Night blindness and Crohn's disease. Int Ophthalmol. 2014;34:1141-1144. [PMID: 24715231 DOI: 10.1007/s10792-014-9940-x]

LLL 44 - Module 3: Micronutrients in Chronic disease

Micronutrients (MN), i.e. trace elements and vitamins, are essential organic molecules, which are required in the diet in relatively small amounts in any form of nutrition (oral, enteral, parenteral). The probability of MN depletion or deficiencies should be considered in all chronic illnesses, especially in those that can interfere with intake, digestion, or intestinal absorption. Low socio-economic status and food deprivation are recognized as the most prevalent reasons for MN deficiencies world-wide. Elderly multimorbid patients with multimodal therapy, as well as patients with long-lasting menu restrictions, are at high risk for both disease related malnutrition as well as multiple MN deficiencies, needing careful specific follow-up. The importance of monitoring MN blood levels along with CRP is essential for optimal care. Drug interactions are also highlighted. In patients with chronic conditions depending on medical nutrition therapy, the provision of adequate dietary reference intakes (DRI) of MN doses and monitoring of their adequacy belongs to standard of care.

Micronutrient deficiencies in inflammatory bowel disease: an incidence analysis

BACKGROUND

Micronutrient deficiencies associated with malnutrition in patients with inflammatory bowel disease (IBD) can lead to complications including anemia, coagulopathy, poor wound healing, and colorectal cancer. This study aimed to investigate micronutrient deficiencies (copper, vitamins A, B9, E, and K) in IBD patients and highlight associated symptoms to aid in the recognition of micronutrient deficiencies.

METHODS

A retrospective electronic chart review was performed on adults diagnosed with Crohn's disease or ulcerative colitis hospitalized at a tertiary care center for IBD flare between January 2013 and June 2017. Patients with serum or whole blood micronutrient levels were included. Pregnant and incarcerated patients were excluded.

RESULTS

A total of 611 IBD patients (440 Crohn's disease, 171 ulcerative colitis) met the inclusion criteria. Micronutrients were assessed in a subset of IBD patients (copper: 12.3%, A: 10.1%, B9 : 95.9%, E: 10.3%, and K: 4.6%). Overall, 10.1% of patients had micronutrient deficiencies. The proportion of patients with copper, A, B9, E, and K deficiencies were 25.4, 53.3, 1.9, 23.7, and 29.4% for Crohn's disease and 50, 52.9, 1.2, 43.8, and 18.2% for ulcerative colitis, respectively. The most common symptoms or historical features associated with micronutrient deficiency were anemia (copper, B9), muscle weakness (copper, E) thrombocytopenia, fatigue (copper, B9), diarrhea (B9), dry skin, hyperkeratosis, pruritus, significant weight loss, elevated C-reactive protein (A), bleeding, and osteoporosis (K).

CONCLUSION

Micronutrient deficiencies are common in IBD patients, yet they are not routinely assessed. Copper, vitamins A, E, and K deficiencies are particularly underrecognized. Associated historical features should raise suspicion and prompt assessment and treatment.

Case Report: Nyctalopia Due to Severe Liver Cirrhosis-induced Vitamin A Deficiency

SIGNIFICANCE

Vitamin A is a micronutrient critical for retinal function. Patients with a deficiency may notice a progressive decline in night vision as rod photoreceptors become unable to regenerate rhodopsin. Although uncommon in developed nations, vitamin A deficiency should be considered in symptomatic patients with chronic, severe liver disease.

PURPOSE

This report presents a rare case of night blindness secondary to poor vitamin A metabolism due to severe liver cirrhosis.

CASE REPORT

A 62-year-old White woman presented with progressively worsening vision in dim lighting over the past 6 to 8 months. She was asymptomatic in daylight but "blind in the dark" to the extent that she was afraid to go outside at night. She had no personal or family history of night blindness or retinal disorders. Ocular health was unremarkable with dilation. Given her medical history of severe nonalcoholic liver cirrhosis, malabsorption of vitamin A was suspected and subsequently confirmed by the very low vitamin A level in her serum analysis. The patient was sent to endocrinology for evaluation, and appropriate repletion therapy was implemented. Subjective improvement in symptoms, along with better performance on visual field testing, was noted after initiating oral vitamin A supplementation for 5 months.

CONCLUSIONS

Although vitamin A deficiency is a relatively rare disorder in the United States, it should be suspected in patients with severe liver disease or other conditions causing malabsorption who experience a loss of night vision.

Genetic Aspects of Micronutrients Important for Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), Crohn’s disease (CD) and ulcerative colitis (UC) are complex diseases whose etiology is associated with genetic and environmental risk factors, among which are diet and gut microbiota. To date, IBD is an incurable disease and the main goal of its treatment is to reduce symptoms, prevent complications, and improve nutritional status and the quality of life. Patients with IBD usually suffer from nutritional deficiency with imbalances of specific micronutrient levels that contribute to the further deterioration of the disease. Therefore, along with medications usually used for IBD treatment, therapeutic strategies also include the supplementation of micronutrients such as vitamin D, folic acid, iron, and zinc. Micronutrient supplementation tailored according to individual needs could help patients to maintain overall health, avoid the triggering of symptoms, and support remission. The identification of individuals’ genotypes associated with the absorption, transport and metabolism of micronutrients can modify future clinical practice in IBD and enable individualized treatment. This review discusses the personalized approach with respect to genetics related to micronutrients commonly used in inflammatory bowel disease treatment.

Extra-intestinal manifestations of inflammatory bowel diseases

Inflammatory bowel disease (IBDs), including the two main subtypes of Crohn's disease and ulcerative colitis, not only affects the gastrointestinal system, but also has a wide range of extra-intestinal manifestations (EIMs) that are major sources of morbidity and disability, and therefore represent what can be considered a real syndrome. The pathogenetic mechanisms underlying these EIMs are unknown, but some may share a common pathogenesis with IBD and others may be due to IBD treatment. The aim of this review is to examine our current knowledge of IBD EIMs and their treatment.

Dermatological Manifestations in Pediatric Inflammatory Bowel Disease

Background and Objectives: Over the last years, inflammatory bowel disease (IBD) has been reported on a high incidence in pediatric populations and has been associated with numerous extraintestinal manifestations, making its management a real challenge for the pediatric gastroenterologist. Dermatological manifestations in IBD are either specific, related to the disease activity or treatment-associated, or non-specific. This literature review aims to identify and report the dermatological manifestations of IBD in children, the correlation between their appearance and the demographical characteristics, the relationship between these lesions and disease activity, and to highlight the impact of dermatological manifestations on an IBD treatment regime. Materials and Methods: A systemic literature review was performed, investigating articles and case reports on dermatological manifestations in children with IBD starting from 2005. A total of 159 potentially suitable articles were identified and after the exclusion process, 75 articles were selected. Results: The most common dermatological manifestations reported in pediatric IBD are erythema nodosum and pyoderma gangrenosum. More rare cases of metastatic Crohn’s disease, epidermolysis bullosa acquisita, small-vessel vasculitis, necrotizing vasculitis, leukocytoclastic vasculitis, cutaneous polyarteritis nodosa, and Sweet’s syndrome have been reported. Oral manifestations of IBD are divided into specific (tag-like lesions, mucogingivitis, lip swelling with vertical fissures, aphthous stomatitis, and pyostomatitis vegetans) and non-specific. IBD treatment may present with side effects involving the skin and mucosa. Anti-tumor necrosis factor agents have been linked to opportunistic skin infections, psoriasiform lesions, and a potentially increased risk for skin cancer. Cutaneous manifestations such as acrodermatitis enteropathica, purpuric lesions, and angular cheilitis may appear secondary to malnutrition and/or malabsorption. Conclusions: The correct diagnosis of dermatological manifestations in pediatric IBD is of paramount importance because of their impact on disease activity, treatment options, and a patient’s psychological status.

REVERSIBLE NYCTALOPIA ASSOCIATED WITH VITAMIN A DEFICIENCY AFTER RESECTED MALIGNANT ILEAL CARCINOID AND PANCREATIC ADENOCARCINOMA

PURPOSE

To describe the rapid time course of visual and electroretinographic recovery from vitamin A deficiency in a patient with a history of multiple resected abdominal tumors, including ileal carcinoid and pancreatic adenocarcinoma.

METHODS

A 61-year-old white man with a history of resected malignant ileal carcinoid and Stage III pancreatic adenocarcinoma referred with complaints of 6 weeks of difficulty with night vision.

RESULTS

Initial testing showed significantly reduced scotopic rod responses in both eyes and decreased vitamin A levels and a normal cancer-associated retinopathy laboratory panel. He had complete recovery of both his symptoms and full-field electroretinography within 5 days of starting intramuscular vitamin A.

CONCLUSION

Vitamin A deficiency-related retinopathy after abdominal surgery may be an underreported complication. This case provides a unique clinical perspective in our patient with a history of ileal carcinoid and Stage III pancreatic adenocarcinoma and confirms that rapid symptomatic and electroretinographic recovery is possible with appropriate treatment.

Serum carotenoids and macular pigment optical density in patients with intestinal resections and healthy subjects: an exploratory study

Reduced absorption capacity in patients with intestinal resections (IR) could result in malabsorption of fat-soluble components like carotenoids, which are of clinical interest in relation to visual health. In this case cohort, we investigated the association between IR and serum lutein, zeaxanthin, β-carotene and macular pigment optical density, when compared with healthy controls. Ten patients with IR and twelve healthy controls were included in the study. Baseline characteristics were comparable between groups, except for higher serum TAG (P < 0·05) and shorter bowel length (P < 0·0001) in the group with IR. Serum lutein, zeaxanthin, β-carotene and macular pigment optical density were >15 % lower in the patient group compared with healthy controls (P < 0·05, adjusted for age) and, in the case of serum lutein and zeaxanthin, also for dietary intake of carotenoids. Results suggest that for a test of macular carotenoid supplementation, subjects with a potentially clinically significant carotenoid deficit could be recruited among patients with IR.

Vitamins and Minerals in Inflammatory Bowel Disease

Indiscriminate use of multivitamin/mineral supplements in the general population may be misguided, but patients with chronic Inflammatory Bowel Diseases (IBD) should be monitored and compensated for nutritional deficiencies. Mechanistic links between vitamin/mineral deficiencies and IBD pathology has been found for some micronutrients and normalizing their levels is clinically beneficial. Others, like vitamin A, although instinctively desirable, produced disappointing results. Restoring normal levels of the selected micronutrients requires elevated doses to compensate for defects in absorptive or signaling mechanisms. This article describes some aspects of vitamin and mineral deficiencies in IBD, and summarizes pros and cons of supplementation.

Ophthalmic manifestations in patients with inflammatory bowel disease: A review

Clinical manifestations of inflammatory bowel disease (IBD) are not locally restricted to the gastrointestinal tract, and a significant portion of patients have involvement of other organs and systems. The visual system is one of the most frequently affected, mainly by inflammatory disorders such as episcleritis, uveitis and scleritis. A critical review of available literature concerning ocular involvement in IBD, as it appears in PubMed, was performed. Episcleritis, the most common ocular extraintestinal manifestation (EIM), seems to be more associated with IBD activity when compared with other ocular EIMs. In IBD patients, anterior uveitis has an insidious onset, it is longstanding and bilateral, and not related to the intestinal disease activity. Systemic steroids or immunosuppressants may be necessary in severe ocular inflammation cases, and control of the underlying bowel disease is important to prevent recurrence. Our review revealed that ocular involvement is more prevalent in Crohn’s disease than ulcerative colitis, in active IBD, mainly in the presence of other EIMs. The ophthalmic symptoms in IBD are mainly non-specific and their relevance may not be recognized by the clinician; most ophthalmic manifestations are treatable, and resolve without sequel upon prompt treatment. A collaborative clinical care team for management of IBD that includes ophthalmologists is central for improvement of quality care for these patients, and it is also cost-effective.

Important effect of micronutrient deficiency in inflammatory bowel disease

As is known to all, deficiencies of protein and other nutrients are common symptoms of inflammatory bowel disease (IBD). Nutrient deficiency is not only a manifestation of complicated diseases but also a cause of morbidity. Micronutrient is also the essential material for human health. However, there are few articles elaborating the influence of micronutrient deficiency. At present, choosing available food to keep healthy and to treat diseases is very popular, which is also suitable for IBD patients. Recent studies show that micronutrient deficiencies occur in more than half of patients with IBD, and deficiencies are more common in Crohn's disease than in ulcerative colitis, and in active disease than in disease in remission. Micronutrient deficiencies are associated with prolonged and complicated course of disease. The present review summarizes the effect of micronutrient deficiencies in IBD with regard to the definition of micronutrient, the deficiency status of micronutrient in IBD, the reasons for the lack of micronutrient and the role of micronutrient in the treatment of IBD.

Micronutrient deficiencies in inflammatory bowel disease

PURPOSE OF REVIEW

Malnutrition, protein-energy, and micronutrient deficiencies are common among patients with inflammatory bowel disease (IBD). The deficiencies are a manifestation of the complicated disease and a cause of morbidity. The present review summarizes recent advances and evidence-based knowledge regarding micronutrients in relation to patients with IBD.

RECENT FINDINGS

Micronutrient deficiencies occur in more than half of patients with IBD. Most common are deficiencies of iron, B12, vitamin D, vitamin K, folic acid, selenium, zinc, vitamin B6, and vitamin B1. Deficiencies are more common in Crohn's disease than in ulcerative colitis, and more in active disease than at times of remission. Micronutrient deficiency is associated with prolonged and complicated course of disease. Iron deficiency is the most common cause for anemia. Definite diagnosis of B12 deficiency cannot be established by serum levels alone. Vitamin D and vitamin K deficiencies are thought to be associated with heightened inflammatory state. The relationship of these deficiencies with bone disease is controversial. The present review focuses on the significance, epidemiology, treatment options, and recommendations regarding micronutrient deficiencies in IBD.

SUMMARY

Micronutrient deficiencies are common and have clinical significance. High suspicion for micronutrient deficiencies is advocated so that treatable causes of morbidity are treated appropriately and late and irreversible sequlae are prevented.

Recurrent episodes of night blindness in a patient with short bowel syndrome

PURPOSE

To describe clinical characteristics in a patient with recurrent episodes of night blindness due to vitamin A deficiency caused by short bowel syndrome in Crohn disease.

METHODS

Retrospective analysis of best-corrected visual acuity (BCVA), kinetic perimetry, slit-lamp biomicroscopy, ophthalmoscopy, fundus photography, fundus autofluorescence (FAF), spectral domain optical coherence tomography (SD-OCT), dark adaptometry (DA) and electroretinography (ERG). Serum vitamin A level was measured.

RESULTS

A 44-year-old man with a 3-year history of night blindness suffered from a short bowel syndrome with chronic malabsorption due to ileocecal resection in Crohn disease. Both eyes had a BCVA of 0.9, Bitot's spots of the conjunctiva and no significant fundus abnormalities. SD-OCT showed no remarkable changes, whereas FAF was brighter than normal in the center of the fovea. DA showed normal cone and a lack of rod function. The dark-adapted 0.01 ERG was non-detectable, the dark-adapted 3.0 ERG severely diminished, but the light-adapted 3.0 and 30 Hz flicker ERGs were within normal limits. Serum vitamin A level was 0.11 µg/ml (normal 0.30-0.65 µg/ml). Treatment with intravenous vitamin A caused a rapid recovery of night vision and ERG. However, during the following 3 years, he had three further episodes of night blindness with loss of rod function. During each period, parenteral vitamin A substitution brought complete recovery of night vision and rod function. BCVA, fundus, FAF findings and SD-OCT remained unchanged during the course.

CONCLUSIONS

In patients with known chronic malabsorption serum vitamin A level should be regularly checked to avoid recurrent night blindness episodes. ERG might be more sensitive than serum vitamin A level and is recommended in case of night blindness but still normal vitamin A level.

Acquired night blindness due to bad eating patterns

We report a case of acquired night blindness in a developed country (Spain) without risk factors for nutritional deficiency disease or family history of hereditary retinal disease. A 76-year-old woman presented with acquired night blindness of 6-month progression. After a thorough inquiry about eating patterns she becomes suspicious of vitamin A low dietary intake, which is analytically confirmed and successfully treated. Despite being very uncommon in our environment and even more in patients without digestive problems, in a patient reporting acquired night blindness vitamin A deficiency should not be discarded until eating patterns have been investigated. It might be especially relevant in certain socioeconomic situations and eating disorders such as bulimia or anorexia nervosa.

Electrophysiological and microperimetry changes in vitamin A deficiency retinopathy

PURPOSE

To describe a follow-up case of vitamin A deficiency (VAD)-related retinopathy with macular involvement monitored with electroretinography and microperimetry.

METHODS

Flash (ERG), pattern (PERG), and multifocal (mfERG) electroretinography were recorded in parallel with microperimetry before and during 7-month follow-up of vitamin A treatment on a 65-year-old man presented with a 1-year history of night blindness. The patient had undergone ileostomy procedure for Crohn's disease 14 years ago. His best corrected visual acuity was 6/6 in each eye. Fundus examination revealed macular and mid-peripheral yellow-white lesions compatible with drusen.

RESULTS

Before treatment, PERG was reduced, and mfERG was reduced and delayed, worse in responses from the central rings. These results revealed evidence of bilateral macular and central cone dysfunction. The flash ERG showed reduced dark-adapted 0.01 ERG (rod response); a-wave of dark-adapted 3.0 and 10.0 ERG was normal but b-wave was reduced (negative configuration); light-adapted 3.0 ERG was slightly reduced. The flash ERG revealed evidence of bilateral generalised retinal dysfunction affecting the rod more than cone system. Microperimetry showed deep reduction in retinal sensitivity. Fixation stability was unstable with eccentric locus. During treatment, ERG and microperimetry demonstrated significant improvements. Fixation stability reached normal values after the third treatment week.

CONCLUSIONS

This case illustrates the importance of electrophysiological investigation in early VAD-related retinopathy detection correlated with microperimetry. Our findings indicate a more delayed central cone function recovery than that of generalised rod and cone function. There was a marked correlation between ERG and microperimetric changes.