8:16 AMA P © + Coan Vitamin B12 + Human cells cannot synthesize vitamin B12 or folates therefore needed in diet. Dietary Sources + Animal products, including meats, dairy products, eggs, fortified cereal + Vitamin B12 is not present in foods deri from plants, a vegan or strict vegetarian diet typically does not contain sufficient amounts of vitamin B12 and should be supplemented Daily requirements: 0.4 mcg per day in young infants, 2.4 meg per day in adults + slightly higher levels during pregnancy and lactation. Total body stores: 2 to 5 mg, with approximately half of this stored in the liver. + If vitamin B12 intake deficiency ally does not develop for at leas to two years, 5 i"8:21 AMA P & eee (omer ee Vitamin B,, Absorption Diet * Vitamin B12 (cobalamin) in foods is bound to proteins, which are dissociated in the acid milieu of the’stomach with the help of pepsin. Salivary Glands + Additional vitamin B12-binding proteins known as R-binders also known, as transcobalamin-1 or haptocorrin (secreted in the saliva) bind to the vitamin B12 in the stomach. Stomach * Gastric parietal c crete intrinsic factor (IF). stric Acid and Pepsin release B,, from other dietary proteins * B,5 bind to R-protein (also known as transcobalamin-1 or haptocorrin), found in’saliva and gastric fluids. COLLINS WANGULU's screen8:24AMA P © eee Fala po DuodenumyPancreas * Pancreas secreted,proteases and HCO; (provides an alkaline environment) + Pancreatic proteases secreted into the duodenum, where the pH is higher, cleave off the R-binders through proteolytic degradation : + This allows vitamin B,, (cobalamin) to bind IF. Tluem + The vitamin B12-IF complex is taken up by mucosal receptors in the ileum through receptor mediated endocytosis. ” + Enterocyte lysosome breaks down IF and Vitamin B,, is bound to transcobalamins (TC-I, TC-II, or TC-III). TC-II is thought to be the physiologically important TC.EVA PA oo OR Ome called multidrug resistance protein 1 [MRP1]). + Vitamin B12 bound to TC-II is taken up by other cells in the body by receptor-mediated endocytosis COLLINS WANGULU's screen PT a8:26 AMA P © eee Ome called multidrug resistance protein 1 [MRP1]). + Vitamin B12 bound to TC-II is taken up by other cells in the body by receptor-mediated endocytosis PT PTA8:27 AMA P AO ae eT | ie Folate (Vitamin B9 or Pteroylglutamic acid) Dietary Sources * Dark green leafy vegetables e.g. Spinach, Broccoli * Poor sources e.g. Liver, Kidney, Milk, Fruits + Fortified foods * Dietary form is in polyglutamate form whereas folic acid (the synthetic vitamin form) is a monoglutamate Daily Requirements Adults 400meg/day * Pregnant women - 600mcg/ day, Lactation - 500mcg/day + 65 meg of dietary folate equivalents in young infants + Total body folate stores are estimated to be approximately 500 to 20,000 mcg (0.5 to 20 mg). / * If folate intake ceases, deficiency may develop within weeks to months8:29 AMA P IO Paar ee me in duodenum and jejunum converts polyglutamate to te: a lutamate form of folic acid i: + Uptake of monoglutamate folate by enterocy 0 is both pa: and carrier-mediated, with the carrier-mediate ss predominatir + Folate transporters include the reduced folate carrier (RFC), the proton- coupled folate transporter (PCFT), and the folate receptor proteins, FRa and FRB. + 5-methyltetrahydrofolate, which is the major circulating form of folate in the human bod: . * This is rapidly cleared by hepatocytes and other cell COLLINS WANGULU's screen8:30 AMA P AO ae eT | A Causes of Vitamin B12 Deficiency + In healthy adults, vitamin B,» deficiency is uncommon, mainly because total body stores can exceed 2,500 pig, daily turnover is slow, and dhietary intake of only 2, g/day is sufficient to maintain adequate vitamin B,, stati Dietary intake + Vegans Stomach * Pernicious anemia - autoimmune condition, Antibodies to intrinsic factor (IF) bind to IF preventing formation of the IF-B. mle, further inhibiting vi By absor] ption Autoantibodies in indi PA may be di oF against gastric parietal cell antigen: * Atrophic gastritis hlohy dria + Gastrectomy /bariatric sui COLLINS WANGULU's screen8:32 AMA P AO ae eT aA fa) * Duodenum Pancreas ancreatic insufficienc Tleum * Terminal ileum resection, Fish Tape Worm, Crohn’s dis: + Infestation with the fish tapeworm Diphyllobothrium latum causes vitamin B12 deficiency because the worm has an affinity for vitamin B12 and competes for its absorption in the ileum8:34 AMA P -@ eee an | C¢ = Causes of Folate Deficiency + Inadequate Intake Y Alcoholism, o + Impaired Absorption se, Tropical Sprue, YPhenytoin, Valproate, Cabarmazepine, Methotrexate, Trimethoprim, 5FU + Increased Demand ¥ Pregnancy, Hemolytic Anemia, Exfoliati i s Hemodial + Genetic causes8:35 AMA P -@ eee an | ae) ole of Folate in Metabolism + Folate coenzymes play a vital role in DNA metabolism through two differ pathways. * The syitte 's of DNA from its precursors (thymidine and purines) is dependent folate - . + A folate coen: from homo ylmethionine ( ised in most biological methy ation reactions, including the ti er oF es within DNA, RNA, proteins, Lacl of vitamin B12 may cause folate to become trapped in the 5-methyl-THF form; Folate Trap8:35 AMA P -@ eee an | rae) Metabolic functions of Vitamin Bj) * Vitamin B,, or cobalamin pla ssential roles i ¥ Folate metabolism YDNA/RNA s} i is required fc the amino acid, methionine, from homocysteine. Methionine in turn is required for the synthesis of S-adenosylmethionine, a methyl] group donor used in many biological methylation reactions, including the methylation of a number of s within DNA, RNA, and proteins. nthesis of the citric acid cycle intermediate, succinyl-CoA.8:37 AMA P | eee one — methionine (momo) seve othy! THs “Folate Homocysteine Vitamin Be Cystathionine Vitamin By AT eee8:38 AMA P 4 « ae eT | PAL Fatty acids Amino acids \ * \ ‘ Propionyl-CoA I D-MethyimalonyCoA _____» Methylmator Limethylmalonyt- CoA mutase LMethyim: oA + C Seosyadenosylcobatamia Se8:40 AMA P ae eT | iA Methylcobalamin is required for the function of the folate- dependent enzyme, methionine synthase. This enzyme is required for the synthesis of the amino acid, methionine, from horiocysteine. Methionine in turn is required for the synthesis of S-adenosylmethionine, a methyl group donor used in many biological methylation reactions, including the mietliylation of a number of sites within DNA, RNA, and proteins. 5-Deoxyadenosylcobalamin is required by the enzyme that catalyzes the conversion of L-methyimalonyl-coenzyme A to succinyl-coenzyme A (succinyl-CoA), which then enters the citric acid cycle Succinyl-CoA plays an important role in, the production of energy from lipids and proteins and is also required for the synthesis of hemoglobin, the oxygen-carrying pigment in red blood cell8:41 AMA P @ eee Cre ae) Clinical Manifestations of B12 Deficiency + Features of anemia: fatigue, weakness, palpitations, palor + Tongue: red “beefy” tongue, glossitis and atrophy of papillae. The patient complains of painful tongue, loss of taste and appetite. + Peripheral neuropathy: Glove and istribution of numbne: paraesthesia. tingling begins in tips of toes and progre proximally and is bilateral and sy: + Ataxia: Ataxic, uncoordinated gait, impairment of vibration and position sense. + Atherosclerosis: Serum homoc ine level is raised and is a risk factor for atherosclerosis and thromb8:44 AMA P | eee ae eT | es * Neurological symptoms are due to peripheral neuritis and Sub acute combine degeneration of the spinal cord due to demyelination of dérsal column and lateral corticospinal tract * Thought to occur due to reduced methylation of neuronal lipia neuronal proteins such as mryelin basic protein. + Myelin basic protein makes up approximately one-third of elin, and demyelination in the setting of vitamin B12 deficiency may explain many of the neurologic findin;8:45 AMA P -@ eee ae eT | Fae) ole of Folate in Metabolism + Folate coenzymes play a vital role in DNA metabolism through two differ pathways. * The synthesis of DNA from its precursors (thymidine and purines) i folate + A folate coen: from homo ylmethionine ( ised in most biological methy ation reactions, including the ti er oF es within DNA, RNA, proteins, Lacl of vitamin B12 may cause folate to become trapped in the 5-methyl-THF form; Folate Trap8:46 AMA P | eee Folate Glycine TH.Folate S10-metnyleneTH, Folate Vitamin By, Riboflavin SemethyiTH, - Folate NUCLEIC ACID ‘SYNTHESIS (Omer iT rae) Dimethylglycine x fmethryltransferases Betaine tiyX ‘TRANSSULFURATION RED BF eariwar8:47 AMA P @ eee Nucleic Acid ‘Synthesis Methylation Reactions TH. | Folate Methylene TH NADPHeH® ductase S-Methy! THe Folate naopé ids, while s required for the formation of methionine from homocysteine. Methionine, in the form of S-adenosylmethionine, is required for many biological methylation reactions, including DNA methylation. Methylene TH, reductase is a flavin-dependent enzyme required to catalyze the reduction of 5,10-methylene TH, to 5-methyl TH,8:47 AMA P @ eee ae eT | ran B12 and Folate in Hematopoeisis + Hematopoietic precursor cells are among the most rapidly dividing cells in the body and hence are one of thé cell types most sensitive to caused by vitamin B12 and folate O cts on hematopoiesis are megaloblastic and ineffective erythropoesis Megaloblastic changes: Megaloblastic changes are caused by _ slowing of the nuclear division cycle relative to the cytoplasmic maturation cycle (nuclear-cytoplasmic dyssynchrony). n in any of the nucleated precursor cells in the bone , including immature or morphologically abnormal nuclei relative to the cytoplasmic maturity co Giant metamyelocytes, and increased mitotic figure.8:49 AMA P @ eee ae eT | iA B12 and Folate in Hematopoeisis + Hematopoietic precursor cells are among the most rapidly dividing cells in the body and hence are one of thé cell types most sensitive to abnormal DNA synth caused by vitamin B12 and folate deficiencies. There are two major effects on hematopoiesis are megaloblastic changes and ineffective erythropoesis Megaloblastic changes: Megaloblastic changes are caused by _ slowing of the nuclear division cycle relative to the cytoplasmic maturation cycle (nuclear-cytoplasmic dyssynchrony). May be seen in any of the nucleated precursor cells in the bone marrow, including immature or morphologically abnormal nuclei relative to the cytoplasmic maturity " Giant metamyelocytes, and increased mitotic figure.8:50 AMA P - + ae eT | ra MACROCYTIC ANEMIA Macrocytic anemias are characterized by large red cells with a diameter of more than 9p and mean corpuscular volume of more than 100 fl. . Causes can be megaloblastic and non-megaloblastic depending on th appearance of developing red cell precursors in the bone marrow. Megaloblas is are characterized by the presence of abnormal red cell precursors in the bone marrow known as megaloblasts Megaloblastic anemia is commonly due to deficiency of vitamin B12 anocobalamin) or folic acid, which are coenzymes required for the ynthesis of one of the four nucleotide bases found in DNA namely thymidine.8:52 AMA P -@ + ae eT | in MACROCYTIC ANEMIA Macrocytic anemias are characterized by large red cells with a diameter of more than 9p and mean corpuscular volume of more than 100 fi. Causes can be megaloblastic and non-megaloblastic depending on the appearance of developing red cell precursors in the bone marrow. Megaloblas is are characterized by the presence of abnormal red cell precursors in the bone marrow known as megaloblasts Megaioblastic anemia is commonly due to deficiency of vitamin B12 anocobalamin) or folic acid, which are coenzymes required for the ynthesis of one of the four nucleotide bases found in DNA namely thymidine.8:52 AMA P -@ eee ae eT | PTA + De iciency of vitamin B12 or folic acid causes defects in the DNA and nuclear maturation with delay or block in cell divi: of RNA and protein is normal resulting in normal cytoplasmic maturation °T , the nuclear maturation lag i e cytoplasmic n continues for a long in formation of large megaloblasts + Erythropoietic cells show reduced number of mitoses which results in‘the production of enlarged red cells namely macrocy COLLINS WANGULU's screen8:53 AMA P -@ eee ae eT | oO nce megaloblast precursors do not mature enough to be released into the blood, the undergo intramedullary destruction. + There is also mild hemolysis of red cells in the peripheral blood.8:56 AMA P | eee OMe ae) Laboratory Findings in Megaloblastic Anemia Complete Blood Count + Hemoglobin: Hemoglobin levels are decreased * Mean cell (corpuscular) volume (MCV) above 100 fl (Macrocytes). * Hemoglobin content in the red cell is proportionately increased and therefore mean corpuscular hemoglobin concentration (MCHC) remait normal. + Variable WBC Count Leukopenia or Normal WBC Counts ariable Platelet Counts - Thrombocytopenia or normal8:57 AMA P< eee ae eT | rae) Peripheral Blood Films * RBCs: Macrocytic and oval (macro-ovalocyte: of dyserythropoiesis may be present like: sophilic stippling appear as blue black cytoplasmic inclusions and represents precipitated ribosomal RNA. + Howell Jolly bodies are nuclear remnants observed in few red hite cells are decreased (leukopenia) and show hypersegmented neutrophils (with five to six or more nuclear lobes). Their presence is the first and specific morphologic s megaloblastic anemia. * Platelets: Decreased (thrombocytopenia) and the count varies8:58 AMA P | eee = alll 24 Co Peripheral Blood Films * RBCs: Macrocytie and oval (macro-o * RBC Inclusions: Evidences of dyserythropoiesis may be present like: hilic stippling appear as blue black cytoplasmic inclu represents precipitated ribosomal RNA. + Howell Jolly bodies are nuclear remnants observed in few red * WBC hite cells are decreased (/eukopenia) and show hypersegmented neutrophils (with five to six or more nuclear lobes). Their presence is the first and specific morphologic s megaloblastic anemia. * Platelets: Decreased (thrombocytopenia) and the count varies8:59 AMA P 4 aoe Ear ety rae) Peripheral Blood Films * RBCs: Macrocytic and oval (macro-ovalocyte: + RB clusions: Evidences of dyserythropoiesis may be present like: sophilic stippling appear as blue black cytoplasmic inclu represents precipitated ribosomal RNA. + Howell Jolly bodies are nuclear remnants observed in few red hite cells are decreased (leukopenia) and show hypersegmented neutrophils (with five to six or more nuclear lobes). Their presence is the first and specific morphologic s megaloblastic anemia. * Platelets: Decreased (thrombocytopenia) and the count va8:59 AMA P | eee (ome Ta Reticulocyte count + It is normal onlow.8:59 AMA P< see © saul rae)9:01AMA P @ « Bone Marrow + Abnormalities in Erythropoiesis are seen. egaloblastic change is detected in all stages of red cell development. hey demonstrate asynchrony of nuclear and cytoplasmic maturatio! ve erythropoiesis (or intramedullary hemolysis) is the term used ythropoiesis in which there is death of developing erythroid cells at the site of production and/or production of non-viable red cells. * Dyserythropoiesis: Dyserythropoiesis means abnormal erythropoie: with bizarre bone marrow morphology and ineffective erythropoiesis9:01 AMA P @ eee Samet} a ysery’ nuclear borders due to nuclear budding, nuclei joi y bridge (internuclear bridging) and abnormal mito Abnormalities in Granulopoesis: granulocytic precu also display nuclear-cytoplasmic asynchrony in the form of giant metamyelocytes and band forms. Abnormalities in Megakaryopoiesis: Megakaryocytes are normal or increased in number. They may be abnormally large and may have bizarre, multilobate nuclei with open nuc chromatin COLLINS WANGULU's screen9:01 AMA P 4 Samet} ra yserythropeitic features: Irregular nuclear borders due to nuclear budding, nuclei joined by bridge (internuclear bridging) and abnormal mitc bnormalities in Granulopoesis: granulocytic precu s also display nuclear-cytoplasmic asynchrony in the form of giant metamyelocytes and band forms. + Abnormalities in Megakaryopoiesis: Megakaryocytes are normal or increased in number. They may be abnormally large and may have bizarre, multilobate nuclei with open nuclear chromatin9:01 AMA P @ eee Samet} tA nuclear budding, nucl and abnormal mito bnormalities in Granulopoesis: granulocytic pr display nuclear-cytoplasmic asynchrony in the form of giant metamyelocytes and band forms. Abnormalities in Megakaryopoiesis: Megakary ocytes are normal or increased in number. They may be abnormally large and may have bizarre, multilobate nuclei with open nuclear chromatin COLLINS WANGULU's screen9:02 AMA P < see © Faull rae) Biochemical Tests v Serum homocysteine: increased. ¥ Serum bilirubin: Mild increase of serum bilirubin Serum lactate dehydrogenase (LDH): Elevated. ¥ Haptoglobulin: Reduced Specific Tests for Folic Acid Defi v Serum folic acid leve ¥ Normal methyl malonic acid9:03 AMA P @ eee © Biochemical Tests v Serum homocysteine: increased. ¥ Serum bilirubin: Mild increase of serum bilirubin Serum lactate dehydrogenase (LDH): Elevated. ¥ Haptoglobulin: Reduced Specific Tests for Folic Acid Defi v Serum folic acid leve ¥ Normal methyl malonic acid PT iA fa)aa laa hee © Faull Pe) Biochemical Tests v Serum homocysteine: increased. ¥ Serum bilirubin: Mild increase of serum bilirubin Serum lactate dehydrogenase (LDH): Elevated. ¥ Haptoglobulin: Reduced Specific Tests for Folic Acid Defi v Serum folic acid leve ¥ Normal methyl malonic acid9:04 AMA P | eee Sane | oe Diagnostic tests for vitamin B12 deficiency ¥ Serum vitamin B12 levels: Decreased ¥ Serum methyl malonic acid and Urinary excretion of methylmalonic acid: Increased ¥ Schilling test for vitamin B12 absorption: Radioactive vitamin B12 is used toa e fi ic factor (IF) and vitamin B12 and helps in distinguishing megaloblastic anemia due to IF deficiency (pernicious anemia) from other causes of vitamin B12 deficiency. It is diagn of PA but now very infrequently performed.9:05 AMA P -@ eee (om Tr Biochemical Tests ‘nt homocysteine: increa rum bilirubin: Mild inc of serum bilirubin vSerum lactate dehydrogenase (LDH): Elevated. ¥ Haptoglobulin: Reduced Specific Tests for Folic Acid Deficiency v Serum folic acid levels: Decreas' ¥ Normal methyl malonic a COLLINS WANGULU's screen9:06 AMA P -@ eee ae eT | iA Diagnostic tests for vitamin B12 deficiency ¥ Serum vitamin B12 levels: Decreased ¥ Serum methyl malonic acid and Urinary excretion of methylmalonic acid: Increased Y Schilling test for vitamin B12 absorption: Radioactive vitamin B12 is used toa e i ic factor (IF) and vitamin B12 and helps in distinguishing megaloblastic anemia due to IF deficiency (pernicious anemia) from other causes of vitamin B12 deficiency. It is diagn of PA but now very infrequently performed9:07 AMA P - see © saul ae) Non-Megaloblastic Causes Macrocytosis + Alcohol + Live: + Hypothyroidism * Cytotoxic drugs * Diabetes Mellitus COLLINS WANGULU's screen9:08 AMA P -@ eee © = aul irae) Non-Megaloblastic Causes Macrocytosis + Alcohol + Liver disea: + Hypothyroidism 5 drugs * Diabetes Mellitus9:09 AMA P -@ eee © SAQ/Essay Questions following about Folate and B12 ological role (5 marks) c) Difference in clinical presentation (5 marks) d) Folate trap (5 marks). ae eT | rae)9:09 AMA P - eee (ome Tre cribe the following about Vitamin B12 deficiency 5 marks) b) Clinical manifestation (5 marks) . Briefly describe the following about Macrocytic Anemia: a. Etiology (5 marks) . Laboratory Evaluation (15 marks).9:10 AMA P <@ eee (omar Ta ribe the following about Vitamin B12 def: (5 marks) station (5 marks) . Briefly describe the following about Macrocytic Anemia: . Etiology (5 marks . Laborato valuation (15 marks)