CLINICAL CHEMISTRY 2

TRACE ELEMENTS
Montalbo, Catherine A. Senete, Charisse T. Tadiosa, John Patrick B.

CASE STUDY
A 36 year old male had undergone multiple partial small bowel resections because of Crohns disease (a type of inflammatory bowel disease that may affect any part of the gastrointestinal tract). After recovery from surgery, he was placed on total parenteral nutrition (TPN), and after adequate rehabilitation he was discharged under the care of a home health care nurse who visited him 3 times a week to follow his overall progress and check his physical and vital conditions. Periodic routine laboratory test were performed to assess nutritional status. His first few months postsurgery were unremarkable. Eventually, he experienced symptoms of weakness, diarrhea, general malaise and hair loss. He visited his physician, who did a complete work up of his problem and obtained the following laboratory values:
Test Sodium Potassium Chloride Glucose Creatinine Calcium Hemogobin Hematocrit Albumin Transferrin Copper Zinc Result 147 mmol/L 4.9 mmol/L 118 mmol/L 102 mg/dL 0.6 mg/dL 7.9 mg/dL 10.4 g/dL 31% 2.5 g/dL 112 mg/dL 38 ug/dL 46 ug/dL Normal Range 136 146 mmol/L 3.5 5.1 mmol/L 98 106 mmol/L 80 100 mg/dL 0.6 1.2 mg/dL 8.4 10.2 mg/dL 13.3 17.7 g/dL 40% - 52% 3.5 5.5 g/dL 200 400 mg/dL 50 150 ug/dL 75 125 ug/dL

QUESTIONS
1. What do the laboratory studies suggest as a possible cause of this patient problem? 2. What is the significance of the low copper and zinc levels? What is the underlying cause of their discrepancy? 3. What medical treatment would be instituted in this patient?

ANSWERS
1. Low albumin and transferring values are hallmarks for malnutrition. Transferrin is a very sensitive indicator of inadequate nutritional status. With cases of severe malnutrition, levels are often lower that 50mg/dL. Low serum and/or copper are commonly observed in patient on long term parenteral nutrition (due to inadequate supplementation of administered fluids). 2. Zinc and/ or copper are commonly observed in patients receiving long-term parental nutrition. It can take several months for these deficiencies to become evident. They ca produce impairment of several biological functions. Low zinc is associated with impaired growth, particularly in children, diarrhea, dermatitidis, and other abnormalities including hair loss (as observed in this case). Copper deficiency commonly produces defective pigmentation of hair and mental cognitive impairment. 3. Treatment would be aimed at ensure adequate nutritional intake of all essential components. Patients on total parenteral nutrition are susceptible to deficiency of essential fatty acids, protein trace minerals and vitamins.