Letter: Zinc deficiency and cellular immune deficiency in acrodermatitis enteropathica

Zinc deficiency and its inherited disorders -a review

Zinc is an essential trace element required by all living organisms because of its critical roles both as a structural component of proteins and as a cofactor in enzyme catalysis. The importance of zinc in human metabolism is illustrated by the effects of zinc deficiency, which include a diminished immune response, reduced healing and neurological disorders. Furthermore, nutritional zinc deficiency can be fatal in newborn or growing animals. While zinc deficiency is commonly caused by dietary factors, several inherited defects of zinc deficiency have been identified. Acrodermatitis enteropathica is the most commonly described inherited condition found in humans. In several of the few cases that have been reported, this disorder is associated with mutations in the hZIP4 gene, a member of the SLC39 family, whose members encode membranebound putative zinc transporters. Mutations in other members of this family or in different genes may account for other cases of acrodermatitis in which defects in hZIP4 have not been detected. Another inherited form of zinc deficiency occurs in the lethal milk mouse, where a mutation in ZnT4 gene, a member of the SLC30 family of transmembrane proteins results in impaired secretion of zinc into milk from the mammary gland. A similar disorder to the lethal milk mouse occurs in humans. In the few cases studied, no changes in ZnT4 orthologue, hZnT4, were detected. This, and the presence of several minor phenotypic differences between the zinc deficiency in humans and mice, suggests that the human condition is caused by defects in genes that are yet to be identified. Taking into account the fact that there are no definitive tests for zinc deficiency and that this disorder can go undiagnosed, plus the recent identification of multiple members of the SCL30 and SLC39, it is likely that mutations in other genes may underlie additional inherited disorders of zinc deficiency.

Plasma copper and zinc concentration in individuals with autism correlate with selected symptom severity

AIM

To assess plasma zinc and copper concentration in individuals with autism and correlate these levels with symptom severity.

SUBJECTS AND METHODS

Plasma from 102 autistic individuals, and 18 neurotypical controls, were tested for plasma zinc and copper using inductively-coupled plasma-mass spectrometry. Copper and zinc levels and Cu/Zn were analyzed for possible correlation with severity of 19 symptoms.

RESULTS

Autistic individuals had elevated plasma levels of copper and Cu/Zn and lower, but not significantly lower, plasma Zn compared to neurotypical controls. There was a correlation between Cu/Zn and expressive language, receptive language, focus attention, hyperactivity, fine motor skills, gross motor skills and Tip Toeing. There was a negative correlation between plasma zinc concentration and hyperactivity, and fine motor skills severity.

DISCUSSION

These results suggest an association between plasma Cu/Zn and severity of symptoms associated with autism.

Analysis of Copper and Zinc Plasma Concentration and the Efficacy of Zinc Therapy in Individuals with Asperger's Syndrome, Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) and Autism

AIM

To assess plasma zinc and copper concentration in individuals with Asperger's Syndrome, Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) and autistic disorder, and to analyze the efficacy of zinc therapy on the normalization of zinc and copper levels and symptom severity in these disorders.

SUBJECTS AND METHODS

Plasma from 79 autistic individuals, 52 individuals with PDD-NOS, 21 individuals with Asperger's Syndrome (all meeting DSM-IV diagnostic criteria), and 18 age and gender similar neurotypical controls, were tested for plasma zinc and copper using inductively-coupled plasma-mass spectrometry.

RESULTS

Autistic and PDD-NOS individuals had significantly elevated plasma levels of copper. None of the groups (autism, Asperger's or PDD-NOS) had significantly lower plasma zinc concentrations. Post zinc and B-6 therapy, individuals with autism and PDD-NOS had significantly lower levels of copper, but individuals with Asperger's did not have significantly lower copper. Individuals with autism, PDD-NOS and Asperger's all had significantly higher zinc levels. Severity of symptoms decreased in autistic individuals following zinc and B-6 therapy with respect to awareness, receptive language, focus and attention, hyperactivity, tip toeing, eye contact, sound sensitivity, tactile sensitivity and seizures. None of the measured symptoms worsened after therapy. None of the symptoms in the Asperger's patients improved after therapy.

DISCUSSION

These results suggest an association between copper and zinc plasma levels and individuals with autism, PDD-NOS and Asperger's Syndrome. The data also indicates that copper levels normalize (decrease to levels of controls) in individuals with autism and PDD-NOS, but not in individuals with Asperger's. These same Asperger's patients do not improve with respect to symptoms after therapy, whereas many symptoms improved in the autism group. This may indicate an association between copper levels and symptom severity.

Increased Copper in Individuals with Autism Normalizes Post Zinc Therapy More Efficiently in Individuals with Concurrent GI Disease

AIM

To assess plasma zinc and copper concentration in individuals with autism.

SUBJECTS AND METHODS

Plasma from 79 autistic individuals, and 18 age and gender similar neurotypical controls, were tested for plasma zinc and copper using inductively-coupled plasma-mass spectrometry.

RESULTS

Autistic individuals had significantly elevated plasma levels of copper and Cu/Zn and lower, but not significantly lower, plasma Zn compared to neurotypical controls. Zn levels increased significantly in autistic individuals with and without GI disease after zinc therapy. Cu decreased significantly after zinc therapy in the GI disease group but not in the autistic group without GI disease. Autistic children significantly improved with respect to hyperactivity and stimming after zinc therapy in autistic children with GI disease. Autistic children without GI disease did not improve in these symptoms after the same therapy.

DISCUSSION

These results suggest an association between zinc and copper plasma levels and autism, and they suggest that zinc therapy may be most effective at lowering copper levels in autistic children with GI disease.

Analysis of plasma zinc and copper concentration, and perceived symptoms, in individuals with depression, post zinc and anti-oxidant therapy

AIM

To assess plasma Zn and Cu levels in individuals with depression.

SUBJECTS AND METHODS

Plasma from 73 clinically depressed individuals, 38 individuals with anxiety and 16 controls were tested for plasma Zn and Cu concentration using inductively-coupled plasma-mass spectrometry.

RESULTS

Depressed individuals, with and without secondary anxiety, had decreased plasma Zn and elevated plasma Cu compared to controls. Zn normalized (increased to the level of normal controls) but Cu increased in individuals with depression (with and without secondary anxiety), after Zn therapy, whereas both plasma Zn increased and Cu levels decreased in anxiety, with and without secondary depression, after Zn therapy. Individuals with depression,with and without secondary anxiety, had significantly higher symptom severity when compared to neurotypical controls. Symptom severity in individuals with anxiety (both with and without secondary depression) significantly decreased after Zn therapy, whereas symptoms remained the same in individuals with primary depression.

DISCUSSION

These data show an association between Zn and Cu plasma levels and clinically depressed individuals, and suggest that high Cu levels are associated with high symptom severity.

Decreased zinc and increased copper in individuals with anxiety

Aim:

To assess plasma zinc and copper levels in individuals with anxiety and to test the hypothesis that there is a relationship between copper and zinc concentration and improved symptoms.

Subjects and methods:

Serum from 38 individuals with anxiety and 16 neurotypical age, gender and size similar controls were tested for plasma zinc and copper concentration using inductively-coupled plasma-mass spectrometry. Zinc and copper levels, pre and post therapy, were compared and assessed for perceived anxiety symptoms.

Results:

In this preliminary study, individuals with anxiety had significantly higher plasma levels of Cu (P = 0.0348), Cu/Zn (P = 0.0493) and lower Zn (P = 0.0294) compared to controls. Zn levels normalized (increased to the normal range) and Cu/Zn significantly decreased after zinc therapy (P = 0.0004, P = 0.0033, respectively), but Cu did not significantly decrease (0.3577). These same patients improved significantly with respect to perceived overall symptoms after zinc and anti-oxidant therapy (P = 0.013).

Discussion:

These results suggest an association between Zn plasma levels and individuals with anxiety, demonstrate that zinc therapy is effective in increasing zinc plasma levels, and show that zinc supplementation may play a role in improved symptoms.

Reprogramming of the immune system during zinc deficiency

Thymic atrophy, lymphopenia, and compromised cell- and antibody-mediated responses that cause increased rates of infections of longer duration are the immunological hallmarks of zinc deficiency (ZD) in humans and higher animals. As the deficiency advances, a reprogramming of the immune system occurs, beginning with the activation of the stress axis and chronic production of glucocorticoids that accelerate apoptosis among pre-B and -T cells. This reduces lymphopoiesis and causes atrophy of the thymus. In contrast, myelopoiesis is preserved, thereby providing protection for the first line of immune defense or innate immunity. Changes in gene expression for cytokines, DNA repair enzymes, zinc transporters, signaling molecules, etc., suggest that cells of the immune system are attempting to adapt to the stress of suboptimal zinc. Better understanding of the molecular and cellular changes made in response to inadequate zinc should lead to the development of immunotherapeutic interventions.

Paraneoplastic dermatoses

Skin manifestations of systemic disease and malignancy are protean. The recognition of a potentially paraneoplastic dermatosis as such must prompt an investigation for occult malignancy. Lack of familiarity with cutaneous clues of internal malignancy may delay diagnosis and treatment of cancer. It is important to consider a paraneoplastic process in the differential diagnosis of a number of eruptive and treatment-resistant dermatoses. These dermatoses may be the first sign of an occult neoplasm. Their recognition may assist in cancer detection and the swift induction of appropriate therapy.

Recurrent aphthous ulceration with zinc deficiency and cellular immune deficiency

Zinc deficiency (serum zinc level 65 micrograms/dl) and cellular immune deficiency (confirmed by lymphoblastic transformation assay) were found in a 15-year-old boy who had had recurrent aphthous ulceration for 6 years. Despite the previous therapy (orally administered steroid, isoprinosine, interferon, lysozyme, and local treatment), the ulcers recurred monthly. After 3 months of zinc therapy (50 mg zinc sulfate orally three times daily) the aphthae disappeared and did not reappear for 1 year. The lymphoblastic transformation activity and serum zinc levels were also normalized with this treatment.

Clinical and laboratory diagnosis of acrodermatitis enteropathica

Acrodermatitis enteropathica is an inborn error of metabolism resulting in zinc malabsorption and severe zinc deficiency. From personal experience and a literature review the following conclusions were drawn: 1. Symptoms other than dermatitis, vary with age. Diarrhoea, mood changes, anorexia, and neurological disturbance were reported most frequently in infancy. Growth retardation, alopecia, weight loss and recurrent infections were prevalent in toddlers and schoolchildren. Spontaneous remission may occur at adolescence. 2. The severity of symptoms also varies. Intermittent or mild cases of the disease and those presenting with uncommon features such as ophthalmic, cerebral or hepatic involvement, are easily overlooked. In the severe cases this may result in a fatal outcome. If untreated, the overall mortality rate is 20%, being higher in males. 3. The laboratory diagnosis is hazardous. In patients, mean zinc values in serum, urine and hair were ca. 50% of normal levels. There is a 15% overlap with healthy controls; moreover, low zinc levels in serum, urine or hair are also found in other diseases. A more specific test is required. 4. In cases of doubt, in vitro or in vivo zinc absorption tests using radioisotopes (65Zn or 69mZn) may be performed. These appear not to be influenced by other conditions and show less overlap with controls. If such tests are unavailable, the clinical response to 3-30 mumol zinc/kg per day for 5 days may be awaited. This is recommended in infants or children with one or more symptoms of acrodermatitis enteropathica.

The effect of zinc on normal and neoplastic T-lymphocyte proliferation

After 24-72 h of PHA-stimulation, T-cells expressed the transferrin receptor. This receptor facilitates zinc uptake. Zinc transferrin stimulated DNA synthesis in pre-activated or activated, but not in resting T-cells. The regulatory nuclear protein matrix fraction increased from 5 to 40% of the total nuclear protein material in lymphocytes simultaneously with the initiation of DNA synthesis. In contrast, optimal concentration (0.1-0.4 mM) of zinc salts induced a mitogenic response in transferrin-receptor negative resting, but not in PHA-activated or leukemic T-cells. Higher concentrations were toxic. These findings can explain earlier reports on the effect of zinc on immunocompetence in zinc deficient mice and enteropathic acrodermatitis as well as present findings of a normalization of the T-suppressor-cell number in immunosuppressed patients.

Acrodermatitis enteropathica

A brief review of the clinical and biochemical features of Acrodermatitis enteropathica is given. This condition in now known to be caused by a systemic zinc deficiency secondary to a defect in the intestinal absorption of zinc and it illustrates the metabolic importance of this element in man.

Lymphocyte and granulocyte function in zinc-treated and zinc-deficient hemodialysis patients

Lymphocyte blast transformation and granulocyte motility were studied in 20 clinically stable hemodialysis patients, 10 of whom were receiving 50 mg of zinc (as zinc acetate) per day and 10 of whom were not. Plasma zinc concentration was significantly higher in zinc-treated than in untreated patients (108 +/- 5 vs. 82 +/- 2 micrograms/dl). Mononuclear cell subpopulation analysis showed equivalent proportions of T lymphocytes and monocytes in both groups, but B lymphocytes were reduced in untreated patients (10 +/- 0.7 vs 14 +/- 0.5%). Lymphocyte blast transformations in response to nonspecific mitogens, soluble antigen and mixed lymphocyte culture were not significantly different in the two groups, nor was lymphocyte zinc concentration. Zinc-treated patients showed significantly greater granulocyte responsiveness to zymosan-activated serum (21 +/- 1 vs. 14 +/- 2 mean), greater chemokinetic activity (50 +/- 4 vs. 27 +/- 3 mean) and higher granulocyte zinc concentration (114 +/- 6 vs. 47 +/- 2 micrograms/10(6) cells) than untreated patients. Granulocyte zinc correlated significantly with plasma zinc (r = 0.81, P less than 0.001) and with granulocyte motility (r = 0.63, P = 0.001). Moderate zinc deficiency in hemodialysis patients does not result in abnormal lymphocyte blast transformation in vitro, but it does result in granulocyte zinc depletion and impaired granulocyte motility.

Beneficial effects of oral zinc supplementation on the immune response of old people

Zinc is known to have beneficial effects on the immune response. In an attempt to modify age-associated immune dysfunction, supplemental zinc was administered to 15 subjects over 70 years of age (220 mg zinc sulfate twice daily for a month). As compared to 15 controls, matched for age and sex, there was a significant improvement in the following immune parameters in the treated group: (1) number of circulating T lymphocytes; (2) delayed cutaneous hypersensitivity reactions to purified protein derivative, Candidin and streptokinase-streptodornase; (3) immunoglobulin G (IgG) antibody response to tetanus vaccine. Zinc treatment had no influence on the number of total circulating leukocytes or lymphocytes, or on the in vitro lymphocyte response to three mitogens: phytohemagglutinin (PHA), concanavalin A (Con A) and pokeweed mitogen (PWM). The data suggest that the addition of zinc to the diet of old persons could be an effective and simple way to improve their immune function.

Protracted diarrhoea: secondary monosaccharide malabsorption and zinc deficiency with cutaneous manifestations during total parenteral nutrition

Protracted diarrhoea in early infancy gives rise to many diagnostic and therapeutic problems. Jejunal biopsy often reveals villous atrophy of varying degrees. Severe reduction of small intestinal absorptive area causes secondary monosaccharide malabsorption, as well as secondary disaccharide deficiency, consequences which are relevant in any attempts at oral feeding. Morphologic, metabolic, endocrinological and microbiological studies have to be undertaken in order to establish a definitive diagnosis in protracted diarrhoea, but these studies often fail to reveal the aetiology of the disease. Immunologic abnormalities like phagocyte dysfunction, thymic atrophy and hypoplasia of B-cell regions in lymph nodes might be secondary events, but some types of immunodeficiency are of primary importance in the development of protracted diarrhoea. Total parenteral nutrition in many cases has to be instituted, with all its implications and hazards: septicaemia is the most dangerous of these. Zinc deficiency and acrodermatitis enteropathica may occur during total parenteral nutrition, and zinc deficiency secondarily contributes to the symptoms of diarrhoea. Parenteral administration of zinc is able to overcome these effects.

Magnesium (and trace substance) deficiencies in the pathogenesis of cancer

Except for a few experimental models of magnesium (Mg)-deficiency-induced neoplasms, less attention has been paid in the past quarter century in the Western world to this macromineral than to the trace elements; e.g., selenium (Se) and zinc (Zn), and to vitamins, deficiencies of which are each considered probable factors in oncogenesis. Although early epidemiologic studies showed an inverse correlation between the amount of Mg in soil and water and the incidence of (gastric) cancer, and several animal studies supported the premise that Mg has a prophylactic effect against induction of cancer, other studies showed that Mg supplementation increased the growth of established experimental tumors. Thus, enthusiasm for this approach subsided. The early epidemiologic findings have since been confirmed, and there have been studies demonstrating the importance of Mg in maintaining immunocompetence, and others indicating that immunodeficiencies increase susceptibility to the development of cancer. Evidence has now accrued that indicates that Mg deficiency increases susceptibility to chemical oncogens. The abnormal metabolism of tryptophan (yielding a carcinogenic metabolite) that indicates functional or absolute pyridoxine deficiency is an indirect clue to Mg deficiency. Vitamin B6-activated enzymes require Mg as a cofactor. However, the early warnings against the use of Mg as part of an antineoplastic program against established cancer were justified, since rapidly metabolizing cells (such as cancers) are dependent on Mg.There are similarities between experiences with Mg and with Se and Zn. All three are required for normal metabolism; Se also protects against free radicals in the environment. Mg and Zn have increased established tumor growth, and their depletion has been applied to antineoplastic programs, with risks comparable to those of using antimetabolic agents.

Hepatic complications

Hepatic dysfunction is one of the most common complications following major surgical intervention, and it presents a wide spectrum of clinical manifestations as discussed. Recent progress in hepatology has provided better knowledge in etiology and pathophysiology of hepatic dysfunction and its sequelae. In addition, modern medical technology has made the diagnosis of liver disease easier and more precise. Underlying liver disease should be disclosed precisely prior to surgery and surgical complication minimized for patients with hepatic impairment. If hepatic complications occur following surgical intervention, the most logical etiology and pathophysiologic explanation should be found, utilizing all the clinical and laboratory data and diagnostic procedures in order to institute proper treatment. Specific complications in hepatic surgery are also discussed. A good understanding of pathophysiologic alterations following hepatic surgery is mandatory together with detailed anatomic knowledge and surgical skill in order to prevent and to treat serious complications.

Effect of zinc on thymus of recently malnourished children

Zinc-deficient animals and children have thymic atrophy and an increased susceptibility to infections. Children with protein-energy malnutrition similarly have thymic atrophy, zinc deficiency, and increased susceptibility to infections. 8 children, recently malnourished, who were supplemented with zinc, showed an increase in thymic size as judged radiographically. It is suggested that zinc deficiency may play a part in the thymic atrophy and infections associated with malnutrition.