Severe megaloblastic anemia: Vitamin deficiency and other causes

Is serum homocysteine level a biomarker of suicide attempts: A preliminary study

Suicide is a global public health concern, and understanding its multifaceted determinants is crucial for effective prevention. This study was designed to find an answer to the question of whether serum homocysteine level can be a biomarker of suicide attempts. This preliminary study involving 90 participants (45 suicide attempt cases and 45 controls) was conducted at Elazig Fethi Sekin City Hospital. Biochemical analyses were performed to assess serum homocysteine, vitamin B12, and folic acid levels. Statistical analyses, including t-tests, Mann-Whitney U tests, and ROC analysis, were employed to explore differences between groups and assess the diagnostic potential of homocysteine. Elevated homocysteine levels were found in individuals who attempted suicide compared to the control group (p= <0.001). Additionally, lower levels of vitamin B12 (p=<0.001) and folic acid (p=<0.001) were observed in the suicide attempt group. ROC analysis indicated a significant diagnostic potential for homocysteine in predicting suicide attempts (AUC = 0.845, sensitivity = 91%, specificity = 71%). This study establishes a significant association between high homocysteine levels and suicide attempts, accompanied by lower vitamin B12 and folic acid levels. The findings suggest a potential link between disturbances in homocysteine metabolism and suicidal tendencies, urging further research to establish causation and explore therapeutic implications. Consideration of the study's limitations and directions for future research are warranted.

High ambient temperature may increase the risk of anemia in pregnancy: Identifying susceptible exposure windows

Anemia in pregnancy (AIP) is associated with multiple severe maternal and perinatal adverse outcomes. However, there is a lack of evidence on the association between environmental factors and AIP. Aim to explore the association between ambient temperature and the risk of AIP, and identify susceptible exposure windows, we conducted a matched case-control study from 2013 to 2016 in Xi'an, China, which included 710 women with AIP and 1420 women without AIP. The conditional logistic regression model was used to evaluate the association between ambient temperature and AIP at different gestational weeks and gestational months. The association between extreme temperature and AIP was evaluated using the distributed lag nonlinear model (DLNM). We conducted stratified analyses of age, parity, and season of conception, and estimated the interaction between ambient temperature and air pollutants on AIP. Ambient temperature was significantly positively associated with the risk of AIP, and the susceptible exposure windows were 2-25 gestational weeks and 1-6 gestational months, respectively. The strongest effect was observed in the week 8 and month 2, for each 1 °C increase in weekly and monthly mean temperature, the odds ratio (OR) for AIP was 1.038 (95 % confidence interval (CI): 1.022, 1.055) and 1.040 (95 % CI: 1.020, 1.060), respectively. Extreme heat may increase the risk of AIP. Stratified analyses showed that there was no significant difference among different age, parity, and season of conception groups. No significant interaction effect of ambient temperature with air pollution on AIP was found. In summary, high ambient temperature may increase the risk of AIP, and the first and second trimesters may be susceptible exposure windows. Understanding the effect of temperature on pregnant women will be beneficial to reduce the occurrence of AIP.

A novel automated multi-cycle magnetic solid-phase extraction coupled to LC-MS/MS to study the disorders of six functional B vitamins in patients with gastroenterology and hyperhomocysteinemia

B vitamins are essential for human life and their disorders can cause a variety of diseases. Solid-phase extraction (SPE) coupled to LC-MS/MS is a preferred technique for determining multiple B vitamins, however, their complexity in real biological matrices makes it hard to achieve satisfactory recovery and accuracy when simultaneous detection. In this study, a novel automated multi-cycle magnetic SPE (MSPE) coupled to the LC-MS/MS method was established using a mixed-mode anion exchange magnetic adsorbent for the simultaneous extraction of six functional B vitamins, including methylmalonic acid, riboflavin, pantothenic acid, 4-pyridoxic acid, folic acid, and 5-methyltetrahydrofolate. After three consecutive MSPE cycles, the recoveries of all analytes were between 51.5% and 89.6%. The method exhibited excellent sensitivity and linearity, with a dynamic range of 200-fold (R > 0.99 for all analytes), exceptional accuracy (ranging between 95.4% and 105.6%) and precision (with RSDs ≤ 6.2%) without significant matrix effects or interferences. Compared to manual SPE method, the automated multi-cycle MSPE method has better feasibility and greater vitamin coverage. It shows a high correlation with the manual method for the detection of 5-methyltetrahydrofolate and folate (R > 0.99). A study of patients from the gastroenterology department showed that those undergoing surgery and those with malignancies may be at risk of folate deficiency. In addition, patients with hyperhomocystinemia had higher levels of methylmalonic acid and lower levels of 5-methyltetrahydrofolate, which correlated with homocysteine levels (R = 0.404 and -0.311, respectively) and showed dose-response relationships. This method is highly automated and cost-effective, with minimal systematic error, making it suitable for the analysis of clinical samples.

Severe megaloblastic anemia in a patient with advanced lung adenocarcinoma during treatment with erlotinib: a case report and literature review

BACKGROUND

Erlotinib is a first-generation, tyrosine kinase inhibitor of the epidermal growth factor receptor (EGFR-TKI) used for the treatment patients with NSCLC. Erlotinib is considered as a safe and effective treatment option, with generally good tolerance. Diarrhea and rash are the most common side effects, and more rare side effects appear in long-term real-world applications. Severe erlotinib related megaloblastic anemia is rare and remains unreported. This is the first case report of severe megaloblastic anemia in a patient with advanced lung adenocarcinoma with an EGFR L858R mutation treated with erlotinib. In this report, the clinical manifestations, diagnosis and treatment of erlotinib related severe megaloblastic anemia are described, and the possible pathogenesis and related treatment options are discussed.

CASE DESCRIPTION

Herein, we present a 57- year-old non-smoking female diagnosed with metastatic lung adenocarcinoma harboring an EGFR L858R mutation, who had received erlotinib as the first-line therapy. After 44 weeks of treatment, the patient developed severe anemia. Anemia was manifested as megaloblastic anemia with elevated mean corpuscular volume and mean corpuscular hemoglobin. The total vitamin B12 level was below the detection limit of 50.00 pg /mL. Bone marrow smear suggested megaloblastic anemia. Her hematologic parameters were markedly recovered following the withdrawal of erlotinib and vitamin B12 supplement. As a result, the patient was diagnosed with erlotinib-associated megaloblastic anemia.

CONCLUSIONS

This is the first case of severe megaloblastic anemia reported with erlotinib. Few of these hematologic adverse effects have been observed in studies on erlotinib, this case report highlights this possibility for long-term erlotinib administration. Close clinical and blood monitoring is recommended for patients receiving long-term TKI therapy.

Knuckle hyperpigmentation in a young male: A clinical sign of B12 deficiency not to be missed

Vitamin B12 and folate deficiency are reversible causes of megaloblastic anemia. Strict vegetarians are at risk of megaloblastic anemia due to low cobalamin in their diet. Knuckle hyperpigmentation in patients with megaloblastic anemia is due to excess melanin synthesis in skin. Here we present a case of a young vegetarian male with megaloblastic anemia with knuckle hyperpigmentation managed successfully with intravenous followed by oral vitamin b12 and folate supplementation.

A Cross-Sectional Study for the Spectrum of Clinical Diagnosis in Patients Presenting With Macrocytosis

Objective The objectives of this study were to determine the frequency of the clinical spectrum of diseases in patients with macrocytosis and to summarize the diagnostic evaluation of patients found to have macrocytosis on laboratory testing. Background This was a cross-sectional study that took place at the Department of Medicine in Combined Military Hospital, Rawalpindi, Pakistan, from January to June 2023. Methodology One hundred and five patients with macrocytosis with mean corpuscular volume (MCV) values > 100 fL (80 to 100 fL) were inducted as per inclusion and exclusion criteria. Informed consent was obtained from all patients. Complete blood counts (CBC), peripheral blood film, serum vitamin B12 levels, serum folate levels, renal function tests (RFTs), liver function tests (LFTs), and thyroid function tests (TFTs) were performed during the assessment. Results The commonest cause of macrocytosis was vitamin B12 deficiency followed by folate deficiency, combined vitamin B12 and folate deficiency, and other causes were also found in a few cases. Conclusion Serum vitamin B12 and folate deficiency are the most common preventable causes of macrocytosis.

Effects of Spinach Extract and Licorice Extract on Growth Performance, Antioxidant Capacity, and Gut Microbiota in Weaned Piglets

Anemia and weaning stress are important factors affecting piglet growth performance. Spinach extract and licorice extract have been used to improve anemia and antioxidant capacity, respectively. However, whether they have synergistic effects has not been reported. To evaluate the effects of mixed spinach extract and licorice extract on growth performance, serum biochemistry, antioxidant capacity, and gut microbiota in weaned piglets, a total of 160 weaned piglets were randomly allotted to four treatments with four replications of 10 piglets each. The four treatments were as follows: control (CON) group (basal diet), spinach extract (SE) group (basal diet + 1.5 kg/t spinach extract), licorice extract (LE) group (basal diet + 400 g/t licorice extract), and spinach extract and licorice extract (MIX) group (basal diet + 1.5 kg/t spinach extract + 400 g/t licorice extract). The results showed that, compared with the CON group, diets supplemented with spinach extract and licorice extract significantly increased the average daily gain (p < 0.05), while considerably reducing the feed-to-gain ratio (p < 0.05). Moreover, the MIX group exhibited a significant up-regulation of serum total protein, globulin, albumin, glucose, and triglyceride levels in comparison to the CON group (p < 0.05). Meanwhile, both the anemia and antioxidant capacity of piglets were effectively improved. Notably, the MIX group achieved even better results than the individual supplementation in terms of enhancing growth performance, which could potentially be attributed to the increased abundance of the Rikenellaceae_RC9_gut_group. These results demonstrated that the supplementation of diets with spinach extract and licorice extract improves the absorption of nutrients from the diet and antioxidant capacity in weaned piglets.

Association analysis of MTHFR (rs1801133 and rs1801131) and MTRR (rs1801394) gene polymorphisms towards the development of hypertension in the Bai population from Yunnan, China

OBJECTIVE

Hypertension is one of the leading causes of human death and disability. MTHFR and MTRR regulate folate metabolism and are closely linked to hypertension, although the relationship is inconsistent among different ethnic groups. The present study aims to investigate the effects of MTHFR C677T (rs1801133), MTHFR A1298C (rs1801131), and MTRR A66G (rs1801394) polymorphisms on hypertension susceptibility in the Bai nationality of the Yunnan Province, China.

METHODS

This case-control study included 373 hypertensive patients and 240 healthy controls from the Chinese Bai population. The genotyping of MTHFR and MTRR gene polymorphisms was carried out by using the KASP method. The effects of genetic variations of MTHFR and MTRR genes on hypertension risk were evaluated with odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

The present study revealed that the CT and TT genotypes and T allele of MTHFR C677T locus were considerably associated with an increased risk of hypertension. In addition, MTHFR A1298C locus CC genotype could significantly increase the hypertension risk. The T-A and C-C haplotypes of MTHFR C677T and MTHFR A1298C could increase the risk of hypertension. Further stratified analysis by risk rank of folate metabolism indicated that people with poor utilization of folic acid were more prone to develop hypertension. In the hypertension group, the MTHFR C677T polymorphism was significantly associated with fasting blood glucose, fructosamine, apolipoprotein A1, homocysteine, superoxide dismutase, and malondialdehyde levels.

CONCLUSION

Our study suggested that genetic variations of MTHFR C677T and MTHFR A1298C were significantly associated with susceptibility to hypertension in the Bai population from Yunnan, China.

Late-onset cobalamin C deficiency type in adult with cognitive and behavioral disturbances and significant cortical atrophy and cerebellar damage in the MRI: a case report

Background

Late-onset cobalamin C (cblC) deficiency is associated with a wide range of neurological and psychiatric symptoms, hematological manifestations, anorexia, renal failure, ocular abnormalities, dermatitis, and pancreatitis. However, the neuroimaging characteristics of late-onset cblC deficiency remain insufficiently documented. Common findings include diffuse white matter swelling, varying degrees of severe leukoaraiosis, hydrocephalus, corpus callosum atrophy, and symmetric bilateral basal ganglia lesions. In this report, we present a case of late-onset cblC deficiency in adults presenting with cerebellar ataxia as the primary symptom. The MRI findings revealed bilateral lateral cerebellar hemispheres exhibiting symmetric hyperintensity, primarily observed in diffusion-weighted imaging (DWI), which is a rarely reported imaging change in this context.

Case presentation

Our patient was a male who experienced symptoms starting at the age of 30 years, including unsteady walking, apparent cerebellar ataxia, and cognitive impairment upon nervous system examination. Brain magnetic resonance imaging (MRI) exhibited symmetric hyperintensity in the bilateral lateral cerebellar hemispheres, predominantly manifested in DWI, without any enhancement. Subsequently, significantly elevated blood total homocysteine and urinary methylmalonic acid levels were observed. Genetic analysis confirmed the presence of MMACHC compound heterozygous mutants c.482G > A and c.609G > A, thus confirming the diagnosis of cblC deficiency. These variants were classified as likely pathogenic following the guidelines of the American College of Medical Genetics and Genomics (ACMG) and were verified using Sanger sequencing. Following treatment, the patient experienced improvements in walking ability and cognition, a significant decrease in blood total homocysteine levels, and reversal of the imaging lesions.

In conclusion

Late-onset cblC deficiency presents with diverse clinical and imaging manifestations. Early diagnosis and treatment are crucial in achieving a favorable prognosis. This case serves as a reminder to clinicians not to overlook genetic metabolic disorders, particularly those causing multisite damage, in adult patients with undiagnosed neurological disorders, especially those affecting the cerebellum. Notably, methylmalonic acidemia should be considered within the spectrum of bilateral cerebellar lesions.

A Case of Pernicious Anemia Presenting With Severe Hemolysis

Vitamin B12 deficiency is a well-known and overall common disease. While the etiology of vitamin B12 deficiency varies from post-surgical changes to inadequate dietary consumption, pernicious anemia should be considered as it is a common cause. Pernicious anemia is an autoimmune atrophic gastritis impairing the absorption of vitamin B12. Manifestations include neurological changes, macrocytic anemia, glossitis, and nail changes. Hemolytic anemia is an unusual complication of vitamin B12 deficiency and an even more unusual initial presentation. This case identifies a patient with previously undiagnosed pernicious anemia with severe vitamin B12 deficiency compounded by hemolytic anemia as the presenting symptom. Overall, this case highlights the importance of considering vitamin B12 deficiency-related hemolytic anemia and the need for further research into the causes and pathophysiology of vitamin B12-induced hemolysis due to its potential for fatal outcomes despite being easily treatable with cost-effective methods to treat.

Association of B vitamin intake and total homocysteine levels with all-cause and cause-specific mortality in central obesity

OBJECTIVES

Future primary prevention strategies may benefit from understanding the connection between mortality in individuals with central obesity and modifiable lifestyle factors like dietary intake. This study sought to determine whether there was a separate relationship between folate, vitamin B6, and vitamin B12 intake and all-cause and cause-specific mortality in the US population with central obesity.

METHODS

The study analyzed data from the National Health and Nutrition Examination Survey between 1999 and 2016. Using the Cox proportional hazards model, the association between dietary intake of B vitamins and all-cause and cause-specific mortality was examined. A total of 7718 adults with central obesity were enrolled, with a mean age of 49.87 (SD = 0.25) y at baseline.

RESULTS

Folate intake was independently associated with a decreased incidence of all-cause mortality (adjusted hazard ratio = 0.71; 95% CI, 0.58-0.87). Furthermore, higher intake of vitamin B6 and vitamin B12 was inversely correlated with cardiovascular disease mortality (adjusted hazard ratio = 0.63; 95% CI, 0.40-0.98; and adjusted hazard ratio = 0.44; 95% CI, 0.29-0.65, respectively) and the finding reveal an interaction between homocysteine and vitamin B12 and folate on All-cause mortality CONCLUSIONS: The findings of this study suggest that vitamin B12 and folate intake may be protective factors in individuals with central obesity. It is important to consider both their total homocysteine level and body mass index in conjunction with these nutrients. Further research is needed to validate these findings.

Imaging Aspects of Toxic and Metabolic Myelopathies

Metabolic and toxic myelopathies usually occurs due to several different causes. Metabolic myelopathy usually occurs due to deficiency of a nutrient, such as vitamin B12. Toxic myelopathy occurs secondary to the exposure to an external toxic agent. Although they may have a difficult diagnosis, determination of the specific cause of myelopathy is of utmost importance, because many causes are amenable to treatment. Although they have many clinical, electrophysiologic, and neuropathologic similarities, imaging may aid in the suspicion of toxic or metabolic myelopathy. The aim of this article, is to review the imaging features of the main toxic and metabolic myelopathies.

The Association Between Vitamin B1 Deficiency and Anemia Among Elderly Patients at a Rural Hospital in Japan: A Cross-Sectional Study

Background and objective Vitamin B1 deficiency can cause a variety of abnormalities in the neuropsychiatric, cardiovascular, and other systems. This condition can be rapidly corrected and prevented from progressing to irreversible sequelae through vitamin B1 supplementation. Therefore, early detection of and intervention in vitamin B1 deficiency are essential. We have previously demonstrated an association between vitamin B1 deficiency and appetite loss in hospitalized older adult patients in rural Japan. This study aimed to examine the additional predictors of vitamin B1 deficiency in patients with appetite loss and other symptoms suggestive of vitamin B1 deficiency. Material and methods This cross-sectional study involved 519 patients admitted to a rural hospital between April 2020 and March 2022. Data on vitamin B1 levels, age, sex, BMI, albumin levels, functional independence measure (FIM), hemoglobin levels, Charlson Comorbidity Index (CCI), and medications were collected from electronic medical records. Vitamin B1 deficiency was defined as serum vitamin B1 level <20 µg/dL. Data were analyzed using the Mann-Whitney U test, Student's t-test, and chi-square test, followed by multivariate logistic regression to examine the predictors of vitamin B1 deficiency. Results A total of 113 patients (21.5%) were found to be vitamin B1-deficient. Multivariate logistic regression showed that anemia was significantly associated with vitamin B1 deficiency [adjusted odds ratio (AOR): 1.71, 95% confidence interval (CI): 1.07-2.73, p<0.05]. Conclusion Based on our findings, anemia is significantly associated with vitamin B1 deficiency in hospitalized Japanese patients living in rural areas. Therefore, physicians should be mindful of the possibility of vitamin B1 deficiency in hospitalized patients with anemia.

Anemia and Associated Risk Factors in Pediatric Patients

Anemia is the most common hematologic abnormality identified in children and represents a major global health problem. A delay in diagnosis and treatment might place patients with anemia at risk for the development of rare but serious complications, including chronic and irreversible cognitive impairment. Identified risk factors contributing to the development of anemia in children include the presence of nutritional deficiencies, environmental factors, chronic comorbidities, and congenital disorders of hemoglobin or red blood cells. Pediatricians, especially those in the primary care setting, serve a particularly critical role in the identification and care of those children affected by anemia. Prompt recognition of these risk factors is crucial for developing appropriate and timely therapeutic interventions and prevention strategies.

CD36 relative mean fluorescence intensity of CD105+ nucleated erythroid cells can be used to differentiate myelodysplastic syndrome from megaloblastic anemia

This study aims to evaluate the differences in CD105⁺ nucleated erythroid cell (NEC) immunophenotypes between myelodysplastic syndrome (MDS) and megaloblastic anemia (MA) using multiparameter flow cytometry and to screen potential markers. We analyzed bone marrow sample data from 37 patients with MDS, 35 with MA, 53 with iron-deficiency anemia (anemic controls), and 35 without anemia (normal controls). Compared with normal controls, the MDS and MA groups showed a decrease in the proportion of CD117⁺CD105⁺NEC and the relative mean fluorescence intensity (RMFI) of CD71 in CD105⁺NEC, accompanied by an increase in the coefficient of variation (CV) of CD71 and CD36. Additionally, CD36 RMFI of CD105⁺NEC increased in the MA group. Compared with anemia controls, the MDS and MA groups showed a significant increase in CD36 CV of CD105⁺NEC, and the CD36 RMFI in the MA group increased while that in the MDS group decreased. The proportions of CD117⁺CD105⁺NEC, CD36 CV, and CD36 RMFI in CD105⁺NEC differed significantly between MDS and MA groups. Among them, CD36 RMFI had good diagnostic performance (area under the curve: 0.844, 95% confidence interval: 0.753-0.935). CD36 RMFI of CD105⁺NEC may be a helpful marker in differentiating MDS and MA using multiparameter flow cytometry.

Nutritional Factors: Benefits in Glaucoma and Ophthalmologic Pathologies

Glaucoma is a chronic optic neuropathy that can lead to irreversible functional and morphological damage if left untreated. The gold standard therapeutic approaches in managing patients with glaucoma and limiting progression include local drops, laser, and/or surgery, which are all geared at reducing intraocular pressure (IOP). Nutrients, antioxidants, vitamins, organic compounds, and micronutrients have been gaining increasing interest in the past decade as integrative IOP-independent strategies to delay or halt glaucomatous retinal ganglion cell degeneration. In our minireview, we examine the various nutrients and compounds proposed in the current literature for the management of ophthalmology diseases, especially for glaucoma. With respect to each substance considered, this minireview reports the molecular and biological characteristics, neuroprotective activities, antioxidant properties, beneficial mechanisms, and clinical studies published in the past decade in the field of general medicine. This study highlights the potential benefits of these substances in glaucoma and other ophthalmologic pathologies. Nutritional supplementation can thus be useful as integrative IOP-independent strategies in the management of glaucoma and in other ophthalmologic pathologies. Large multicenter clinical trials based on functional and morphologic data collected over long follow-up periods in patients with IOP-independent treatments can pave the way for alternative and/or coadjutant therapeutic options in the management of glaucoma and other ocular pathologies.

A sensitive, robust and high-throughput isotope dilution LC-MS/MS method for quantifying three folate forms in serum

This study aimed to establish an isotope dilution LC-MS/MS method for the determination of folic acid, 5-formyltetrahydrofolate and 5-methyltetrahydrofolate in human serum. This method was then used to quantify these three folate forms in the healthy adult population and supplement users. A stable 96-well solid-phase extraction system was used to prepare serum samples. The highly sensitive method was established using a Shimadzu LCMS-8060NX. The linearity was good in the range of 0.1-10 nmol/l for folic acid and 5-formyltetrahydrofolate and 1.0-100 nmol/l for 5-methyltetrahydrofolate. The accuracy and precision were good. The method was sensitive, robust and high-throughput and could be used for the routine clinical monitoring of these three folate forms in the Chinese population.

The Role of Folic Acid in SARS-CoV-2 Infection: An Intriguing Linkage under Investigation

BACKGROUND

SARS-CoV-2 is a life-threatening RNA virus that may cause an acute respiratory syndrome associated with extremely high morbidity and mortality rates. Folic acid (FA), also known as folate, is an essential vitamin vital for human homeostasis, participating in many biochemical pathways, and its deficiency has been associated with viral infection vulnerability. In this review, we investigated the association between FA intake and SARS-CoV-2 infection, along with the existence of any potential impact of FA on the health outcome of patients suffering from this new viral infection.

METHODS

Studies included were patients' and in silico and molecular docking studies.

RESULTS

Data from in silico studies and molecular docking support that FA inhibits SARS-CoV-2 entry into the host and viral replication, binding at essential residues. Accordingly, in patients' studies, a protective role of FA supplementation against SARS-CoV-2 infection is indicated. However, contradictory data from observational studies indicate that FA supplementation, often linked to deficits during systemic inflammation due to SARS-CoV-2, increases the risk of post-infection mortality.

CONCLUSIONS

Future randomized controlled trial studies, including the FA pharmacological group, are needed to better understand the role of FA as a potential protective or mortality risk indicator in COVID-19 patients.

Study on the correlation between B vitamins and breast cancer

BACKGROUND

Relevant studies suggest that serum vitamin level is related to the risk of breast cancer, and dietary pattern and drug supplementation can significantly affect the level of vitamin in the body. Therefore, intervention of vitamin level in the body is expected to be a potential strategy to reduce the risk of breast cancer. However, the current epidemiological findings of serum vitamin levels and breast cancer risk are inconsistent, and the relationship between serum vitamin and breast cancer is still controversial. In this study, we compared the serum vitamin expression levels of healthy people, benign breast patients, and breast cancer patients, and evaluated the relationship between B vitamin levels and breast cancer risk.

METHODS

The study used liquid chromatography-tandem mass spectrometry to determine the serum vitamin levels of 520 people who attended Yunnan Cancer Hospital from September 2020 to December 2020. After screening by exclusion criteria, 38 patients with benign breast diseases, 87 patients with breast cancer and 91 healthy controls were finally included. The kruskal-wallis H test was used to compare the differences in serum vitamin levels of subjects. Χ² test was used to evaluate the relationship between B vitamin level and age,BMI,TNM staging,Ki-67,Her-2,surgery and chemotherapy, and other baseline characteristics and through binary logistic regression analysis, calculating odds ratio and 95% confidence interval (CI) to evaluate the relationship between B vitamins and breast cancer risk.

CONCLUSION

The levels of VitB1 and VitB5 in the serum of breast cancer patients and patients with benign breast diseases were higher than those in the healthy control group, while the expression levels of VitB3 in breast cancer patients were lower than those in the healthy control group and the breast benign disease groups. The level of VitB1 was positively correlated with breast cancer risk. The VitB3 level was negatively correlated with breast cancer risk. The VitB5 level is not significantly related to the risk of breast cancer.

Anemia in the pediatric patient

The World Health Organization estimates that approximately a quarter of the world's population suffers from anemia, including almost half of preschool-age children. Globally, iron deficiency anemia is the most common cause of anemia. Other important causes of anemia in children are hemoglobinopathies, infection, and other chronic diseases. Anemia is associated with increased morbidity, including neurologic complications, increased risk of low birth weight, infection, and heart failure, as well as increased mortality. When approaching a child with anemia, detailed historical information, particularly diet, environmental exposures, and family history, often yield important clues to the diagnosis. Dysmorphic features on physical examination may indicate syndromic causes of anemia. Diagnostic testing involves a stepwise approach utilizing various laboratory techniques. The increasing availability of genetic testing is providing new mechanistic insights into inherited anemias and allowing diagnosis in many previously undiagnosed cases. Population-based approaches are being taken to address nutritional anemias. Novel pharmacologic agents and advances in gene therapy-based therapeutics have the potential to ameliorate anemia-associated disease and provide treatment strategies even in the most difficult and complex cases.

Comparison of four different immunoassays and a rapid isotope-dilution liquid chromatography-tandem mass spectrometry assay for serum folate

OBJECTIVES

Accurate measurement of serum folate is essential for the diagnosis and management of various disorders. This study aims to investigate the between-method differences of four immunoassays and a rapid isotope-dilution liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS) method.

METHODS

Roche Cobas (USA), Abbott Alinity i2000 (USA), Beckman Coulter Access (USA), Mindray CL-6000i (China), and the ID-LC-MS/MS method were compared using 46 human serum samples. The results were analysed by Passing-Bablok regressions and Bland-Altman plots. A bias of 13.31% based on biological variation was used as the bias criterion.

RESULTS

All the within-run and total coefficients of variation (CVs) met the specification. The folate concentrations determined by all the assays were significantly different (p=0.0028). All assays had correlation coefficients over 0.97 with each other. The 95% confidence intervals (CIs) for the slope seldom contained 1 and few 95% CIs for the intercept contained 0 in the regression equations. Compared to ID-LC-MS/MS, the biases of all assays ranged from -20.91 to 13.56 nmol/L, and the mean relative biases ranged from -9.85 to 40.33%. The predicted mean relative biases at the medical decision levels rarely met the criterion.

CONCLUSIONS

Assays for serum folate had good correlations with each other but lacked good agreement. The accuracy and consistency of assays for serum folate should be measured and assessed routinely. Standardization work to improve the accuracy of serum folate assays, such as the extension of traceability to reference methods or materials, calibration standardization efforts, and assay-adjusted cut-offs should be promoted.

Food-inspired innovations to improve the stability of active pharmaceutical ingredients

Food-processing and pharmaceutical industries share a lot of stability issues against the same physical, chemical, and microbiological phenomena. They also share some solutions to improve the stability as the use of preservatives and packaging. Ecological concerns lead to the development of tremendous innovations in food. Some of these innovations could also be beneficial in the pharmaceutical domain. The objective of this review is to evaluate the potential application of these findings in the pharmaceutical field and the main limits in terms of toxicity, environmental, economic and regulatory issues. The principal factors influencing the shelf-life were highlighted through the description of the stability studies usually performed in the pharmaceutical industry (according to European guidelines). To counter those factors, different solutions are currently available as preservatives and specific packaging. They were described and debated with an overview of recent food innovations in each field. The limits of the current solutions in the pharmaceutical field and the innovation in the food field have inspired a critical pharmaceutical outlook. The active and intelligent packaging for active pharmaceutical ingredients of the future is imagined.

Transporters in drug development: International transporter consortium update on emerging transporters of clinical importance

During its 4^th transporter workshop in 2021, the International Transporter Consortium (ITC) provided updates on emerging clinically relevant transporters for drug development. Previously highlighted and new transporters were considered based on up-to-date clinical evidence of their importance in drug-drug interactions and potential for altered drug efficacy and safety, including drug-nutrient interactions leading to nutrient deficiencies. For the first time, folate transport pathways (PCFT, RFC, and FRα) were examined in-depth as a potential mechanism of drug-induced folate deficiency and related toxicities (e.g., neural tube defects, megaloblastic anemia). However, routine toxicology studies conducted in support of drug development appear sufficient to flag such folate deficiency toxicities, while prospective prediction from in vitro folate metabolism and transport inhibition is not well enough established to inform drug development. Previous suggestion of retrospective study of intestinal OATP2B1 inhibition to explain unexpected decreases in drug exposure were updated. Furthermore, when the absorption of a new molecular entity is more rapid and extensive than can be explained by passive permeability, evaluation of OATP2B1 transport may be considered. Emerging research on hepatic and renal OAT2 is summarized, but current understanding of the importance of OAT2 was deemed insufficient to justify specific consideration for drug development. Hepatic, renal, and intestinal MRPs (MRP2, MRP3, MRP4) were revisited. MRPs may be considered when they are suspected to be the major determinant of drug disposition (e.g., direct glucuronide conjugates); MRP2 inhibition as a mechanistic explanation for drug-induced hyperbilirubinemia remains justified. There were no major changes in recommendations from previous ITC whitepapers.

Folate Deficiency Is Spatially Dependent and Associated with Local Farming Systems among Women in Ethiopia

Background

Folate is essential for the synthesis and integrity of DNA, normal cell formation, and body growth. Folate deficiency among women of reproductive age (WRA) increases the risk of poor birth outcomes including neural tube defect (NTD)-affected pregnancies. Folate status is largely dependent on dietary intakes.

Objectives

We aimed to explore the spatial distribution of biomarkers of folate status and their association with farming systems among nonpregnant WRA in Ethiopia.

Methods

Serum and RBC folate concentration data were derived from the Ethiopia National Micronutrient Survey of 2015. The spatial dependencies of folate concentration of WRA were investigated and its relation with the dominant local farming system was explored.

Results

The median serum folate and RBC folate concentrations were 12.3 nmol/L and 567.3 nmol/L, respectively. The national prevalence of folate deficiency using homocysteine concentration as a metabolic indicator based on serum and RBC folate concentration was 11.6% and 5.7%, respectively. The majority of women (77.9%) had low RBC folate concentrations consistent with increased risk of NTD-affected pregnancies. Folate nutrition was spatially dependent at distances of ≤ 300 km. A marked variability in folate concentration was observed between farming systems: greater RBC folate concentration (median: 1036 nmol/L) was found among women from the Lake Tana fish-based system, whereas the lowest RBC folate concentration (median: 386.7 nmol/L) was observed in the highland sorghum chat mixed system.

Conclusions

The majority (78%) of WRA in Ethiopia had low folate status potentially increasing the risk of NTD-affected pregnancies. These findings may help national and subnational nutrition intervention strategies to target the most affected areas in the country.

Macrocytic Anaemia: Not Always a Straightforward Diagnosis

Macrocytosis is defined as a mean corpuscular volume greater than 100 femtolitres (fL). There are several causes for macrocytic anaemia, and they can be divided into megaloblastic or non-megaloblastic anaemia. Vitamin B12 deficiency is one of the most common causes of megaloblastic anaemia.

The cause of vitamin B12 deficiency must be evaluated including the presence of pernicious anaemia as it could alter the treatment and follow-up.

Pernicious anaemia can be associated with other autoimmune diseases constituting polyglandular syndromes.

How I investigate acquired megaloblastic anemia

In this review of megaloblastic anemia (MA), an overview of vitamin B₁₂ and folate body requirements, biochemical pathways, and laboratory testing strategies will be provided. However, the focus of this review is the classic and unique features of MA in blood and bone marrow. Acquired MA is a benign disorder for many, but can be detrimental for some. The clinical presentation can vary considerably, and the spectrum of symptoms and signs is diverse and quite broad. Prompt recognition and therapy are critical to prevent potential irreversible damage and clinical sequelae, especially in patients with vitamin B₁₂ deficiency. A delay in diagnosis of vitamin B₁₂ deficiency can result in significant neurologic sequelae that may not fully resolve with treatment, including in neonates and young infants. The blood and bone marrow features in MA can closely mimic thrombocytopenic purpura, myelodysplasia, and other myeloid neoplasms. Both pancytopenia and normal MCV at presentation are common in MA and raise unique challenges for the diagnostician. Partially treated MA is also a significant diagnostic "trap". MA is highly responsive to treatment, and patients tend to improve rapidly upon treatment initiation. However, the broad range of clinical and hematologic features makes the rapid, successful diagnosis of MA a unique challenge for the hematopathologist. Even in the era of state-of-the-art laboratory testing, a high suspicion is required.

Kobalamina – właściwości biomedyczne i niedobór w ujęciu biochemicznym

Kobalamina (witamina B12) jest rozpuszczalnym w wodzie związkiem organicznym, zaliczanym do witamin grupy B. Złożona budowa i polarność cząsteczki witaminy B12 sprawiają, że do jej prawidłowego wykorzystania i przemian w organizmie człowieka niezbędny jest udział wyspecjalizowanych białek. Głównym źródłem kobalaminy człowieka jest pokarm pochodzenia zwierzęcego. Ze względu na rezerwy tkankowe tej witaminy, jej niedobór ujawnia się dopiero po kilku latach niewystarczającej podaży z pożywieniem. Badania przesiewowe pod kątem deficytu kobalaminy są jednak uzasadnione u osób z czynnikami ryzyka hipokobalaminemii, takimi jak: stan po resekcji żołądka lub jelita cienkiego, dieta wegańska, długotrwałe stosowanie metforminy, antagonistów receptora histaminowego H2 oraz leków z grupy inhibitorów pompy protonowej, a także podeszły wiek.

Witamina B12 jako kofaktor enzymatyczny uczestniczy w licznych przemianach wewnątrzmitochondrialnych oraz w syntezie metioniny, niezbędnej do powstania S-adenozylometioniny istotnej w procesie metylacji cząsteczek biologicznie czynnych. Przez powiązania metaboliczne z kwasem foliowym kobalamina wpływa na proces syntezy DNA i podział komórki. Obecnie coraz częściej zwraca się uwagę na potencjalny udział niedoboru witaminy B12 w patogenezie chorób neurodegeneracyjnych, a także nowotworowych. Niedobór kobalaminy na poziomie molekularnym destabilizuje genom komórek, zwiększając ryzyko ich złośliwej transformacji. Jednak u osób z chorobą nowotworową lub obciążonych ryzykiem jej rozwoju witamina B12 może nasilać ekspansję komórek neoplastycznych.

A comprehensive analysis of cytopenias and bone marrow morphology in patients with a history of bariatric and metabolic surgery

INTRODUCTION

Following bariatric and metabolic surgery (BMS), patients may develop persistent cytopenia(s) despite adequate micronutrient levels. A comprehensive analysis of laboratory and hematopathologic findings in BMS patients with unexplained cytopenia(s) has not been previously described.

METHODS

We reviewed the clinical and laboratory data, bone marrow histology, and used ancillary testing to characterize patients with a history of BMS who had subsequent bone marrow biopsies due to unexplained cytopenia(s).

RESULTS

All patients had anemia and 59% (23/39) had additional cytopenias. Myelodysplastic syndrome (MDS) and clonal cytopenia of unknown significance (CCUS) were diagnosed in 8% (3/39) and 10% (4/39), respectively. Remaining cases were classified as idiopathic cytopenia of unknown significance (ICUS) with anemia alone (ICUS-A) in 47% (15/32) or multiple cytopenias (ICUS-PAN) in 53% (17/32). Time since surgery, age, or amount of weight loss was not associated with a specific diagnosis. No patient was vitamin B12 or folate deficient. However, vitamin B6 and zinc were decreased in 47% (5/11) and 29% (9/29), respectively. Examination of bone marrow aspirates revealed slight erythroid dyspoiesis affecting <10% of precursors in 60% (9/15) ICUS-A and 59% (10/17) ICUS-PAN.

CONCLUSION

Bone marrow findings in patients with unexplained cytopenia(s) after BMS are not specific in the majority of cases, and caution is advised when interpreting dyserythropoiesis. Levels of micronutrients and vitamins other than iron, folate and vitamin B12 are frequently disturbed in this patient cohort and warrant correction and close clinical follow-up.

How to Make the Right Diagnosis in Neutropenia

Isolated neutropenia without anemia or thrombocytopenia is a common clinical problem. The etiology of neutropenia may vary from transient bone marrow suppression, caused by self-limited viral illnesses, to previously undiagnosed congenital syndromes or serious systemic diseases. Consequently, determining the underlying cause of neutropenia and what treatment is required can be challenging. Acquired neutropenia is common and most of the times an etiologic factor can be found. Congenital neutropenia (CN) is rare, and we still have a lot to learn from mutational analysis as to the exact role of gene abnormalities in the pathogenesis of these complex diseases. This mini-review discusses a proposed approach to neutropenia in the adult patient.

A Brief Review on Vitamin B12 Deficiency Looking at Some Case Study Reports in Adults

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.

The Concept of Folic Acid in Health and Disease

Folates have a pterine core structure and high metabolic activity due to their ability to accept electrons and react with O-, S-, N-, C-bounds. Folates play a role as cofactors in essential one-carbon pathways donating methyl-groups to choline phospholipids, creatine, epinephrine, DNA. Compounds similar to folates are ubiquitous and have been found in different animals, plants, and microorganisms. Folates enter the body from the diet and are also synthesized by intestinal bacteria with consequent adsorption from the colon. Three types of folate and antifolate cellular transporters have been found, differing in tissue localization, substrate affinity, type of transferring, and optimal pH for function. Laboratory criteria of folate deficiency are accepted by WHO. Severe folate deficiencies, manifesting in early life, are seen in hereditary folate malabsorption and cerebral folate deficiency. Acquired folate deficiency is quite common and is associated with poor diet and malabsorption, alcohol consumption, obesity, and kidney failure. Given the observational data that folates have a protective effect against neural tube defects, ischemic events, and cancer, food folic acid fortification was introduced in many countries. However, high physiological folate concentrations and folate overload may increase the risk of impaired brain development in embryogenesis and possess a growth advantage for precancerous altered cells.

Long-term outcome of a patient with Transcobalamin deficiency caused by the homozygous c.1115_1116delCA mutation in TCN2 gene: a case report

BACKGROUND

Transcobalamin deficiency is a rare autosomal recessive inborn error of cobalamin transport (prevalence: < 1/1000000) which clinically manifests in early infancy.

CASE PRESENTATION

We describe the case of a 31 years old woman who at the age of 30 days presented with the classical clinical and laboratory signs of an inborn error of vitamin B₁₂ metabolism. Family history revealed a sister who died at the age of 3 months with a similar clinical syndrome and with pancytopenia. She was started on empirical intramuscular (IM) cobalamin supplements (injections of hydroxocobalamin 1 mg/day for 1 week and then 1 mg twice a week) and several transfusions of washed and concentrated red blood cells. With these treatments a clear improvement in symptoms was observed, with the disappearance of vomiting, diarrhea and normalization of the full blood count. At 8 years of age injections were stopped for about two and a half months causing the appearance of pancytopenia. IM hydroxocobalamin was then restarted sine die. The definitive diagnosis could only be established at 29 years of age when a genetic evaluation revealed the homozygous c.1115_1116delCA mutation of TCN2 gene (p.Q373GfsX38). Currently she is healthy and she is taking 1 mg of IM hydroxocobalamin once a week.

CONCLUSIONS

Our case report highlights that early detection of TC deficiency and early initiation of aggressive IM treatment is likely associated with disease control and an overall favorable outcome.

Synthetic biology-driven microbial production of folates: Advances and perspectives

With the development and application of synthetic biology, significant progress has been made in the production of folate by microbial fermentation using cell factories, especially for using generally regarded as safe (GRAS) microorganism as production host. In this review, the physiological functions and applications of folates were firstly discussed. Second, the current advances of folate-producing GRAS strains development were summarized. Third, the applications of synthetic biology-based metabolic regulatory tools in GRAS strains were introduced, and the progress in the application of these tools for folate production were summarized. Finally, the challenges to folates efficient production and corresponding emerging strategies to overcome them by synthetic biology were discussed, including the construction of biosensors using tetrahydrofolate riboswitches to regulate metabolic pathways, adaptive evolution to overcome the flux limitations of the folate pathway. The combination of new strategies and tools of synthetic biology is expected to further improve the efficiency of microbial folate synthesis.

Association between antiseizure medication use and risk of urinary tract infection: A case-control study

AIM

The aim of this study was to analyze the association between antiseizure medication (ASM) and the risk of urinary tract infections (UTI) in patients with epilepsy treated in general practices in Germany.

METHODS

This study includes a total of 2201 patients (mean age: 61.4) whose first documented UTI diagnosis occurred between January 2015 and December 2019 (index date) and who were prescribed at least one ASM in 1198 general practices in Germany within one year prior to the index date. Based on a case-control design, the association between predefined criteria and UTI was investigated by matching (1:1) controls without UTI to cases with UTI by sex, age, and codiagnoses. Logistic regression models were used to analyze the association between ASM use and UTI risk.

RESULTS

In the first regression model, phenytoin (PHT), primidone, carbamazepine (CBZ), and valproate (VPA) were associated with an increased risk of UTI. In the second model, these associations were confirmed with effects per prescription for PHT, primidone, CBZ, and VPA use. Additionally, the effect per prescription was significant for oxcarbazepine (OXC), topiramate, and gabapentin.

CONCLUSION

The study found that PHT, primidone, CBZ, and VPA in particular are associated with an increased risk of infections of the urinary tract. Oxcarbazepine, topiramate, and gabapentin are also associated with increased risk of UTI, albeit to a less significant extent. In general, the immunological and hematological side effects of these molecules may play an important role in the development of UTI under anticonvulsant therapy.

How I investigate neutropenia

Neutropenia is a common laboratory finding in adults and children. Its underlying causes are extremely heterogeneous and include benign conditions, autoimmune disorders, infections, and malignancies. The clinical laboratory plays a central role in the diagnosis of these disorders, including data derived from hematology, microbiology, molecular biology/cytogenetics, and clinical chemistry. The purpose of this review is to (a) highlight the clinical, hematologic, and molecular genetic features of the major entities resulting in neutropenia and (b) outline an algorithm-based approach to permit the classification of neutropenias.

Effect of Harvest Age on Total Phenolic, Total Anthocyanin Content, Bioactive Antioxidant Capacity and Antiproliferation of Black and White Glutinous Rice Sprouts

Black (cv. BGR) and white (cv. RD6) glutinous rice sprouts from fertilizer- and pesticide-free farm in Khon Kaen province, Thailand were investigated for antioxidation and antiproliferative activity. Three different ages of rice sprouts were collected and prepared as the extract. BGR exerted higher antioxidant capacity than RD6 based on total phenolic (TPC) and total anthocyanin contents (TAC), DPPH, and FRAP assays. BGR at 10–15 days contained the highest TPC (29.72 ± 1.42 mg gallic acid equivalent/g extract) and reducing power (2.22 ± 0.014 mmole FeSO4/g extract). BGR at 20–25 days contained the highest TAC (0.86 ± 0.096 equivalence of cyanidin-3-glucoside/g extract) and DPPH radical scavenging activity (IC50 = 231.09 ± 12.99 μg/mL). Antiproliferative activity of the extracts was evaluated in the human T-lymphocyte (Jurkat), hepatocellular carcinoma (HepG2), colorectal carcinoma (HCT116), melanoma (SK-MEL-2) and noncancerous cells (Vero) by neutral red assay. BGR showed the most selective antiproliferation against Jurkat cells, by inducing apoptosis, and caspase 3/7 activity. BGR at 200 μg/mL from all ages significantly decreased ROS using DCFH-DA and increased endogenous glutathione levels in Jurkat cells compared to the control (p < 0.05). The higher antiproliferation of BGR than RD6 was via its antioxidation capacity and attributed to its higher phenolic and anthocyanin contents. BGR sprout is a potential source of biologically active substances good for wellness and health benefits.

Correlation between anemia and clinical severity in subacute combined degeneration patients

OBJECTIVES

Subacute combined degeneration (SCD) is a demyelinating disease commonly caused by vitamin B12 deficiency. Several studies have been reported SCD could be accompanied by anemia. However, the correlation between anemia and clinical severity of SCD patients is unclear. In this study, we aim to analyze the clinical characteristics of SCD concomitant with anemia, and investigate the effect of anemia in predicting the severity of SCD.

METHODS

A total 42 patients were included in the study. Clinical, laboratory, radiological findings, and outcomes from the patients were analyzed. All patients were treated with vitamin B12 for no less than 6 months and a functional disability rating scale was used to evaluate severity of neurological impairment at the time of admission and 3 and 6 months after admission in our study.

RESULTS

85.7% patients had macrocytosis. Decreased serum vitamin B12 levels were found in 27 patients (64.3%). MRI showed long-segment abnormality on the spinal cord in 22 patients. No differences in rating score were found in patients grouped by sex, age, clinical course, serum vitamin B12, or MRI manifestations at the time of admission or at the follow-up visits. Negative correlation was seen between hemoglobin levels and the clinical severity scores on admission.

CONCLUSION

Not all patients with SCD concomitant with anemia had decreased serum vitamin B12 level. The inverse correlation between hemoglobin level and clinical severity suggests the degree of anemia can help in evaluating the extent of neurologic impairment.

Vitamin B12 and folic acid alleviate symptoms of nutritional deficiency by antagonizing aryl hydrocarbon receptor

Despite broad appreciation of their clinical utility, it has been unclear how vitamin B12 and folic acid (FA) function at the molecular level to directly prevent their hallmark symptoms of deficiency like anemia or birth defects. To this point, B12 and FA have largely been studied as cofactors for enzymes in the one-carbon (1C) cycle in facilitating the de novo generation of nucleotides and methylation of DNA and protein. Here, we report that B12 and FA function as natural antagonists of aryl hydrocarbon receptor (AhR). Our studies indicate that B12 and FA bind AhR directly as competitive antagonists, blocking AhR nuclear localization, XRE binding, and target gene induction mediated by AhR agonists like 2,3,7,8-tetrachlorodibenzodioxin (TCDD) and 6-formylindolo[3,2-b]carbazole (FICZ). In mice, TCDD treatment replicated many of the hallmark symptoms of B12/FA deficiency and cotreatment with aryl hydrocarbon portions of B12/FA rescued mice from these toxic effects. Moreover, we found that B12/FA deficiency in mice induces AhR transcriptional activity and accumulation of erythroid progenitors and that it may do so in an AhR-dependent fashion. Consistent with these results, we observed that human cancer samples with deficient B12/FA uptake demonstrated higher transcription of AhR target genes and lower transcription of pathways implicated in birth defects. In contrast, there was no significant difference observed between samples with mutated and intact 1C cycle proteins. Thus, we propose a model in which B12 and FA blunt the effect of natural AhR agonists at baseline to prevent the symptoms that arise with AhR overactivation.

An Exceedingly Rare Presentation of Severe Folate Deficiency-Induced Non-Immune Hemolytic Anemia

Macrocytic anemia is usually associated with vitamin B12 or folate deficiency. However, folate deficiency was rarely reported as a cause of hemolytic anemia. We present a case of a young man with a history of alcohol abuse who initially presented with an acute on chronic abdominal pain and was found to have jaundice and scleral icterus. His liver enzymes were unremarkable, and his abdominal imaging did not reveal any acute pathology. However, he was found to have a severe non-immune hemolytic anemia secondary to folate deficiency.

Cobalamin C deficiency presenting with diffuse alveolar hemorrhage and pulmonary microangiopathy

OBJECTIVE

Combined methylmalonic acidemia and homocysteinemia is a genetically heterogeneous disorder of cobalamin (cbl; vitamin B12) metabolism, which consists of five subtypes including cblC, cblD, cblF, cblJ, and cblX deficiencies. The purpose of this study is to summarize new clinical features mainly diffuse alveolar hemorrhage (DAH) in cblC deficiency.

METHODS

We made a retrospective analysis of four pediatric patients diagnosed with DAH and pulmonary microangiopathy due to cblC deficiency between January 2017 and December 2018 in Beijing Children's Hospital.

RESULTS

This study describes four patients with their ages ranging from 4 years 2 months to 7 years 6 months with cblC deficiency who developed late-onset diffuse lung disease (DLD). Of these, the first three patients presented predominantly with DAH, and the last patient with pulmonary microangiopathy confirmed by thoracoscopic lung biopsy. All patients were accompanied by pulmonary arterial hypertension (PAH), two accompanied by respiratory failure, and two accompanied by moderate megaloblastic anemia. Diffuse ground-glass opacification and poorly defined ground-glass centrilobular nodules were seen on high-resolution computed tomography in one patient and three patients, respectively. All patients were suspected of having idiopathic pulmonary hemosiderosis or interstitial lung disease at other hospitals. All of them received treatment with corticosteroid before admission, but the symptoms did not improve. Moreover, all patients carried compound heterozygous mutations (c.80A>G, c.609G>A) in MMACHC and improved significantly after being treated for cblC deficiency and PAH.

CONCLUSIONS

CblC deficiency should be considered in the differential diagnosis of DAH especially with PAH, and pulmonary microangiopathy be the main reason of DLD in these patients.