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Lubega G, Lutaakome J, Kibirige M, Opoka D, Atukunda I, Ruzagira E. Vitamin B12 deficiency presenting as progressive blindness in a 33-year-old HIV-positive female patient on Efavirenz-based regimen: case report. Pan Afr Med J 2024; 47:164. [PMID: 39036015 PMCID: PMC11260043 DOI: 10.11604/pamj.2024.47.164.43048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/19/2024] [Indexed: 07/23/2024] Open
Abstract
Optic neuritis is a rare presentation of vitamin B12 deficiency. We describe a 33-year-old female patient living with HIV presenting with progressive loss of vision for 1 week. She had a history of severe peripheral neuropathy that was managed with vitamin B12-containing tablets approximately three years before presenting with progressive loss of vision. On examination, she had no perception of light in the left eye and no perception of hand motion in the right eye. The fundus in her left eye had mild blurring of disc margins. Results from tests done showed a haemoglobin of 12.9g/dl, MCV 101fl, a serum vitamin B12 of 78pmol/l, and cytomegalovirus (CMV) test showed no active disease. She was diagnosed with optic neuritis and started on 30 mg tablets of prednisolone for 1 week with slight improvement. She was then started on vitamin B12 injections 1 mg daily for 10 days and thereafter, monthly for 6 months. She reported gradual improvement and regained her sight after 5 months treatment of with Vitamin B12 injections. Ophthalmic manifestations of vitamin B12 deficiency are not common and may present without haematological signs therefore, a high index of suspicion is required for early diagnosis and management of vitamin B12 deficiency.
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Affiliation(s)
- Gloria Lubega
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Moses Kibirige
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Daniel Opoka
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Immaculate Atukunda
- Makerere University, College of Health Sciences, Department of Ophthalmology, Kampala, Uganda
| | - Eugene Ruzagira
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
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2
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Zanella PB. Highlights of the importance of vitamin B 12 for neurological and cognitive function: from pregnancy to childhood. Br J Nutr 2023; 130:1034-1035. [PMID: 36503533 DOI: 10.1017/s0007114522003920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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3
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Berger MM, Talwar D, Shenkin A. Pitfalls in the interpretation of blood tests used to assess and monitor micronutrient nutrition status. Nutr Clin Pract 2023; 38:56-69. [PMID: 36335431 DOI: 10.1002/ncp.10924] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/17/2022] [Accepted: 10/02/2022] [Indexed: 11/09/2022] Open
Abstract
Assessment of micronutrient (MN) status is of particular importance in patients who require medical nutrition therapy, especially those requiring parenteral nutrition. Blood testing is generally the only tool available in clinical settings to assess MN status. However, using plasma or serum concentration faces pitfalls mainly because of the impact of inflammation that diverts the MNs from the circulating compartment. This review aims to review the blood tests that are useful and provide information about how to integrate functional markers of status to reach a clinically relevant diagnosis. Most impacted, with a significant and proportional decrease in plasma concentrations, are iron, selenium, zinc, thiamin, folic acid, cobalamin, and vitamins A, C, and D; copper is the only MN for which the plasma concentration increases. Therefore, a surrogate marker of inflammation, C-reactive protein, must always be determined simultaneously. Validated intracellular and functional tests are proposed to improve status assessment. A protocol is suggested for tests required both on commencing and during nutrition support. A timely turnaround of analysis is essential for results to be clinically useful. In some cases, the appropriate provision of MNs should be commenced before results have been obtained to confirm the clinical assessment. Laboratory tests of MN status are an area prone to misuse and misinterpretation. The appropriate use and interpretation of such tests are essential to ensure the correct management of nutrition problems.
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Affiliation(s)
- Mette M Berger
- Department of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Dinesh Talwar
- Scottish Trace Element and Micronutrient Diagnostic and Research Laboratory, Department of Clinical Biochemistry, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Alan Shenkin
- Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
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4
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Reversible Splenial Lesion Syndrome (RESLES) after Nitrous Oxide Abuse: A Case Report. Brain Sci 2022; 12:brainsci12101284. [DOI: 10.3390/brainsci12101284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/16/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Reversible splenial-lesion syndrome (RESLES) is a relatively rare and underrecognized clinical-imaging syndrome involving the splenium of the corpus callosum (SCC). RESLES can be caused by various etiologies. Case description: An 18-year-old man with no previous history of neurological or psychiatric disorders presented to our hospital with headache, intermittent blurred vision, and limb weakness after 150 days of recreational nitrous-oxide abuse. The patient’s serum vitamin B12 concentration was normal, and magnetic-resonance imaging (MRI) examination revealed isointensity on T1-weighted imaging (T1WI) of the corpus callosum and high signal intensity on T2WI, T2FLAIR, and diffusion-weighted MRI (DWI); thus, a diagnosis of RESLES was established. The patient received 0.5 mg of mecobalamin daily and nitrous oxide was discontinued. After 4 weeks, the patient’s symptoms disappeared and the imaging examination revealed normal findings. Conclusion: We report for the first time a case of headache, blurred vision, and hallucination caused by RESLES associated with nitrous-oxide abuse. In cases of headaches and hallucinations of unknown etiology, the possibility of RESLES caused by nitrous oxide abuse should be considered.
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Mullins E, Bresson J, Dalmay T, Dewhurst IC, Epstein MM, Firbank LG, Guerche P, Hejatko J, Moreno FJ, Nogue F, Rostoks N, Sanchez Serrano JJ, Savoini G, Veromann E, Veronesi F, Casacuberta J, Zurbriggen MD, Fernandez A, Gomez Ruiz JA, Gennaro A, Papadopoulou N, Lanzoni A, Naegeli H. Evaluation of existing guidelines for their adequacy for the food and feed risk assessment of genetically modified plants obtained through synthetic biology. EFSA J 2022; 20:e07410. [PMID: 35873722 PMCID: PMC9297787 DOI: 10.2903/j.efsa.2022.7410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Synthetic biology (SynBio) is an interdisciplinary field at the interface of molecular engineering and biology aiming to develop new biological systems and impart new functions to living cells, tissues and organisms. EFSA has been asked by the European Commission to evaluate SynBio developments in agri-food with the aim of identifying the adequacy and sufficiency of existing guidelines for risk assessment and determine if updated guidance is needed. In this context, the GMO Panel has previously adopted an Opinion evaluating the SynBio developments in agri-food/feed and the adequacy and sufficiency of existing guidelines for the molecular characterisation and environmental risk assessment of genetically modified plants (GMPs) obtained through SynBio and reaching the market in the next decade. Complementing the above, in this Opinion, the GMO Panel evaluated the adequacy and sufficiency of existing guidelines for the food and feed risk assessment of GMPs obtained through SynBio. Using selected hypothetical case studies, the GMO Panel did not identify novel potential hazards and risks that could be posed by food and feed from GMPs obtained through current and near future SynBio approaches; considers that the existing guidelines are adequate and sufficient in some Synbio applications; in other cases, existing guidelines may be just adequate and hence need updating; areas needing updating include those related to the safety assessment of new proteins and the comparative analysis. The GMO Panel recommends that future guidance documents provide indications on how to integrate the knowledge available from the SynBio design and modelling in the food and feed risk assessment and encourages due consideration to be given to food and feed safety aspects throughout the SynBio design process as a way to facilitate the risk assessment of SynBio GMPs and reduce the amount of data required.
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6
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White ND. Vitamin B12 and Plant-Predominant Diets. Am J Lifestyle Med 2022; 16:295-297. [PMID: 35706595 PMCID: PMC9189588 DOI: 10.1177/15598276221076102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Vitamin B12 deficiencies are common in individuals consuming plant-predominant diets, including those who consume diary and/or eggs. Deficiencies can lead to megaloblastic anemia and peripheral neuropathy, among other multi-system manifestations. The prevalence, assessment and prevention of vitamin B12 deficiency in patients following plant-predominant diets will be discussed.
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7
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Pierzchala K, Simicic D, Sienkiewicz A, Sessa D, Mitrea S, Braissant O, McLin VA, Gruetter R, Cudalbu C. Central nervous system and systemic oxidative stress interplay with inflammation in a bile duct ligation rat model of type C hepatic encephalopathy. Free Radic Biol Med 2022; 178:295-307. [PMID: 34890769 DOI: 10.1016/j.freeradbiomed.2021.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 12/06/2021] [Indexed: 02/07/2023]
Abstract
The role and coexistence of oxidative stress (OS) and inflammation in type C hepatic encephalopathy (C HE) is a subject of intense debate. Under normal conditions the physiological levels of intracellular reactive oxygen species are controlled by the counteracting antioxidant response to maintain redox homeostasis. Our previous in-vivo1H-MRS studies revealed the longitudinal impairment of the antioxidant system (ascorbate) in a bile-duct ligation (BDL) rat model of type C HE. Therefore, the aim of this work was to examine the course of central nervous system (CNS) OS and systemic OS, as well as to check for their co-existence with inflammation in the BDL rat model of type C HE. To this end, we implemented a multidisciplinary approach, including ex-vivo and in-vitro electron paramagnetic resonance spectroscopy (EPR) spin-trapping, which was combined with UV-Vis spectroscopy, and histological assessments. We hypothesized that OS and inflammation act synergistically in the pathophysiology of type C HE. Our findings point to an increased CNS- and systemic-OS and inflammation over the course of type C HE progression. In particular, an increase in the CNS OS was observed as early as 2-weeks post-BDL, while the systemic OS became significant at week 6 post-BDL. The CNS EPR measurements were further validated by a substantial accumulation of 8-Oxo-2'-deoxyguanosine (Oxo-8-dG), a marker of oxidative DNA/RNA modifications on immunohistochemistry (IHC). Using IHC, we also detected increased synthesis of antioxidants, glutathione peroxidase 1 (GPX-1) and superoxide dismutases (i.e.Cu/ZnSOD (SOD1) and MnSOD (SOD2)), along with proinflammatory cytokine interleukin-6 (IL-6) in the brains of BDL rats. The presence of systemic inflammation was observed already at 2-weeks post-surgery. Thus, these results suggest that CNS OS is an early event in type C HE rat model, which seems to precede systemic OS. Finally, our results suggest that the increase in CNS OS is due to enhanced formation of intra- and extra-cellular ROS rather than due to reduced antioxidant capacity, and that OS in parallel with inflammation plays a significant role in type C HE.
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Affiliation(s)
- K Pierzchala
- Center for Biomedical Imaging, EPFL, Lausanne, Switzerland; Animal Imaging and Technology, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland; Laboratory of Functional and Metabolic Imaging, EPFL, Lausanne, Switzerland.
| | - D Simicic
- Center for Biomedical Imaging, EPFL, Lausanne, Switzerland; Animal Imaging and Technology, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland; Laboratory of Functional and Metabolic Imaging, EPFL, Lausanne, Switzerland
| | - A Sienkiewicz
- Laboratory for Quantum Magnetism, Institute of Physics, EPFL, Lausanne, Switzerland; ADSresonances Sàrl, Préverenges, Switzerland
| | - D Sessa
- Swiss Pediatric Liver Center, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals Geneva and University of Geneva, Geneva, Switzerland
| | - S Mitrea
- Center for Biomedical Imaging, EPFL, Lausanne, Switzerland; Animal Imaging and Technology, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - O Braissant
- Service of Clinical Chemistry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - V A McLin
- Swiss Pediatric Liver Center, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals Geneva and University of Geneva, Geneva, Switzerland
| | - R Gruetter
- Center for Biomedical Imaging, EPFL, Lausanne, Switzerland; Laboratory of Functional and Metabolic Imaging, EPFL, Lausanne, Switzerland
| | - C Cudalbu
- Center for Biomedical Imaging, EPFL, Lausanne, Switzerland; Animal Imaging and Technology, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
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8
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A Brief Review on Vitamin B 12 Deficiency Looking at Some Case Study Reports in Adults. Int J Mol Sci 2021; 22:ijms22189694. [PMID: 34575856 PMCID: PMC8471716 DOI: 10.3390/ijms22189694] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/28/2021] [Accepted: 09/04/2021] [Indexed: 11/16/2022] Open
Abstract
In the era of evidence-based medicine, the randomized clinical trial corresponds to the top step in the qualitative scale of the evidence available in the literature, while small series of cases or the description of individual cases occupy the last place. However, the latter represent an important part of clinical practice and have significantly influenced the evolution of medicine, contributing significantly to the advancement of scientific knowledge. Vitamin B12 deficiency shares several common symptoms that affect several tissues and organs with health aliments, so its diagnosis could be unobvious for the broad array of its effects and investigation methods used. In this review, we focused our attention on some case reports related to the vitamin B12 deficiency associated to anemia, neurologic disorders, and hyperhomocysteinemia. B12 deficiency reversal is simply achieved by prompt therapy, even though it is not the same for several disorders.
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9
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Dorsal thoracic arachnoid web – Confounders of a rare entity in the developing setting. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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10
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Gupta S, Dixit PK, Prasad AS. Myositis in a patient with coronavirus disease 2019: A rare presentation. Med J Armed Forces India 2021; 77:S486-S489. [PMID: 34334917 PMCID: PMC8313044 DOI: 10.1016/j.mjafi.2020.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/17/2020] [Indexed: 01/08/2023] Open
Abstract
The world is presently struggling with coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A patient with COVID-19 typically presents with fever, non-productive cough, dyspnea, and myalgia. A 49-year-old female presented with complaints of subacute onset and progressive symmetrical proximal muscle weakness of both upper limbs and lower limbs with no sensory, cranial nerve deficit. She had elevated creatine phosphokinase levels of 906 U/L, an aspartate aminotransferase level of 126 IU/L, a lactate dehydrogenase level of 354 U/L, and an erythrocyte sedimentation rate of 68 mm/1 hr, and magnetic resonance imaging of the pelvis and thigh revealed muscle edema suggestive of myositis. Her reverse transcriptase-polymerase chain reaction result for SARS-CoV-2 was positive. Her evaluation for other causes of myositis was negative. She was managed with intravenous immunoglobulins and supportive care. She showed rapid improvement in symptoms and motor weakness. To our knowledge, this is the first reported case of COVID-19 related disabling myositis in India.
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Affiliation(s)
- Salil Gupta
- Consultant (Medicine), Command Hospital (AF), Bengaluru, India
| | - Prashant Kumar Dixit
- Graded Specialist (Medicine), Command Hospital (AF), Bengaluru, India
- Corresponding author.
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11
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Electrochemical sensors as a versatile tool for the quantitative analysis of Vitamin B12. CHEMICAL PAPERS 2021. [DOI: 10.1007/s11696-021-01574-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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12
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Chen X, Wang R, Huang X, Yang F, Yu S. The Level of Serum Pepsinogen in Diagnosing and Evaluating the Severity of Subacute Combined Degeneration Due to Vitamin B12 Deficiency. Front Neurol 2021; 12:604523. [PMID: 33815244 PMCID: PMC8017177 DOI: 10.3389/fneur.2021.604523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/04/2021] [Indexed: 12/14/2022] Open
Abstract
Subacute combined degeneration (SCD) is a neurological complication of cobalamin deficiency, which is usually caused by chronic autoimmune atrophic gastritis. Serum pepsinogen 1 and the ratio of pepsinogen 1/pepsinogen 2 (PG1/2) can reflect the severity of gastric atrophy. Objective: This work aims to investigate whether decreased serum PG1 and PG1/2 ratio are helpful in diagnosing SCD and reflecting the severity of SCD. Methods: We retrospectively analyzed the clinical and laboratory tests of 65 cases of SCD due to vitamin B12 deficiency and compared the laboratory parameters of SCD with 65 age- and sex-matched amyotrophic lateral sclerosis (ALS) patients. Results: PG1 and PG1/2 ratio were decreased in 80 and 52.3% of SCD patients, respectively. Compared to patients with PG1/2 ratio ≥3.0, patients with PG1/2 ratio <3.0 had more severe anemia, larger mean corpuscular volume (MCV), lower level of vitamin B12, higher folate and homocysteine (Hcy), more severe changes in somatosensory evoked potential (SEP), and higher rate of lesions in spinal MRI (P < 0.05). PG1 and PG1/2 ratio had inverse correlation with MCV and N20 latency in SEP examination (P < 0.05). PG1/2 ratio, RBC count, and Hcy were independent risk factors for SCD in logistic regression analyses. The ROC curve analysis revealed that the diagnostic accuracy of PG1 and PG1/2 ratio was 72.2 and 73.0%, respectively, while the cutoff values were 22.4 ng/ml and 2.43 for SCD, respectively. Conclusions: Decreased PG1 and PG1/2 ratio are helpful for the diagnosis and evaluation of the severity of SCD due to vitamin B12 deficiency.
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Affiliation(s)
- Xiaoyan Chen
- Department of Neurology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Rong Wang
- Department of Neurology, First Medical Center of Chinese PLA General Hospital, Beijing, China.,General Hospital of Taiyuan Iron and Steel (Group, Co., Ltd.) Shanxi, China
| | - Xusheng Huang
- Department of Neurology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Fei Yang
- Department of Neurology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Shengyuan Yu
- Department of Neurology, First Medical Center of Chinese PLA General Hospital, Beijing, China
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13
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Das S, Dubey S, Pandit A, Ray BK. Myeloradiculoneuropathy due to vitamin B 12 deficiency: an unusual clinical and radiological presentation. BMJ Case Rep 2021; 14:e239415. [PMID: 33495192 PMCID: PMC7839883 DOI: 10.1136/bcr-2020-239415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 01/27/2023] Open
Abstract
A 42-year-old man from rural India presented with asymmetric progressive paraparesis mimicking compressive dorsal myelopathy, followed by distal upper limb, truncal and neck-flexor weakness, further complicated by acute urinary retention. His sensory deficits were marked by loss of joint position sense (JPS) and graded loss of vibration sense, along with a definite sensory level. Deep tendon jerks were hypo-to-areflexic, plantar was bilaterally extensor. He had become less attentive and occasionally failed to keep track with conversations. A syndromic diagnosis of myeloradiculoneuropathy with cognitive impairments was made. Further tailored investigations revealed vitamin B12 deficiency with positive anti-parietal cell antibody. Diagnosis of subacute combined cord degeneration (SACD) was confirmed. Neuro-imaging revealed intramedullary intensity changes only along lateral aspect of spinal cord instead of characteristic posterior involvement. Following parenteral vitamin B12 supplementation, patient started showing improvement in motor power and subjective sensory symptoms. His bladder symptoms persisted initially, however recovered finally after 6 months.
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Affiliation(s)
- Shambaditya Das
- Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Souvik Dubey
- Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Alak Pandit
- Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Biman Kanti Ray
- Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
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Arıcan P, Bozkurt O, Cavusoglu D, Gencpınar P, Haspolat S, Duman O, Olgac Dundar N. Various Neurological Symptoms with Vitamin B12 Deficiency and Posttreatment Evaluation. J Pediatr Neurosci 2021; 15:365-369. [PMID: 33936299 PMCID: PMC8078635 DOI: 10.4103/jpn.jpn_130_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/16/2020] [Accepted: 01/16/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Vitamin B12 deficiency occurs primarily as a result of insufficient dietary intake in children in developing countries. Vitamin B12 deficiency produces a cluster of neurological symptoms in children. Aim: The aim of this study was to describe the vitamin B12 status of patients who were admitted with neurological symptoms and to evaluate the clinical response to vitamin B12 treatment. Materials and Methods: This study was conducted on children who had vitamin B12 deficiency presented with neurological findings from January 2014 to October 2016. Patients with serum vitamin B12 levels lower than 300 pg/mL received intramuscular or oral vitamin B12 treatment. Results: Three hundred and fifty-one patients presenting with neurologic symptoms and who had low serum vitamin B12 deficiency were analyzed. Our study population was composed mainly of adolescent age. The most common symptom with respect to age was headache. In infant patients, most common symptoms were seizure and developmental delay. Conclusion: Early diagnosis and vitamin B12 treatment are advocated to avoid long-term injury. Our study shows that patients with serum vitamin B12 levels lower than 300 pg/mL showed clinical improvement of neurological symptoms after receiving vitamin B12 treatment.
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Affiliation(s)
- Pinar Arıcan
- Department of Pediatric Neurology, Izmir Tepecik Education and Research Hospital, Izmir, Turkey
| | - Oznur Bozkurt
- Department of Pediatric Neurology, Akdeniz University, Antalya, Turkey
| | - Dilek Cavusoglu
- Department of Pediatric Neurology, Izmir Katip Celebi University, Izmir, Turkey
| | - Pinar Gencpınar
- Department of Pediatric Neurology, Izmir Katip Celebi University, Izmir, Turkey
| | - Senay Haspolat
- Department of Pediatric Neurology, Akdeniz University, Antalya, Turkey
| | - Ozgur Duman
- Department of Pediatric Neurology, Akdeniz University, Antalya, Turkey
| | - Nihal Olgac Dundar
- Department of Pediatric Neurology, Izmir Katip Celebi University, Izmir, Turkey
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15
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Nutrition and Sarcopenia-What Do We Know? Nutrients 2020; 12:nu12061755. [PMID: 32545408 PMCID: PMC7353446 DOI: 10.3390/nu12061755] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023] Open
Abstract
Muscle health is important for the functionality and independence of older adults, and certain nutrients as well as dietary patterns have been shown to offer protective effects against declines in strength and function associated with aging. In this paper, micronutrients, macronutrients, and food groups have been reviewed, along with their studied effects on the prevalence and incidence of sarcopenia, as well as their ability to preserve muscle mass and optimize physical performance. Randomized controlled trials appear to suggest a critical role for dietary intake of protein in preventing sarcopenia and muscle loss, although the optimal dose and type of protein is unknown. There are some promising data regarding the role of vitamin D and sarcopenia, but it is unclear whether the dose, frequency of dose, or length of treatment impacts the efficacy of vitamin D on improving muscle mass or function. Selenium, magnesium, and omega 3 fatty acids have been studied as supplements in clinical trials and in the diet, and they appear to demonstrate a potential association with physical activity and muscle performance in older individuals. Following the Mediterranean diet and higher consumption of fruits and vegetables have been associated with improved physical performance and protection against muscle wasting, sarcopenia, and frailty.
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16
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Winstock AR, Ferris JA. Nitrous oxide causes peripheral neuropathy in a dose dependent manner among recreational users. J Psychopharmacol 2020; 34:229-236. [PMID: 31679459 DOI: 10.1177/0269881119882532] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Nitrous oxide (N2O) has been used in clinical and recreational settings for over 150 years. Through inactivation of the Vitamin B12 dependent enzyme, methionine synthase, N2O can lead to the development of peripheral neuropathy. This study sought to determine the relationship between the exposure and risk of neurological symptoms in the largest ever sample of users. DESIGN Data are drawn from the Global Drug Survey (GDS) over three consecutive years (2014-2016). The Global Drug Survey is an online, cross-sectional survey of substance use, translated into multiple languages. PARTICIPANTS Respondents to the Global Drug Survey who provided details on N2O use and the experience of paraesthesia in the previous 12 months. MEASUREMENTS Questions relating to N2O use, peripheral neuropathy, age and gender were explored among last year's users. FINDINGS Of 241,566 respondents, 41,181 (17.0%) indicated that they had ever used nitrous oxide; of these, 42.1% had used in the last 12 months. For the final model, data from 16,124 participants who had used N2O in the last 12 months and had provided responses on age, dose, gender and paraesthesia were used. Of these, the number of respondents reporting persistent numbness/tingling (paraesthesia) in their hands or feet was 537 (3.3%). Although the risk was very low among infrequent users, there was a strong dose-response relationship. For people indicating one or two doses per session, the probability of reporting paraesthesia was approximately 0.018 by comparison; for people indicating 100 doses per session the probability was approximately 0.085. The association, between dose and paraesthesia was influenced by gender and age. CONCLUSION While infrequent, episodic users are not at risk, a minority of heavy users are at dose-dependent risk of developing serious neurological consequences. Better education and raised awareness of early symptoms are required.
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Affiliation(s)
- Adam R Winstock
- Institute of Epidemilogy and Health Care, University College London, London, UK.,Global Drug Survey, London, UK
| | - Jason A Ferris
- Centre for Health Services Research, Faculty of Medicine, University of Queensland, Woolloongabba, QLD, Australia
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17
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Naik S, Mahalle N, Greibe E, Ostenfeld MS, Heegaard CW, Nexo E, Fedosov SN. Cyano-B12 or Whey Powder with Endogenous Hydroxo-B12 for Supplementation in B12 Deficient Lactovegetarians. Nutrients 2019; 11:nu11102382. [PMID: 31590426 PMCID: PMC6835307 DOI: 10.3390/nu11102382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 12/31/2022] Open
Abstract
Lactovegetarians (n = 35) with low vitamin B12 (B12) status were intervened for eight weeks capsules containing cyano-B12 (CN-B12), (2 × 2.8 µg/day), or equivalent doses of endogenous B12 (mainly hydroxo-B12 (HO-B12)) in whey powder. Blood samples were examined at baseline, every second week during the intervention, and two weeks post-intervention. The groups did not differ at baseline in [global median (min/max)] plasma B12 [112(61/185)] pmol/L, holotranscobalamin [20(4/99)] pmol/L, folate [13(11/16)], the metabolites total homocysteine [18(9/52)] µmol/L and methylmalonic acid [0.90(0.28/2.5)] µmol/L, and the combined indicator of B12 status (4cB12) [-1.7(-3.0/-0.33)]. Both supplements caused significant effects, though none of the biomarkers returned to normal values. Total plasma B12 showed a higher increase in the capsule group compared to the whey powder group (p = 0.02). However, the increase of plasma holotranscobalamin (p = 0.06) and the lowering of the metabolites (p > 0.07) were alike in both groups. Thereby, the high total plasma B12 in the capsule group was not mirrored in enhanced B12 metabolism, possibly because the B12 surplus was mainly accumulated on an "inert" carrier haptocorrin, considered to be of marginal importance for tissue delivery of B12. In conclusion, we demonstrate that administration of whey powder (HO-B12) or capsules (CN-B12) equivalent to 5.6 µg of B12 daily for eight weeks similarly improves B12 status but does not normalize it. We document that the results for plasma B12 should be interpreted with caution following administration of CN-B12, since the change is disproportionately high compared to the responses of complementary biomarkers.
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Affiliation(s)
- Sadanand Naik
- Department of Pathology, Deenanath Mangeshkar Hospital and Research Center, Pune, 411004, India.
| | - Namita Mahalle
- Department of Pathology, Deenanath Mangeshkar Hospital and Research Center, Pune, 411004, India.
| | - Eva Greibe
- Department of Clinical Biochemistry and Institute of Clinical Medicine, Aarhus University Hospital, DK-8200 Aarhus N, Denmark.
| | | | - Christian W Heegaard
- Department of Molecular Biology and Genetics, Aarhus University, DK-8000 Aarhus C, Denmark.
| | - Ebba Nexo
- Department of Clinical Biochemistry and Institute of Clinical Medicine, Aarhus University Hospital, DK-8200 Aarhus N, Denmark.
| | - Sergey N Fedosov
- Department of Molecular Biology and Genetics, Aarhus University, DK-8000 Aarhus C, Denmark.
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18
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Fava E, Kofler M, Saltuari L. Reversible cutaneous silent period abnormalities in vitamin B12 deficiency: A case report. Clin Neurophysiol Pract 2019; 4:128-132. [PMID: 31249907 PMCID: PMC6586985 DOI: 10.1016/j.cnp.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/29/2019] [Accepted: 05/15/2019] [Indexed: 11/30/2022] Open
Abstract
Polyneuropathy is a frequent neurological manifestation of B12 hypovitaminosis. Thin-myelinated A-delta fibers may be affected in B12 hypovitaminosis. CSP testing is a useful diagnostic tool for A-delta fiber function in B12 deficiency.
Objectives Vitamin B12 deficiency is common in adult and elderly patients and is often underdiagnosed because of its polymorphous manifestations. Neurological symptoms of this condition include subacute combined degeneration and polyneuropathy, with possible affection of thin-myelinated A-delta fibers. Cutaneous silent periods (CSPs) may serve to test small-diameter fiber function non-invasively, using routine electrodiagnostic equipment, but to the best of our knowledge have not been studied so far in vitamin B12 deficiency. Methods We report a 49-year-old male patient suffering from B12 hypovitaminosis due to autoantibodies against gastric parietal cells, who underwent neurophysiological investigation to confirm clinically suspected polyneuropathy during the first month of intramuscular vitamin B12 supplementation. We performed standard electroneurography, needle electromyography in tibialis anterior muscle, quantitative sensory testing, and cutaneous silent periods six months after symptom onset and repeated the electrodiagnostic study 21 months later, after intramuscular vitamin B12 supplementation. Results Standard electroneurography demonstrated axonal sensory polyneuropathy. Needle electromyography (EMG) in tibialis anterior muscle was unremarkable. Cutaneous silent periods in tibialis anterior muscle after noxious electrical sural nerve stimulation were delayed, with incomplete EMG suppression concurring with dysfunction of thin-myelinated A-delta fibers. Quantitative sensory testing revealed altered cold and warm perception thresholds in both upper limbs, but normal values in both lower limbs. A follow-up electrodiagnostic study after 21 months intramuscular vitamin B12 supplementation revealed improvement of all neurophysiological findings, including normalization of cutaneous silent periods. Conclusions Thin-myelinated A-delta fibers may be affected in B12 hypovitaminosis and may show recovery after intramuscular vitamin B12 supplementation. CSP may serve to diagnose small fiber affection in this medical condition and to monitor their recovery after vitamin supplementation. Significance CSP testing represents a useful, non-invasive, rapidly available diagnostic and follow-up tool in vitamin B12 deficiency.
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Affiliation(s)
- Elena Fava
- Department of Neurology, Hochzirl Hospital, Zirl, Austria
| | - Markus Kofler
- Department of Neurology, Hochzirl Hospital, Zirl, Austria
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19
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Massironi S, Zilli A, Elvevi A, Invernizzi P. The changing face of chronic autoimmune atrophic gastritis: an updated comprehensive perspective. Autoimmun Rev 2019; 18:215-222. [PMID: 30639639 DOI: 10.1016/j.autrev.2018.08.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 08/30/2018] [Indexed: 02/07/2023]
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20
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Jolobe OMP. The wider implications of suspected cobalamin deficiency myelopathy. QJM 2018; 111:427. [PMID: 29474664 DOI: 10.1093/qjmed/hcy034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- O M P Jolobe
- From the Division of medicine, Manchester Medical Society, Simon Building, Brunswick Street, Manchester M13 9PL, UK
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21
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Selected B vitamins and their possible link to the aetiology of age-related sarcopenia: relevance of UK dietary recommendations. Nutr Res Rev 2018; 31:204-224. [DOI: 10.1017/s0954422418000045] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractThe possible roles of selected B vitamins in the development and progression of sarcopenia are reviewed. Age-related declines in muscle mass and function are associated with huge and increasing costs to healthcare providers. Falls and loss of mobility and independence due to declining muscle mass/function are associated with poor clinical outcomes and their prevention and management are attractive research targets. Nutritional status appears a key modifiable and affordable intervention. There is emerging evidence of sarcopenia being the result not only of diminished anabolic activity but also of declining neurological integrity in older age, which is emerging as an important aspect of the development of age-related decline in muscle mass/function. In this connection, several B vitamins can be viewed as not only cofactors in muscle synthetic processes, but also as neurotrophic agents with involvements in both bioenergetic and trophic pathways. The B vitamins thus selected are examined with respect to their relevance to multiple aspects of neuromuscular function and evidence is considered that requirements, intakes or absorption may be altered in the elderly. In addition, the evidence base for recommended intakes (UK recommended daily allowance) is examined with particular reference to original datasets and their relevance to older individuals. It is possible that inconsistencies in the literature with respect to the nutritional management of sarcopenia may, in part at least, be the result of compromised micronutrient status in some study participants. It is suggested that in order, for example, for intervention with amino acids to be successful, underlying micronutrient deficiencies must first be addressed/eliminated.
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Gupta K, Jain A, Rohatgi A. An observational study of vitamin b12 levels and peripheral neuropathy profile in patients of diabetes mellitus on metformin therapy. Diabetes Metab Syndr 2018; 12:51-58. [PMID: 28882470 DOI: 10.1016/j.dsx.2017.08.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 08/20/2017] [Indexed: 02/08/2023]
Abstract
METHODS A descriptive, observational study was completed in a tertiary care hospital between November 2014 and March 2016. Fifty consecutive patients of Type 2-Diabetes Mellitus who had been on metformin therapy for at least three months were included in our study. Several Parameters were compared with vitamin B12 levels and severity of peripheral neuropathy (using Toronto Clinical Scoring System (TCSS) and Nerve Conduction Velocity). These included the duration of diabetes, duration of metformin usage, dietary history, and HbA1c levels. Definite B12 deficiency was defined as B12<150pg/ml and possible B12 deficiency as <220pg/ml. RESULTS In our study, we found a negative correlation between duration of metformin use and Vitamin B12 levels(r=-0.40). The mean Vitamin B12 levels seen in our study was 212.3pg/mL. There is a positive correlation between the duration of metformin therapy and peripheral neuropathy (r=0.40). The mean TCSS score was 6.8. The percentage of patients with mild neuropathy was 28%, with moderate neuropathy was 20% and severe neuropathy in 12% of the patients. The average duration of metformin use in patients without peripheral neuropathy was 5.5yrs whereas the average length of metformin use in patients with peripheral neuropathy was 10.4 yrs. CONCLUSION Patients on long-term metformin therapy are at a high risk for Vitamin B12 deficiency and peripheral neuropathy. Interval Screening for peripheral neuropathy is recommended for patients on metformin even if Vitamin B12 levels appear to be normal.
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Affiliation(s)
- Kamesh Gupta
- Department of Medicine, Lady Hardinge Medical College, Shaheed Bhagat Singh Road, Diz Area, Connaught Place, New Delhi, 110001, India.
| | - Anand Jain
- Department of Medicine, Lady Hardinge Medical College, Shaheed Bhagat Singh Road, Diz Area, Connaught Place, New Delhi, 110001, India.
| | - Anurag Rohatgi
- Department of Medicine, Lady Hardinge Medical College, Shaheed Bhagat Singh Road, Diz Area, Connaught Place, New Delhi, 110001, India.
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23
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Franques J, Chiche L, Mathis S. Sensory Neuronopathy Revealing Severe Vitamin B12 Deficiency in a Patient with Anorexia Nervosa: An Often-Forgotten Reversible Cause. Nutrients 2017; 9:nu9030281. [PMID: 28294987 PMCID: PMC5372944 DOI: 10.3390/nu9030281] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 03/09/2017] [Accepted: 03/13/2017] [Indexed: 11/16/2022] Open
Abstract
Vitamin B12 (B12) deficiency is known to be associated with various neurological manifestations. Although central manifestations such as dementia or subacute combined degeneration are the most classic, neurological manifestations also include sensory neuropathies. However, B12 deficiency is still rarely integrated as a potential cause of sensory neuronopathy. Moreover, as many medical conditions can falsely normalize serum B12 levels even in the context of a real B12 deficiency, some cases may easily remain underdiagnosed. We report the illustrating case of an anorexic patient with sensory neuronopathy and consistently normal serum B12 levels. After all classical causes of sensory neuronopathy were ruled out, her clinical and electrophysiological conditions first worsened after folate administration, but finally improved dramatically after B12 administration. B12 deficiency should be systematically part of the etiologic workup of sensory neuronopathy, especially in a high risk context such as anorexia nervosa.
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Affiliation(s)
- Jérôme Franques
- Hôpital de La Casamance, 13400 Aubagne, France.
- Service de Médecine Interne, Hôpital Européen, 13003 Marseille, France.
| | - Laurent Chiche
- Service de Médecine Interne, Hôpital Européen, 13003 Marseille, France.
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Minalyan A, Benhammou JN, Artashesyan A, Lewis MS, Pisegna JR. Autoimmune atrophic gastritis: current perspectives. Clin Exp Gastroenterol 2017; 10:19-27. [PMID: 28223833 PMCID: PMC5304992 DOI: 10.2147/ceg.s109123] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
At present there is no universally accepted classification for gastritis. The first successful classification (The Sydney System) that is still commonly used by medical professionals was first introduced by Misiewicz et al in Sydney in 1990. In fact, it was the first detailed classification after the discovery of Helicobacter pylori by Warren and Marshall in 1982. In 1994, the Updated Sydney System was proposed during the International Workshop on the Histopathology of Gastritis followed by the publication in The American Journal of Surgical Pathology by Dixon et al. Using the new classification, distinction between atrophic and nonatrophic gastritis was revised, and the visual scale grading was incorporated. According to the Updated Sydney System Classification, atrophic gastritis is categorized into multifocal (H. pylori, environmental factors, specific diet) and corpus-predominant (autoimmune). Since metaplasia is a key histological characteristic in patients with atrophic gastritis, it has been recommended to use the word “metaplastic” in both variants of atrophic gastritis: autoimmune metaplastic atrophic gastritis (AMAG) and environmental metaplastic atrophic gastritis. Although there are many overlaps in the course of the disease and distinction between those two entities may be challenging, the aim of this review article was to describe the etiology, epidemiology, pathogenesis, diagnosis, clinical manifestations and treatment in patients with AMAG. However, it is important to mention that H. pylori is the most common etiologic factor for the development of gastritis in the world.
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Affiliation(s)
- Artem Minalyan
- Division of Gastroenterology, Hepatology and Parenteral Nutrition
| | | | - Aida Artashesyan
- Division of Gastroenterology, Hepatology and Parenteral Nutrition
| | - Michael S Lewis
- Department of Pathology and Laboratory Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Joseph R Pisegna
- Division of Gastroenterology, Hepatology and Parenteral Nutrition
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25
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Rizzo G, Laganà AS, Rapisarda AMC, La Ferrera GMG, Buscema M, Rossetti P, Nigro A, Muscia V, Valenti G, Sapia F, Sarpietro G, Zigarelli M, Vitale SG. Vitamin B12 among Vegetarians: Status, Assessment and Supplementation. Nutrients 2016; 8:E767. [PMID: 27916823 PMCID: PMC5188422 DOI: 10.3390/nu8120767] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 11/23/2016] [Accepted: 11/23/2016] [Indexed: 02/06/2023] Open
Abstract
Cobalamin is an essential molecule for humans. It acts as a cofactor in one-carbon transfers through methylation and molecular rearrangement. These functions take place in fatty acid, amino acid and nucleic acid metabolic pathways. The deficiency of vitamin B12 is clinically manifested in the blood and nervous system where the cobalamin plays a key role in cell replication and in fatty acid metabolism. Hypovitaminosis arises from inadequate absorption, from genetic defects that alter transport through the body, or from inadequate intake as a result of diet. With the growing adoption of vegetarian eating styles in Western countries, there is growing focus on whether diets that exclude animal foods are adequate. Since food availability in these countries is not a problem, and therefore plant foods are sufficiently adequate, the most delicate issue remains the contribution of cobalamin, which is poorly represented in plants. In this review, we will discuss the status of vitamin B12 among vegetarians, the diagnostic markers for the detection of cobalamin deficiency and appropriate sources for sufficient intake, through the description of the features and functions of vitamin B12 and its absorption mechanism.
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Affiliation(s)
| | - Antonio Simone Laganà
- Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood, "G. Barresi", University of Messina, Via Consolare Valeria 1, Messina 98125, Italy.
| | - Agnese Maria Chiara Rapisarda
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Via S. Sofia 78, Catania 95124, Italy.
| | - Gioacchina Maria Grazia La Ferrera
- Department of Gastroenterology and Digestive Endoscopy Maddalena Raimondi San Cataldo, Via Forlanini 5, San Cataldo, Caltanissetta 93017, Italy.
| | - Massimo Buscema
- Unit of Diabetology and Endocrino-Metabolic Diseases, Hospital for Emergency Cannizzaro, Via Messina 829, Catania 95126, Italy.
| | - Paola Rossetti
- Unit of Diabetology and Endocrino-Metabolic Diseases, Hospital for Emergency Cannizzaro, Via Messina 829, Catania 95126, Italy.
| | - Angela Nigro
- Unit of Diabetology and Endocrino-Metabolic Diseases, Hospital for Emergency Cannizzaro, Via Messina 829, Catania 95126, Italy.
| | - Vincenzo Muscia
- Unit of Diabetology and Endocrino-Metabolic Diseases, Hospital for Emergency Cannizzaro, Via Messina 829, Catania 95126, Italy.
| | - Gaetano Valenti
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Via S. Sofia 78, Catania 95124, Italy.
| | - Fabrizio Sapia
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Via S. Sofia 78, Catania 95124, Italy.
| | - Giuseppe Sarpietro
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Via S. Sofia 78, Catania 95124, Italy.
| | - Micol Zigarelli
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Via S. Sofia 78, Catania 95124, Italy.
| | - Salvatore Giovanni Vitale
- Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood, "G. Barresi", University of Messina, Via Consolare Valeria 1, Messina 98125, Italy.
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