it is thought that optic neuropathy in patients treated with some drugs such as ethambutol may be a secondary change due to Zn-deficiency following drug administration.

Zinc and the immune system

Zn is an essential trace element for all organisms. In human subjects body growth and development is strictly dependent on Zn. The nervous, reproductive and immune systems are particularly influenced by Zn deficiency, as well as by increased levels of Zn. The relationship between Zn and the immune system is complex, since there are four different types of influence associated with Zn. (1) The dietary intake and the resorption of Zn depends on the composition of the diet and also on age and disease status. (2) Zn is a cofactor in more than 300 enzymes influencing various organ functions having a secondary effect on the immune system. (3) Direct effects of Zn on the production, maturation and function of leucocytes. (4) Zn influences the function of immunostimulants used in the experimental systems. Here we summarize all four types of influence on the immune function. Nutritional aspects of Zn, the physiology of Zn, the influence of Zn on enzymes and cellular functions, direct effects of Zn on leucocytes at the cellular and molecular level, Zn-altered function of immunostimulants and the therapeutic use of Zn will be discussed in detail.