Medic rezident an II neurologie • In afara de deficitul de fier, o alta cauza majora pentru aparitia anemiei o reprezinta deficitul de vitamina B12 si acid folic.
• Frecventa de aparitie depinde foarte mult de
populatia studiata, astfel: - din cauza faptului ca deficitul de vitamina B12 se dezvolta de a lungul mai multor ani, este mai frecvent la varstnici; - iar deficitul de folat aparand cel mai frecvent datorita unei diete inadecvate, este mai frecvent in cadrul populatiilor care sunt la risc pentru dezvolatrea malnutritiei sau in zonele unde mancarea nu este fortificata*. • Bacteriile din intestinul animalelor erbivore sintetizeaza vitamina B12 care apoi este preluata de organismul gazda, ajungang ulterior la oameni sub forma de carne (produse lactate, peste...). • Plantele nu sintetizeaza vitamina B12, dar pot o contine prin contaminare bacteriana. • Plantele sintetizeaza acid folic si il furnizeaza oamenilor direct sub forma de fructe si legume (nuci, legume verzi, drojdie) si indirect prin carnea erbivorelor. • Absorbtie si transport: vitamina B12 (factorul extrinsec) odata ajunsa in stomac se leaga de FACTORUL INTRINSEC (secretat in paralel cu acidul clorhidric de catre celulele parietale gastrice), care transporta cobalamina la nivelul ileonului si de aici in sistemul venos portal legata de transcobalamina.
• Absorbtie si transport: acidul folic este o
substanta solubila in apa si se absoarbe rapid in portiunea superioara a intestinului subtire, ulterior ajungand in plasma. Rolurile metabolice ale vitaminei B12 si acidului folic sunt foarte interconectate. • Vitamina B12 este un cofactor important in procesul de metilare -> necesar in reactiile de formare ADN si metabolism celular. • Intracelular vitamina B12 se transforma in 2 enzime: adenozil-cobalamina (in mitocondrie) si metil-cobalamin (in cotiplasma), necesare pentru homeostaza acidului metil-malonic si respectiv homocisteina. La oameni doar 2 reactii enzimatice sunt cunoscute a fi dependente de vitamina B12: 1. (intramitocondrial) adenozil-cobalamina ->acidului metil-malonic -> succinil CoA (vitamina b12 fiind cofactor al reactiei). Aceasta reactie permite utilizarea acidului propionic si este importanta pentru sinteza acizilor grasi, indispensabili pentru structura normala a membranelor neuronale si a tecilor de mielina din sistemul nervos central. Astfel, deficitul de vit B12 duce la acumularea metilmalonil-CoA si respectiv propionil-CoA. Conform acestui mecanism propionil-CoA inlocuieste succinil-CoA, care este in mod normal amorsa pentru sinteza lanturilor de acizi grasi =>rezultand lanturi anormale de acizi grasi gresit inserate la nivelul membranelor lipidice/tecilor de mielina. 2. (intracitoplasmatic) metil-cobalamina -> homocisteina - -> metionina. Afectarea acestei reactii, cauzata de deficitul de cobalamina ar putea cauza un esec in sinteza ADN ului, fiind afectata in special productia de megaloblaste (deoarece neuronii nu se divid, aceasta cascada de evenimente nu explica leziunile de la nivelul SNC). metil-cobalamina -> rol in reactia de transformare a metiltetrahidrofolatului in tetrahidrofolat. 5MTHF->DHF->THF Tetrahidrofolatul interactioneaza cu 5-10 metilentetrahidrofolatul si dihidrofolatul, contribuind la sinteza timidilatului din dezoxiuridilat, reactie majora in sinteza ADN. • The metabolic roles of folate and B12 are closely interrelated (Fig. 2.1). Folate derivatives are essential cofactors in thymidylate synthesis, which is a rate-limiting step in the synthesis of DNA. RNA synthesis, however, is not dependent on folate. Therefore, deficiency of folate limits gene transcription but not RNA translation, retarding cell division but not cytoplasmic protein synthesis. This leads to the typical cytonuclear dissociation of maturation characteristic of megaloblastic hematopoiesis. Because cobalamin supports the recycling of folate, vitamin B12 deficiency causes megaloblastic changes by restricting the folate supply. This restriction can be at least partially overcome by increasing dietary folate, allowing the hematopoietic effects of cobalamin deficiency to be ameliorated by high doses of folic acid. In contrast, the hematopoietic effects of folate deficiency cannot be overcome by treatment with vitamin B12. • COBALAMIN-FOLATE RELATIONS Folate is required for many reactions in mammalian tissues. Only two reactions in the body are known to require cobalamin. MethylmalonylCoA isomerization requires adocobalamin, and the methylation of homocysteine to methionine requires both methylcobalamin and 5-MTHF (Fig. 95-1). This reaction is the first step in the pathway by which 5-MTHF, which enters bone marrow and other cells from plasma, is converted into all the intracellular folate coenzymes. The coenzymes are all polyglutamated (the larger size aiding retention in the cell), but the enzyme folate polyglutamate synthase can use only THF, not MTHF, as substrate. In cobalamin deficiency, MTHF accumulates in plasma, and intracellular folate concentrations fall due to failure of formation of THF, the substrate on which folate polyglutamates are built. This has been termed THF starvation, or the methylfolate trap. This theory explains the abnormalities of folate metabolism that occur in cobalamin deficiency (high serum folate, low cell folate, positive purine precursor aminoimidazole carboxamide ribonucleotide [AICAR] excretion; Table 95-2) and also why the anemia of cobalamin deficiency responds to folic acid in large doses. • vitamin B12 deficiency may exert indirect cardiovascular effects. Similar to folic acid deficiency, vitamin B12 deficiency produces hyperhomocys-teinemia, which is an independent risk factor for atherosclerotic disease.7 Although the role of folic acid supplementation in reducing homocysteine levels as a method for preventing coronary artery disease and stroke continues to be a subject of great interest, there has been little emphasis on the potential role of vitamin B12 deficiency as a contributing factor in the development of cardiovascular disease. This possibility becomes especially important when considering vitamin replacement therapy. Folic acid supplementation may mask an occult vitamin B12 deficiency and further exacerbate or initiate neurologic disease. Therefore, clinicians should consider ruling out vitamin B12 deficiency before initiating folic acid therapy.8 • CLINICAL PRESENTATION • The clinical presentation of vitamin B12 and folic acid deficiency covers a wide range from asymptomatic, to life- threatening pancytopenia or myelopathy (Table 2.4). The investigation of any new neuropsychiatric changes should include an evaluation of vitamin B12 (and folate status) even in the absence of hematologic signs of a deficiency.7 B12 deficiency is commonly associated with neurologic changes, and only rarely with folate deficiency; hereditary folate malabsorption and/ or metabolism are the exception and associates with progressive neurologic deterioration in childhood.25 Classically, changes in the tongue mucosa and mouth angle stomatitis are the earliest signs of folate deficiency on physical examination.26 CLINIC Manifestari neuro-psihiatrice:
• Deficitul de vitamina B12 (cobalamina) afecteaza
maduva spinarii, creierul, nervii optici si nervii periferici, dand nastere unui sindrom neurologic clasic. • Maduva spinarii este de obicei prima si de multe ori si singura afectata. • Termenul de DEGENERESCENTA COMBINATA SUBACUTA (DCS) este in mod obisnuit rezervat leziunilor medulare provocate de deficitul de vitamina B12 si ne ajuta sa distingem aceasta afectiune de alte boli ale maduvei spinarii care includ modificari la nivelul cordoanelor posterioare si laterale. CLINIC: Neuro-psihiatric: • Semnele si simptomele sunt simetrice, predominant distale, iar cele senzitive le preceda pe cele motorii.
Astfel, initial pacientul acuza slabiciune generalizata si parestezii (furnicaturi,
intepaturi) ce implica mainile > picioarele.
Pierderea simtului vibrator (sensibilitate tactila fina /epicritica si vibratorie)
este cel mai consistent semn. In paralele apare si afectarea sensibilitatii proprioceptive. (afectare cordoane posterioare) Afcetarea sensibilitatii termoalgice prin afectarea nervilor periferici (distal, simetric) sau rar a tracturilor spinotalamice laterale. Fenomenul Lhermitte
Semnele motorii, apar prin afectarea tracturilor spinocorticale, de obicei sunt
limitate la nivelul mb inf: deficit motor (moderat mm proximali, simtric, spasticitate), ROT exagerate si clonus (ROT pot fi diminuate sau absente in afectarea periferica), RCP in extensie. La inceput mers ataxic ulterior ataxic si spastic. • Cognitiv: Frecvente, de la apatie, iritabilitate, somnolenta, neincredere, instabilitate emotionala, psihoza confuziva sau depresiva, dementa (megaloblastic madness). • Vedere: Este secundara neuropatiei optice; Scotom centrocecal, atrofie optica. • Disfunctie autonoma: Disfunctie sfincter vezical, impotenta.
• Afectarea tesuturilor (stratul epitelial) de la nivelul cavitatii
bucale (GLOSITA), stomac, intestin subtire, tract respirator, urinar si genital. (macrocitoza, moarte celulara...) • Gonadele sunte afectate de asemenea, pana la infertilitate. • Avort, prematuritate, defecte de tub neural. Hematologic – sangele periferic:
• Celule rosii macrocitare, ovale sau macroovalocite, variate
forme celulare fragmentate, celule rosii nucleate, neutrofile hipersegmentate (1% cu 6lobi sau 5% cu 5lobi); • Anemie, de obicei macrocitara, dar poate fi si normo sau microcitara daca se insoteste de talasemie sau de deficitul de fier; • Leucopenie, trombocitopenie, pancitopenie; • Nivel crescut de LDH, bilirubina indirecta, nivel scazut de haptoglobina; • Maduva hipercelulara, eritropoieza megaloblastica cu diferite grade de displazie si cromatina nucleara imatura; Cauze: Gastrointestinal • Gastric atrophy: achlorhydria, achlorhydria + intrinsic factor deficiency • Bariatric surgery • Gastrectomy • Gastric bypass • Terminal ileal resection • Extensive celiac disease • Crohn’s disease of the stomach • Bacterial overgrowth in the small bowel (achlorhydria, anatomical defects, impaired motility) • Zollinger–Ellison syndrome • Pancreatic insufficiency • HIV • Intestinal parasites
Medications Megadoses of vitamin C, metformin, proton pump inhibitors
Increased utilization Pregnancy
Cauze: • Cobalamin deficiency is rarely caused by inadequate intake or increased use of the vitamin (Table 2.2). This is in part due to the pronounced enterohepatic circulation of cobalamin. Although strict vegetarians become depleted of vitamin B12, vegetables often contain sufficient bacteria to provide a marginally adequate supply. A developing fetus shunts cobalamin from its mother, placing her at risk of deficiency, particularly if her baseline stores are low. Rarely, intestinal parasites can induce deficiency; for example the fish tapeworm, Diphyllobothrium latum, competesas well, although this is rare.8
• DEVELOPMENT OF VITAMIN B12 DEFICIENCY
• Cobalamin deficiency is rarely caused by inadequate intake or increased use of the vitamin (Table 2.2). This is in part due to the pronounced enterohepatic circulation of cobalamin. Although strict vegetarians become depleted of vitamin B12, vegetables often contain sufficient bacteria to provide a marginally adequate supply. A developing fetus shunts cobalamin from its mother, placing her at risk of deficiency, particularly if her baseline stores are low. Rarely, intestinal parasites can induce deficiency; for example the fish tapeworm, Diphyllobothrium latum, competes with the host for cobalamin.9 Acutely, cobalamin metabolism can be disrupted by nitrous oxide anesthesia and induce a rapid, usually transient, megaloblastic anemia.10 However, fatalities and severe neuropsychiatric damage have been associated with chronic administration in patients and recreational use of nitrous oxide.11 • Far more commonly, defects in any of the three levels of the gastrointestinal tract can lead to vitamin B12 malabsorption: the fundus of the stomach, the pancreas, or the small bowel.12 Obviously, surgical removal or bypass of any of these regions leads to B12 malabsorption.13 Bariatric surgery is becoming more prevalent and subsequently an important risk factor for developing B12 deficiency. Otherwise the etiology is inflammatory. • Stomach: In the stomach, food (protein)-bound vitamin B12 must be freed by digestion with pepsin and bound to “R-proteins,” which is a generic term for proteins that bind B12.1 The parietal cells in the fundus secrete both the acid necessary for this digestion and intrinsic factor, the protein to which cobalamin is later transferred in the alkaline duodenum. Therefore, any process that damages the parietal cells can lead to vitamin B12 malabsorption and eventually deficiency. The most common cause is autoimmune atrophic gastritis, which increases in prevalence with age and is sometimes associated with other autoimmune diseases, such as thyroiditis. Helicobacter pylori, however, which typically causes antral gastritis, can occasionally also infect the fundus.14,15 Proton pump inhibitors induce chronic hypochlorhydria but rarely cause clinically significant B12 malabsorption. Parodoxically, the hypersecretion of acid in theZollinger–Ellison syndrome leads to B12 malabsorption by acidifying the small bowel, which must remain alkaline for the transfer of B12 from the R-binders to intrinsic factor. Antibodies to intrinsic factor, as in the case of pernicious anemia, also lead to a reduction of vitamin B12-intrinsic factor complexes necessary for absorption in the small bowel. • Pancreas: Deficiency of pancreatic enzymes impairs the digestion of R-binders in the small bowel and therefore the release of B12 to intrinsic factor. Although pancreatic insufficiency causes cobalamin malabsorption, it rarely is significant enough to become clinically apparent. • Small bowel: Vitamin B12–intrinsic factor complexes are endocytosed by the mucosa of the terminal ileum. Inflammatory bowel disease or particularly extensive celiac or tropical sprue interfere with this process.16 Bacterial overgrowth in the small bowel, especially common in the elderly, competes for B12 and makes it less available for absorption.17 Calcium dependent ileal membrane antagonism of metformin leads to diminished B12 absorption in up to one-third of diabetic patients, but rarely leads to anemia, and is reversed with supplemental calcium.12,18,19 HIV infection is sometimes also associated with B12 malabsorption, especially in the presence of chronic diarrhea. Tratament: