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STEP > Vitamins, Minerals and Trace Elements > Flashcards

Vitamins, Minerals and Trace Elements Flashcards

1
Q

What is Vitamin A necessary for?

A
  • Cofactor for parathyroid hormone.
  • Necessary for cerebrospinal fluid.
  • Used for epithelial cell maturation (hair, skin, eyes)
  • Used for night vision
  • Mild antioxidant
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2
Q

What does vitamin A deficiency lead to?

A
  • Poor night vision
  • Decreased CSF production
  • Hypoparathyroidism
  • Epithelial cells fail to mature
  • T (15/17) associated with AML or premature form, Promyeloblastic leukemia.
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3
Q

What does Vitamin A excess lead to?

A

Hyperparathyroidism
- Calcium will increase
- Phosphorus will decrease
- Moans, groans, bones and stones
Pseudotumor cerebri
- Vitamins A, D, E, K get stuck in adipose tissue and one day they suddenly flush the serum
- Sign: Papilledema (high intracranial pressure)
- Symptom: Headache
- Evaluation: CT scan (shows enlarged ventricles)
- Treatment: D/C Vit A; Serial lumbar punctures
- Main complication: Blindness
- The only cause of increased intracranial pressure that does not cause herniation

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4
Q

Vitamin A is used anytime you want cells to what? Give 4 examples?

A
  • Mature Faster
  • Ex 1. Measles (Rubeola): Regenerate lung epithilium.
  • Ex 2. Cancer (T15/17)
  • Ex 3. Infections that wear away a lot of cells
  • Ex 4. Burn patients
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5
Q

What do antioxidants do?

A
  • Eat up free radicals (made of oxygen; high energy molecules).
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6
Q

What do free radicals do in the body?

A
  • Pierce cell membranes first, then nuclear membrane and then DNA.
  • Causes cells to die or mutate
  • If they mutate they will lead to cancer
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7
Q

What is the most common cause of free radicals?

A
  • Infections, of which viruses are the most common.

- Neutrophils are the cells that make free radicals via NADPH oxidase.

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8
Q

How do you manage papilledema?

A

Step 1. Rule out the worst thing it can be.
- Mass (ex. cancer)
- How? CT scan (non contrast first in case it is a bleed, this way the contrast will not leak out all over the brain and cause more damage)
Step 2. What is the next worse thing it can be?
- Infection (ex. meningitis)
- How? Lumbar puncture
Step 3. If dilated ventricles (+), next step will be treatment of pseudotumor cerebri.
- Discontinue vitamin A
- If acute: serial lumbar punctures
- Remove < 30 cc/24 hrs until papilledema is gone
-If chronic: weight loss and carbonic anhydrase inhibitors (acetazolamide) stop the production of CSF

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9
Q

What is Vitamin B1: Thiamine necessary for?

A
  • Needed by 4 important enzymes:
    1. Pyruvate dehydrogenase
  • Converts pyruvate to acetyl-CoA
    2. Alpha-ketoglutarate dehydrogenase
  • Produces succinyl-CoA and NADH
    3. Branched chain amino acid dehydrogenase
    4. Transketolase
  • All of them use thiamine pyrophosphate (TPP)
  • The heart uses the 3 dehydrogenases
  • The brain uses transketolase
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10
Q

What does thiamine deficiency lead to?

A
  1. Beriberi: Heart has given out; dilation
    - Dry: Up until you have heart failure.
    - Wet: When there is fluid in the lungs; massive ventricular dilation
  2. Wernicke’s encephalopathy: Signs of increased ICP
    - Wernicke’s area is located in the posterior Temporal lobe; responsible for receiving spoken or written language.
    - Transketolase requires thiamine as a co-factor
    - Def leads to phosphorylated sugars trapped in wernicke’s are.
    - They pull water and cause swelling
  3. Wernicke’s aphasia (once the cells lyse and die)
    - Receptive aphasia: can not understand spoken/written language.
    - What they say does not match.;
  4. Wernicke’s-Korsakoff syndrome
    - Mamillary bodies are now involved.
    - Confabulation: They start making things up.
    - Unable to move short term into long term memory.
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11
Q

What is Vitamin B2: Riboflavin necessary for?

A

Used in co-factors such as FAD and FMN
FAD is needed for:
1. Oxidation of pyruvate, bcaa and alpha ketogluterate dehydrogenases.
2. Required for pyridoxic acid formation from B6
3. Required for Niacin production from tryptophan
Used in the Krebs cycle for energy
Best source is found in milk

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12
Q

What does riboflavin deficiency lead to?

A

Leads to angular cheilosis (fissures in corners of mouth)

Sunlight breaks down riboflavin (why milk is not left out in the sun anymore)

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13
Q

What is vitamin B3: Niacin necessary for?

A

Necessary for Cofactors (NAD, NADH, NADP, NADPH)
Needed by
- Pyruvate dehydrogenase
- Alpha-ketoglutarate dehydrogenase
- Branched chain amino acid dehydrogenase
- All other dehydrogenase’s

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14
Q

What does niacin deficiency lead to?

A

Pellagra
- Diarrhea, dermatitis, dementia and death
Hartnup’s Disease
- Similar to pellagra
- Defective renal transport of tryptophan
- Causes leak of tryptophan into the urine
- Tryptophan is necessary to make niacin

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15
Q

What is niacin used for? What are the side effects?

A
  1. Niacin blocks VLDL production in the liver
    - VLDL carries triglycerides to adipose tissue for storage
    - Treats hypertriglyceridemia
    - Increases HDL better than any other drug (45%) histamine
    - Probucol does the same but less potent
  2. Side effects
    a. Flushing and itching due to prostaglandin release which stimulate mast cells to degranulate and release
    histamine causing itching and vasodilation.
    - To prevent this use aspirin or NSAIDS as prophylaxis
    b. Blocks insulin receptors leading to insulin resistance.
  3. Competes with uric acid causing gout.
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16
Q

How do you manage acute gout?

A
  1. Most effective treatment
    Colchicine (acid)
    - Blocks microtubules, blocking rapidly dividing cells
    - Remember microtubules needed for mitosis
    - Causes bone marrow suppression and renal failure.
  2. Current treatment
    Indomethacin (acid)f
    - NSAID
  3. In ase of renal failure
    Inject with IV steroid locally
    - Because Colchicine and Indomethacin are renally excreted
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17
Q

How do you manage chronic/recurrent gout?

A
  1. Allopurinol
    - Blocks xanthine oxidase.
    - Xanthine oxidase catalyzes the conversion of hypoxanthine = > xanthine = > uric acid
  2. Probenecid
    - Increases excretion of uric acid by blocking its reabsorption in the S2 segment of PCT
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18
Q

What is Vitamin B4: Lipoic acid necessary for?

A

Needed by
- Pyruvate dehydrogenase
- Alpha-ketoglutarate dehydrogenase
- Branched chain amino acid dehydrogenase
No deficiency state because it is found in everything we consume.

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19
Q

What is Vitamin B5: Pantothenic acid necessary for?

A

Needed by
- Pyruvate dehydrogenase
- Alpha ketoglutarate dehydrogenase
- Branched chain amino acid dehydrogenase
- Coenzyme A
No deficiency state because found in everything we consume.

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20
Q

What is Vitamin B6: Pyridoxine necessary for?

A

Needed to make heme
Needed by all transaminases (AST, ALT, GGT)
- Forms the cofactor pyridoxal phosphate
which acts as coenzyme for all transaminases.
- Transamination occurs in the liver and necessary to degrade old amino acids and form new ones without forming ammonia (NH3)

21
Q

What does Pyridoxine deficiency lead to?

A

Every organ is affected, however we are always worries about the brain first.
Neuropathy
- Means a neurological problem (confusion, depression, tremors, seizures, etc)

22
Q

How is chronic neuropathy/pain managed?

A
  1. Drug of choice
    Amitryptiline (Tricyclic Antidepressant)
    - Blocks the reuptake of catecholamines
    - Increases Dopamine and Norepinephrine
    - Increases sympathetic tone
    - Anticholinergic (blocks parasympathetic stimuli)
    - Blocks alpha-1 receptors, relaxing smooth muscle decreasing blood pressure
    - Blocks AV conduction and sometimes Na+ channels in ventricles
    - Can lead to arrhythmias
  2. If heart disease
    Gabapentin
    - GABA slows down the pain without affecting sympathetic tone
  3. Carbamezipine
    - Blocks Na+ and Ca+
23
Q

What is Vitamin B9: Folate necesary for?

A

The first vitamin to run out anytime you have rapidly dividing cells (lasts about 24 hrs)
- Illness with rapidly diving cells need as supplement (ex. psoriasis)
- Necessary for pregnant mothers for fetal development
Necessary to make tetrahydrofolate (THF)
- Needed to make nucleotides
- Always worried about the bone marrow

24
Q

What does folate deficiency lead to and what is the most common cause?

A
  1. Megaloblastic anemia
    - Macrocytic anemia (increased MCV)
    - Larger RBC’s due to cytoplasm trying to divided but nucleus unable to
  2. Hypersegmented neutrophils
    - Due to cytoplasm trying to divide but nucleus unable to.
    - 6 or more lobes in neutrophils
  3. Neural tube defects in fetuses
  4. Usually caused by overcooked vegetables
25
Q

What is Vitamin B12: Cyanocobalomine necessary for?

A

Needed by:

  1. Homocysteine methyltransferase
    - Along with B9, needed to make THF
  2. Methylmalonyl-CoA mutase
    - Used to recycle odd-numbered carbon fatty acids
    - Cholesterol is a 27 carbon FA used to make myelin
26
Q

What does vitamin B12 deficiency lead to?

A

Deficiency occurs in a year or more because acts as a fat soluble vitamin

  1. Megaloblastic anemia
  2. Hypersegmented neutrophils
  3. Neuropathy
  4. Main cause is pernicious anemia
    - Type A gastriris
    - Parietal cells of the GI tract fail to provide adequate production of intrinsic factor which is necessary for B12 absorption in the ileum
27
Q

Name three clues that separate B12 deficiency from B9 deficiency?

A
  1. Methylmalonic acid in the urine.
  2. Neuropathy
  3. Chronic state
28
Q

What is vitamin C necessary for?

A

Used for hydroxylation reactions
Hydroxylates proline and lysine in collagen and elastin
Main antioxidant in GI system
- This is why we take vitamin C to fight off cold and flu

29
Q

What does vitamin C deficiency lead to?

A

Scurvy

  • Common in people out at sea
  • Leads to bleeding from hair follicles and gums
30
Q

What is Vitamin D necessary for?

A

Needed for bone and teeth formation.
Stimulates osteoblastic activity (bone forming)
- Puts calcium and phosphorus in bone
Stimulates calcium and phosphorus absorption and reabsorption from kidney and GI tract
- Both go in the same direction

31
Q

Why do we advise patients to take iron supplements with orange juice or fruit juice?

A

Vitamin C protects iron from being oxidized in the GI tract

32
Q

What does Vitamin D deficiency lead to?

A
  1. Rickets (children)
    - Lateral bowing of the legs
    - Interferes with deposition in growth plates of legs
    - Reversibles with dietary supplementation.
  2. Osteomalacia (adults)
    - Soft bones
    - Bone is under-mineralized during remodeling (osteoclasts)
    - Bone is incompletely calcified with wide seams of osteoid.
    - Bone is week and prone to fracture
  3. Vitamin D Resistant Rickets
    - X-linked dominant (Dad gives it to all daughters)
    - Defective renal absorption of phosphorus
    - As phosphorus leaks out, pulls calcium with it.
    - Lab findings: Low calcium and low phosphorus
    - Diagnosis: if Vitamin D administered calcium and phosphorus levels will stay low
33
Q

What other infection can cause anterior bowing of legs?

A

Syphilis

  • Acquired tertiary or congenital can both cause sabre shin or sabre tibia.
  • MRI helpful in showing osseous involvement
34
Q

What is Vitamin E necessary for?

A

The main antioxidant in your blood

- Absorbs free radicals and eats them from your blood stream.

35
Q

What diseases involve oxidation where vitamin E can be used?

A

Cancer: Mutations caused by free radicals
Alzheimer’s Disease: Free radicals oxidize neurofibrillary tangles (tau proteins)
Coronary Artery Disease: Too much vitamin E can lead to a heart attack

36
Q

What is biotin necessary for?

A

Necessary for carboxylation

  • All enzymes ending in carboxylase
  • If deficient carboxylases would lose their function
37
Q

What is vitamin K necessary for?

A

Needed for gamma-carboxylation

  • Adds a third carboxyl group to vitamin K dependent clotting factors (II, VII, IX, X, Protein C and Protein S)
  • Each carboxyl group has 10 glutamic acids
  • Each glutamic acid has 2 carboxyl groups
  • 2 x 10 = 20 negative charges
  • Add a third, 3 x 30 = 30 negative charges
  • Negative charges attract calcium released by platelets
  • Factors II, VII, IX, X, C and S now know where they have to clot.
38
Q

What does the gut flora make?

A
  1. 90% of vitamin K
  2. Biotin
  3. Folate
  4. Pantothenic acid
39
Q

When do you not have enough gut flora?

A
  1. Newborns
    - This is why vitamin K is given IM after birth
    - Hemorrhagic disease occurs in 2 days if present
    - Because Factor VII has a half-life of 2 days
  2. Broad spectrum antibiotics (cephalosporins)
    - Cefamandol
    - Cefotetan
    - Moxalactam
    - Cefaparazone
40
Q

What is calcium necessary for?

A
  • Intracellular calcium needed for all muscle contraction
  • Smooth muscles use extracellular calcium for second messenger systems
  • Atrium and thalamus use calcium to depolarize
  • Cardiac ventricle depends on extracellular calcium to trigger its intracellular calcium release.
  • Used for axonal transport by nerves (Neuropathy if deficient)
  • Presynaptic influx needed for all neurotransmitter release.
  • For normal bone and teeth development.
  • In utero needed by fetus for the release of neurotransmitters (if deficient leads to MR)
41
Q

What is magnesium necessary for?

A
  • Cofactor for all kinases, they make and use negatively charged ATP
  • Cofactor for PTH
  • Interacts with potassium in early distal convoluted tubules of the kidneys.
  • Cotransport protein for magnesium and calcium
42
Q

What is zinc necessary for? What does deficiency lead to?

A

Hair, skin, sperm and taste buds.
Deficiency leads to dysgusia
- Metalic taste in mouth.
Oysters contain lots of zync.

43
Q

What is copper necessary for?

A

Needed by lysine hydroxylase in the formation of collagen.

Also needed by complex IV of the electron transport system.

44
Q

What is wilson’s disease?

A

Autosomal recessive (1/4 chance of getting it)
Ceruloplasmin deficiency (protein that carries cooper)
Copper deposition in:
- Lenticular nucleus (basal ganglia)
- Iris (kayser-fleischer rings)
- Liver (cirrhosis)
Symptoms
- Neuropsychiatric symptoms (ataxia, difficulty speaking)
Treatment: Penicillamine
- Binds 2+ ions (iron, calcium, zinc, magnesium)
- Can cause drug induced lupus

45
Q

What does copper deficiency lead to?

A

Minky’s Kinky’s hair syndromne

  • Orange colored hair (copper gets trapped)
  • Hair feels like copper
  • Can die of heart failure due to low energy state
46
Q

What is iron necessary for?

A

Formation of heme and hemoglobin
Ferrous iron Fe2+ binds oxygen
Becomes oxidized to feeric iron
Needed by complex III and IV of ETC

47
Q

What other symptoms can Vitamin E deficiency lead to?

A
  • Neurological symptoms that mimic friedreich ataxia
  • Ataxia due to degeneration of the spinocerebellar tracts
  • Loss of position and vibration sense due to degeneration of the dorsal columns
  • Loss of deep tendon reflexes due to peripheral nerve degeneration
48
Q

Which people in the general population are most at risk for developing vitamin B12 deficiency?

A
  • Strict vegans or patients with pernicious anemia (autoimmune gastritis with deficient intrinsic factor), gastrectomy, ileal resections or infected by tapeworm (Diphillobothrium latum).
  • In vegans, develops after a complete absence of intake of 4-5 years
  • Patients can develop anemia
  • RBC synthesis relies on B12 dependant recycling of folate
  • Deficiency in either can lead to megaloblastic anemia
  • Neurologic symptoms are due to impaired myelin synthesis in the dorsal and lateral columns
  • Results in subacute combined degeneration of the spinal cord
  • Begins as symmetrical weakness and paresthesias
  • Leads to loss of vibration and position sensation with development of ataxic gait
49
Q

Neurological damage associated with B12 deficiency damages which areas? What are the signs and symptoms?

A 
Subacute combined degeneration of: 
1. The dorsal columns 
- Loss of position and vibration sensation and sensory ataxia
- Positive Romberg sign on exam
2. Lateral corticospinal tracts
- Spastic paresis
3. Spinocerebellar tracts 
- Contributes to ataxia
B12 damages bilaterals and 12 o'clock on the spinal cord

STEP (28 decks)

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