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Vitamin E Deficiency

Deficiencies Vitamin E

Vitamin E deficiency is most commonly seen in the developed world as a result of inadequate dietary intake, whereas malabsorption syndrome after various gastrointestinal diseases or surgery may be the cause as well. Neurological deficits and hemolytic anemia are two main symptoms. Measuring vitamin E levels in blood is necessary for diagnosis, whereas supplementation is the mode of treatment.


Presentation

Neurological deficits may include hyporeflexia, ataxia, strabismus, limitations in upward gaze, but also constriction of the visual field and profound muscle weakness [5]. Dysarthria, absence of deep tendon reflexes, loss of vibratory sensations and positive Babinski reflexes may also be encountered in vitamin E deficient individuals [2]. In most severe cases, blindness, dementia, irreversible nerve damage and cardiac arrhythmias can develop [2] [5].

Splenomegaly
  • Autopsy revealed intrahepatic cholestatic cirrhosis without obliterative lesions in the bile duct system and marked splenomegaly with splenoma-like nodules.[ncbi.nlm.nih.gov]
Malnutrition
  • Three infants are described with cystic fibrosis (CF) and malnutrition leading to severe anemia beginning as early as 6 weeks of age.[ncbi.nlm.nih.gov]
  • In this study, 100 children with protein-energy malnutrition (PEM) were studied and compared to a suitably age-matched control group.[ncbi.nlm.nih.gov]
  • Anyone suffering from malnutrition Adults following extremely low fat diets People more than 55 years old Anyone with liver, pancreatic or gallbladder disease Anyone under excess stress for a prolonged period of time If you have experienced recent injuries[vitamins.lovetoknow.com]
  • Individuals most at-risk for vitamin E deficiency include: elderly adults, premature and/or underweight infants, those with abnormal fat absorption, people on very low-fat diets, and those with any type of malnutrition. 8 Signs You Have A Vitamin E Deficiency[powerofpositivity.com]
  • "Cognitive Function of Children with Cystic Fibrosis: Deleterious Effect of Early Malnutrition." Pediatrics 113 (June 2004): 1549-1558. Laso, N., S. Mas, M. Jose Lafuente, et al.[medical-dictionary.thefreedictionary.com]
Difficulty Walking
  • Without treatment, AVED may progress to cause significant difficulties walking and, potentially over the course of many years, can result in an affected individual becoming wheelchair bound.[rarediseases.org]
Jaundice
  • A 16-month-old infant with hepatic fibrosis, cholestasis, and chronic jaundice had signs of vitamin E deficiency, including mild acanthocytosis, thrombocytosis, increased peroxide haemolysis, and absent serum vitamin E.[ncbi.nlm.nih.gov]
  • A ten-year-old girl had obstructive jaundice in the newborn period which persisted for 4 years despite choledochojejunostomy at 6 weeks.[ncbi.nlm.nih.gov]
Proximal Muscle Weakness
  • This report describes a 7-year-old boy with severe malabsorption since birth who presented with progressive external ophthalmoplegia, proximal muscle weakness, peripheral neuropathy, hyporeflexia, and bilateral Babinski signs.[ncbi.nlm.nih.gov]
Ataxia
  • Abstract Ataxia with vitamin E deficiency is an autosomal recessive condition associated with a defect in the a-tocopherol transfer protein. Clinically it manifests as a progressive ataxia with a phenotype resembling that of Friedreich's ataxia.[ncbi.nlm.nih.gov]
  • Ataxia with vitamin E deficiency (AVED) is a rare cause of hereditary ataxia in north European countries with unknown prevalence. Few cases are reported from these countries.[ncbi.nlm.nih.gov]
  • Abstract Ataxia is a common and important neurological finding in medical practice. Severe deficiency of Vitamin E can profoundly affect the central nervous system and can cause ataxia and peripheral neuropathy resembling Friedreich's ataxia.[ncbi.nlm.nih.gov]
  • Abstract The authors report a comparative study of peripheral nerve conductions and nerve biopsy and somatosensory evoked potentials between 15 patients with Friedreich's ataxia and 15 patients with Friedreich's ataxia phenotype with selective vitamin[ncbi.nlm.nih.gov]
  • Abstract Ataxia with vitamin E deficiency is an autosomal recessive cerebellar ataxia caused by mutations in the α-tocopherol transfer protein coding gene localized on chromosome 8q, leading to lower levels of serum vitamin E.[ncbi.nlm.nih.gov]
Cerebellar Ataxia
  • Abstract Ataxia with vitamin E deficiency is an autosomal recessive cerebellar ataxia caused by mutations in the α-tocopherol transfer protein coding gene localized on chromosome 8q, leading to lower levels of serum vitamin E.[ncbi.nlm.nih.gov]
  • The clinical features included dysarthria, cerebellar ataxia, and prominent proprioceptive loss with depressed or absent tendon reflexes. Serum vitamin E was undetectable in both cases.[ncbi.nlm.nih.gov]
  • We present a 36-year-old Dutch woman who suffered from a progressive form of cerebellar ataxia since school age. In her childhood she was diagnosed with Friedreich's ataxia.[ncbi.nlm.nih.gov]
  • Subjects affected by cerebellar ataxia due to congenital isolated vitamin E deficiency (AVED) show vitamin E deficiency caused by a selective impaired gastrointestinal absorption of vitamin E for a mutation in the gene for α-tocopherol transfer protein[ncbi.nlm.nih.gov]
  • Other autosomal recessive cerebellar ataxias may be considered as well (Refsum disease, ataxia telangiectasia, Charcot-Marie-Tooth disease 1A and ataxia with oculomotor apraxia types 1 and 2 (see these terms)).[orpha.net]
Neurologic Manifestation
  • A gluten-free diet and vitamin E supplementation reversed both the clinical neurological manifestations and the abnormalities in the muscle biopsy. Anti-gliadin antibodies were no longer present.[ncbi.nlm.nih.gov]
  • Only one patient had typical neurological manifestations of vitamin E deficiency, which improved with supplementary vitamin E. The pathological findings in this patient were also compatible with vitamin E deficiency.[ncbi.nlm.nih.gov]
  • In abetalipoproteinemia, retinopathy and neurologic manifestations may be prevented by vitamin E supplementation (1). In infants with very low birthweight, vitamin E deficiency may present as hemolytic anemia and edema (2).[annals.org]
  • Discussion Secondary vitamin E deficiency (precipitated by abetalipoproteinaemia or other fat malabsorptive states) is known to be associated with neurological manifestations including ataxia.[jnnp.bmj.com]
  • manifestation, 054078, 症状, ショウジョウ, symptom, 040039, 神経系疾患, シンケイケイシッカン, nervous system disease, 023401, 酸素複素環化合物, サンソフクソカンカゴウブツ, oxygen heterocyclic compound, 022640, 複素環化合物, フクソカンカゴウブツ, heterocyclic compound, 036132, 脂溶性ビタミン, シヨウセイビタミン, fat-soluble[togodb.biosciencedbc.jp]
Slurred Speech
  • Symptoms of AVED include slurred speech ( dysarthria ), difficulty coordinating movements ( ataxia ), numbness in the hands and feet ( peripheral neuropathy ), and progressive leg weakness.[rarediseases.info.nih.gov]
  • Slurred speech (dysarthria) may also be present. Some affected individuals may develop a tremor or shaking of the head (titubation). Intellect and emotions are rarely affected.[rarediseases.org]
Decreased Proprioception
  • Vitamin E deficiency can cause poor balance due to decreased proprioception. Person is unable to do certain basic test like standing straight with narrow base of support with eye close.[medlife.com]
  • Physical Neurologic findings follow a pattern of progression that can be divided into early and late stages, as follows: [3, 19] Early findings include hyporeflexia, decreased proprioception, decreased vibratory sense, distal muscle weakness, nyctalopia[emedicine.medscape.com]

Workup

A thorough neurological examination to assess the extent of symptoms is vital in the diagnostic workup [5], but to confirm vitamin E deficiency, serum levels of α-tocopherol should be determined and values of < 5 µg/mL (or < 11.6 µmol/L) are diagnostic for this hypovitaminosis [4]. A lipid profile should also be obtained and a reduced α-tocopherol to lipid ration can also provide an accurate diagnosis. The search for an underlying cause should start with a thorough abdominal examination through ultrasonography or more invasive procedures (such as endoscopy) if there is valid clinical suspicion toward fat malabsorption [4].

Liver Biopsy
  • Measures of vitamin E in lipoprotein fractions and in liver biopsy after vitamin E oral load suggested that free diffusion of vitamin E between the different compartments was possible and even increased.[ncbi.nlm.nih.gov]

Treatment

Supplementation of α-tocopherol, either in oral or parenteral formulations, is the mainstay of treatment [5] [6]. A dose of 15-25 mg/kg is given every day in the setting of oral supplementation, while parenteral dosages may be higher in order to overcome the inability to utilize vitamin E from the gut [4].

Prognosis

Early recognition of the disease carries a good prognosis, but profound nerve damage may be irreversible without timely identification of the underlying cause and appropriate treatment.

Etiology

Various diseases have shown to induce vitamin E deficiency. Abetalipoproteinemia, chronic cholestatic liver disease, pancreatitis, short bowel syndrome, but also cystic fibrosis may cause fat malabsorption in the gut and thus impair normal vitamin E utilization from the gastrointestinal tract [4] [5].

Epidemiology

The exact rates of vitamin E deficiency in the world are unknown, but isolated reports showed that more than 50% of individuals in Thailand suffer from this hypovitaminosis [6]. Additionally, it is estimated that more than 90% of individuals living in the United States do not meet the recommended dietary intake of vitamin E (15 mg/day) [1], suggesting that the issue of insufficient ingestion of vitamin E is on a global scale.

Sex distribution
Age distribution

Pathophysiology

α-tocopherol is one of the most potent free radical scavengers in the human body and it is absorbed from the gastrointestinal tract as a fat-soluble vitamin [4]. Under physiological conditions, vitamin E is the primary defense against lipid peroxidation that can cause severe damage to cell membranes and neurons [7]. In its absence, fragility of red blood cells and degeneration of neurons is the main cause of symptom development [4].

Prevention

Ensuring sufficient dietary intake is an effective preventive strategy. Edible oils are abundant with vitamin E and the the richest source of this nutrient, whereas almonds, hazelnuts, peanuts, spinach, broccoli, mango and tomato are also sources of α-tocopherol [2].

Summary

Vitamin E is a lipid-soluble vitamin considered to be one of the most important antioxidant nutrients in the body, as it prevents cell membrane lipid peroxidation [1]. The form which is considered to be most active, α-tocopherol, acts as a peroxyl radical scavenger in lipid environments and possesses numerous beneficiary roles in the body, including prevention of oxidative stress, but also regulation of platelet aggregation, protein kinase C activation and preservation of the cardiovascular and immune systems [1] [2]. Its deficiency can stem from inadequate dietary intake, the most common cause in the developed world, or from gastric surgery and diseases that induce fat malabsorption (cystic fibrosis, abetalipoproteinemia) [3] [4]. Hemolytic anemia and a myriad of neurological symptoms (due to neuronal death induced by free radicals that are not scavenged by α-tocopherol) are principal symptoms and the diagnosis can be made by determining levels of α-tocopherol in blood together with serum lipids [2] [4]. Vitamin E supplementation and diet correction (when possible) are two main methods of treatment [2].

Patient Information

Vitamin E deficiency is a condition that stems either from inadequate dietary intake or due to diseases that impede its absorption from the gastrointestinal tract, such as abetalipoproteinemia, cholestatic liver disease, cystic fibrosis, short bowel syndrome or cystic fibrosis. Vitamin E, in its most biologically active form, α-tocopherol, is an essential part of defense against free radicals that can cause cell membrane damage and in its absence, the neurons and the red blood cells are most severely affected, leading to anemia and various neurological symptoms. Attenuated reflexes, visual deficits, muscle weakness, difficulties with speech and dementia are some of the most common symptoms, whereas severe deficiencies can lead to blindness and cardiac arrhythmias. To diagnose vitamin E deficiency, it is necessary to measure its concentrations in blood and to obtain a full lipid profile. Treatment comprises supplementation with vitamin E, either through tablets or injections, depending on the underlying cause. Many studies have concluded that inadequate dietary intake of vitamin E is a global issue, which is why vitamin E-rich foods - edible oils, almonds, hazelnuts, peanuts, spinach and broccoli must be taken on a regular basis.

References

Article

  1. Traber MG, Frei B, Beckman JS. Vitamin E revisited: do new data validate benefits for chronic disease prevention?. Curr Opin Lipidol. 2008;19(1):30-38. T
  2. Rizvi S, Raza ST, Ahmed F, Ahmad A, Abbas S, Mahdi F. The Role of Vitamin E in Human Health and Some Diseases. Sultan Qaboos Univ Med J. 2014;14(2):e157-e165.
  3. Rino Y, Suzuki Y, Kuroiwa Y, et al. Vitamin E malabsorption and neurological consequences after gastrectomy for gastric cancer. Hepatogastroenterology. 2007;54(78):1858-1861.
  4. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  5. anyel MC, Mancano LD. Neurologic findings in vitamin E deficiency. Am Fam Physician. 1997;55(1):197-201.
  6. Assantachai P, Lekhakula S. Epidemiological survey of vitamin deficiencies in older Thai adults: implications for national policy planning. Public Health Nutr. 2007;10(1):65-70.
  7. Pekmezci D. Vitamin E and immunity. Vitam Horm. 2011;86:179-215.

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Last updated: 2019-07-11 21:09