Vitamin Deficiency Flashcards by Anjali Pradeep

summarise each vitamin, its site of absorption and the deficiency syndrome?

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what is the active form of vitamin A?

Retionic acid

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where is vitamin A found ?

liver, kidneys, butter, egg yolks, leafy vegetables

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what is the deficiency syndrome for vitamin A?

XEROPHTHALMIA (ocular manifestations)

Abnormal dryness of conjunctiva and cornea of the eye with inflammation

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outine the pathophysiology of vitamin A deficiency?

Vitamin A is required for formation of rhodopsin, photoreceptor pigment in the retina so important for vision. It is also important for antioxidation, gene transcription, differentiation of epi cells into specialised tissue and prevent squamous metaplasia (hence prevent formation of Bitot spots)

Deficiency can be due to inadequate intake, fat malabsorption or liver disorders (liver stores vit A)

In xerophthalmia, there is dryness of the conjunctiva and cornea due to keratinisation of the eyes. Conjunctivae develop oval/triangular spots (Bitots spots), and cornea becomes cloudy and soft.

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what are the risk factors/causes of vitamin A deificency?

inadequate intake

fat malabsorption

liver disorders ( liver stores vitamin A)

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summarise the epidemiology of vitamin A deficiency?

common in southern and eastern asia where rice is staple food- rice is completely lacking beta carotene ( precursor to vitamin A )

Rare in the uK

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What are the presenting symptoms of vitamin A deficiency?

Starts off with night blindness

As diseases progresses, cornea becomes hazy and can develop erosions which can lead to its destruction 🡪 complete blindness.

Can also get drying, scaling and follicular thickening of the skin due to keratinisation of skin

Respiratory infections due to keratinisation of mucous membranes in respiratory tract.

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what are the clinical features of xerophthalmia?

dryness of the conjuctiva and cornea due to keratinisation of eyes

conjuctiva develop oval/ triangular spots ( Bitot spots)

cornea becomes cloudy and soft

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what are the signs of vitamin A deficiency?

Night blindness, which may cause injuries

Bitots spots on conjunctiva

Corneal xerosis – cornea appears dry and dull

Corneal ulcerations

Keratomalacia – last stage of xerophthalmia - softening of cornea, followed by perforation of eyeball and blindness

Dry skin

Dry hair

More prone to infection

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what are the appropriate investigations for vitamin A deficiency and interpret the results?

Check sight in darkness

serum renitol binding protein

zinc levels- zinc deficiency can interfere with production of retinol binding protein

iron studies - can affect metabolism of vitamin A

FBC- for anaemia or infection

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Generate a management plan for vitamin A deficiency

Treat with vitamin A supplements

Re-educate and monitor diet

High vit A: chicken, eggs, leafy green veg

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Identify the possible complications of vitamin A deficiency

Blindness

Respiratory infections

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Summarise the prognosis for patients with vitamin A deficiency

Good if treated early, before blindness progresses

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What is the deficiency syndrome for B1 ( thiamine)?

Beri Beri-> can lead to Wernicke’s encephalopathy

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what systems can be affected by a B1 ( thiamine) deficiency?

Cardio, MSK, GI and nervous system can be affected

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What are the risk factors for B1 ( thiamine) deficiency?

Diets consisting of high levels of milled rice and raw freshwater fish

High consumption of tea, coffee and betel nuts

Alcoholic state

Starvation state

Prolonged vomiting

Gastric bypass surgery – due to limited caloric intake post surgery

Parental nutrition without adequate thiamine supplementation

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What are the 2 main types of beriberi?

Dry beriberi

Wet beriberi

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what are the features of dry beriberi?

Thiamine deficiency with nervous system involvement
Usually occurs with poor caloric intake and physical inactivity

Involves peripheral neuropathy
Wernicke encephalopathy and Korsakoff syndrome are forms of dry beriberi

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What are the features of wet beriberi?

Thiamine deficiency with cardiovascular involvement
First, peripheral vasodilation occurs causing high CO. This leads to salt and water retention via RAAS. As vasodilation progresses, kidneys detect relative loss of volume and therefore conserve salt. Salt retention causes fluid absorption into vessels, hence oedema.
The high cardiac workload results in heart failure with general oedema.

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summarise the epidemiology of B1/ thiamine deficiency?

Common in alcoholics

More common in developing countries due to malnutrition

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what are the symptoms of B1 ( thiamine ) deificency?

EARLY FEATURES: fatigue, apathy, irritability, drowsiness, depression, poor concentration, anorexia, N+V, abdo pain

LATER FEATURES Wet: palpitations, SOB, leg swelling, dyspnoea, orthopnea

LATER FEATURES Dry: numbness of peripheries, confusion, trouble moving legs, pain (cramps)

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What are the signs of B1 ( thiamine) deificency?

Tachycardia

Cardiomegaly

Pallor and waxy skin

Signs of malnutrion and wasting

Hepatomegaly

Ankle oedema

Peripheral neuropathy

Depressed tendon reflexes

Loss of vibration sensation

Tender leg muscles

Identify appropriate investigations for vitamin B deficiency and interpret the results?

Diagnosis primarily clinical – high suspicion with chronic alcohol abuse and special diets/malnutrition

Thiamine loading test (rarely performed): administer thiamine and in deficient patients there is less excretion of thiamine than in normal patients.

Red cell transketolase activity is decreased – rarely done

Maybe test blood thiamine level, pyruvate and transketolase level (as the level of these will rise in Wernicke’s encephalopathy)

MRI if Wernicke’s encephalopathy is detected

what is the management plan for b1 ( thiamine) deficiency?

**Thiamine (Pabrinex) IV – admin slowly over 10 mins** **Oral supplementation to continue after IV** If there is coexisting hypoglycaemia, ensure thiamine given before glucose Food sources of thiamine: **beef, nuts, oats, pork, egg, liver, dried milk, peas and legumes (**some foods like rice, pasta, breads and cereals can be fortified with thiamine)

Identify the possible complications of vitamin B deficiency?

Irreversible korsakoff syndrome (chronic memory disorder) If untreated =\> HF (which can be fatal) Anaphalaxis of IV treatment

Summarise the prognosis for patients with vitamin B1 deficiency

Good if treated early, but Korsakoff is minimally reversible

what is the deficiency syndrome for vitamin C?

scurvy

what is the cause of vitamin C deficiency?

inadequate dietary intake

what is vitamin C needed for?

wound healing and immune function and iron absorption

what are the risk factors for vitamin C deficiency?

victims of famine, alcoholics

what are the presenting symptoms of vitamin C deficiency?

Fatigue Depression Rash Internal bleeding, Petechiae Gingivitis, loose teeth, foul breath Impaired wound healing Bleeding from gums, nose, hair follciles or into joints In children, bone growth may be impaired so gait impairment or leg pain Anorexia, cachexia Muscle pain and weakness Weight loss Oedema Joint swelling

what are the signs of vitamin C deficiency?

Rash Petechiae Oedema Cachexia Follicular hyperkeratosis Anorexia

What are the appropriate investigations for vitamin C deficiency and interpret the results?

**clinical diagnosis** **FBC and peripheral smear to look for other haem disorders mimicking scurvy** (normocytic anaemia expected) **Serum, whole blood and leukocyte ascorbic acid** – should be ordered during initial evaluation to help identify the amount and severity of scurvy x ray of knee and wrist

what is seen on the x ray of the knee and wrist in a vitamin C deficiency?

Frankel's sign (lucent line) right below the margin of the growth plate Wimberger corner fraction sign trabecular atrophy Pelkan's sign

describe a management plan for vitamin C deficency?

Dietary education – broccoli, peppers, spinach, tomatoes, blackcurrant, kiwis, brussel sprouts, strawberries, oranges (other citrus fruits) Ascorbic acid – 300-500mg/day orally for about 2 weeks and then prevention of vitC def

what are the possible complications of a vitamin C deficiency?

Intracerebral haemmorhage Endocardial haemorrhage Neck and back pain

summarise the prognosis of patients with vitamin C deficiency?

GOOD (full recovery) if no haemorrhagic complications occur

define a vitamin E deficiency?

Deficiency of vitamin E (alpha-tocopherol)

outline the aetiology risk factors for vitamin E deficiency?

Can be caused by **cystic fibrosis , abetalipoproteinaemia, chronic cholestatic hepatobiliary disease, short bowel syndrome - all affecting absorption** May result from a rare inherited condition called A**taxia with Vitamin E deficiency (AVED)**

what is the deficiency syndrome of vitamin E deficiency?

haemolysis and neurological deficit

what are the fucntions of vitamin E?

Vitamin E is an antioxidant; has roles in the immune system; important in the formation of RBC and helps body use Vit K

Summarise the epidemiology of vitamin E deficiency

very rare

what are the presenting symptoms of vitamin E deficiency?

Weakness Loss of vibration sense Decline in visual field Numbness and tingling

what are the signs of vitamin E deficiency?

Hyporeflexia Decreaed proprioception Distal muscle weakness Limited upward gaze Loss of vibration sense Ataxia Dysarthria Retinopathy Compromise immune system

What are the appropriate investigations for vitamin E deficiency an interpret the results?

Serum alpha-tocopherol level

Generate a management plan for vitamin E deficiency

Supplements (around 1000 IU/day) Food sources of Vitamin E: veg oils, nuts, seeds, spinach/broccoli, fortified foods like cereals and fruit juices

what are the complications of vitamin E deficiency?

Complete blindness Cardiac arrhythmia Dementia

describe the pathophysiology of vitamin K deficiency?

Vitamin K is important for coagulopathy (co-factor for synthesis of clotting factors II, VII, IX and X) so main symptom is excessive bleeding; imp for bone health

what are the risk factors for vitamin K deficiency?

Anticoagulants Lack of vitamin K in diet **Liver disease** – decreased synthesis of vitamin-K dependent factors **Antibiotics** which interfere with vit K absorption **Fat malabsorption** e.g. in coeliac disease, CF, IBD, short bowel syndrome, biliary tract disease Infants at risk of breast milk low in vit K

recognise the presenting symptoms of vitamin K deficiency?

Easily bruising Dark black, tar like stool Nose bleeds Epistaxis Bleeding gums

what are the signs of vitamin K deficiency?

bruising

what are the appopriate investigations for vitamin K deficiency and interpret the results?

History Prothrombin time Plasma level of Vit K can be measured

generate a management plan for vitamin K deficiency?

In life-threatening bleeds, **administer FFP before vitK** Vitamin K supplement – available as phytomenadione or synthetic water-soluble analogue menadiol sodium diphosphate Diet rich in vitK: **green leafy vegs, green peas and beans, spinach, broccoli, whole wheat and oats**

identify the possible complications of vitamin K deficiency?

Excessive bleeding and anaemia

summarise the prognosis of patients with vitamin K deficiency

Good if treated early