Lecture4:

Clinical Biochemistry

1
1-Cell Biology

*The cells of prokaryotes& eukaryotes possess 2 important

features:
1. Cytoplasm: is the gel like structure.
2. Plasma membrane: is the outermost surface of the cell.

*The normal cell contains the following:

1. Cell wall: it is the structure outside cell membrane.

*Most bacteria have a thick, rigid cell wall which gives them shape.
*In fungi, the cell wall is composed of chitin, however in plant cell, the wall is normally
composed of cellulose.
*function of cell wall: provides support & helps resist mechanical pressure.

2. Cell membrane: It normally consists of phospholipids. The li pid is present in two

layers, known as bilayers in which protein is embedded. It forms border of the cell.

3. Nucleus: prokaryotes lack nucleus, however they still carry nuclei. They have no
protein to support them and no membrane to cover them.
*The nucleus of eukaryotic cells is primarily composed of proteins & DNA. They
nucleus is surrounded by an outer membrane called the nuclear envelope.

4. Cytoplasm: it is gel like material enclosed by the plasma membrane.

5. Endoplasmic reticulum (ER): It is a series of membranes extending throughout the

cytoplasmic eukaryotic cells.
*In some places, the ER is studded with ribosomes which give the rough texture to the
ER & therefore it is known as the rough endoplasmic reticulum.
*The other part of the ER which doesn't contain any ribosomes is known as the smooth
endoplasmic reticulum.

6. Golgi body" Golgi apparatus": It is a series of flattened sacs.

*Function: synthesize cell's proteins & lipids.

7. Lysosomes: It is a drop like sac of enzymes in the cytoplasm. These enzymes help
digestion within cells.

8. Mitochondria "power house of a cell": It releases energy in the form of ATP.

9. Chloroplast: It is normally present in green plants. Its function is to absorb energy

from the sun.

10. Vacuoles: They are large, fluid like structures, & may occupy more than 75% of the
plant cells.
*Function: to store nutrients as well as toxic wastes.

11. Flagella: They are long hair like structures protruding out from the c ell. They help
bacteria to move.

12. Cilia: They are shorter & more numerous than flagella. They also help to move.

2
Difference between Prokaryotic & Eukaryotic cells.

Prokaryotic cells Eukaryotic cells

Genetic information Found in single chromosome Found in paired chromosomes
Location of genetic Nucleoid nucleus
information
Nucleus Absent Present
Histones Absent Present
Extrachromosomal DNA In plasmids In organelles such as mitochondria,
chloroplast & plasmids.
Plasma membrane Fluid –mosaic structure Fluid-mosaic structure containing sterol.
lacking sterol
Endoplasmic reticulum Absent present
Respiratory enzyme In cell membrane In mitochondria
chromatophores Present Absent
Chloroplast Absent Present in some
Golgi body Absent Present
Lysosomes Absent Present
Peroxisomes Absent Present
Ribosomes 70s 80s in cytoplasm & 70s in organelles
Cytoskeleton Absent Present
Cell wall Composed of peptidoglycan Composed of cellulose, chitin
Cilia Absent Present
Pilli Present Absent

3
2- Natural Products
*The following are naturally occurring products:
*Carbohydrates *Lipids *Proteins *Glycosides
*Alkaloids *Volatile oils *Prostaglandins.

A. Carbohydrates:
They are classified into the following:

1. Monosaccharides: the basic & simple form of sugar

e.g. dextrose (glucose) & fructose.

2. Disaccharides: they consist of two molecules of monosaccharides.

Lactose (glucose + galactose):→ found in milk.
Maltose (glucose + glucose):→ found in germinating cereal & malt.
Sucrose (glucose + fructose):→ in sugar, pineapples, carrots, sweet potatoes &honey.

3. Oligosaccharides: they consist of 2-10 monosaccharides e.g. maltotriose.

4. Polysaccharides: consists of 10 or more molecules of monosaccharides.

*They are subdivided into:
a. Heteropolysaccharides: contain more than one simple sugar e.g. mucopolysaccarides.
b. Homopolysaccharides: contain the same monosaccharide of simple sugar, e.g. starch,
glycogen, cellulose.

B. Lipids "lipoids":
They are fat & fat-like substances which occur in plants & animals.

*Lipids are generally divided into five different categories:

a. Fixed oils & Fats: they are produced upon esterification of glycerol & fatty acids.
The fixed oil which is solid at room temperature is Fat.
e.g. Fixed oil = Olive oil fat =lard.

b. Waxes: they are esters of monohydroxylic alcohol & fatty acid, e.g. spermaceti

c. Sterols: they are alcohol containing cyclopentanophenanthrene nucleus e.g.

cholesterol & ergosterol.

d. Phospholipids: these are esters of fatty acid, glycerol, phosphoric acid & nitrogenous
compound e.g. Lecithin.

e. Glycolipids "Galactolipids": they consist of fatty acid, galactose & sphingosine. They
are isolated from the brain. E.g. phrenosin & kerasin.

4
C. Proteins: they are very important constituents for regeneration & function.
The fundamental structure of protein consists of different amino acids.

They are classified into the following:

1. Simple protein: e.g. Albumin, globulin, glutelin, prolamine, albuminoids, Histones &
Protamine. They naturally occur & yield - amino acids upon hydrolysis.

2. Conjugated proteins: these type of proteins are conjugated with non-protein groups,
generally known as prosthetic groups.

Conjugated proteins Prosthetic groups Examples

1. Phosphoprotein
2. Nucleoprotein
3. Glycoprotein
4. Chromoprotein
5. Lipoprotein
6. Metaloprotein
Phosphoric acid Casein in milk
Ovovitellin in egg
Nucleic acid Nuclein in nucleus
Carbohydrate Mucin in saliva
Colored group Hemoglobin in blood
Sterol, fatty acid glycerin -
Metal Tyrosinase, Arginase,
Xanthine oxidase.

3. Derived protein: are prepared from simple or conjugated proteins by action of heat,
acid, alkali, water, enzyme or alcohol.

*They are further classified into:

a. Primary derived protein "denatured proteins": they differ slightly from the original
protein from which they are derived. They are subdivided into:

1. Proteans: They are insoluble substances formed during the early stages of the
action of water, enzymes or dilute acids on the original proteins.
e.g. Fibrin from fibrinogen & myosan from myosin.
2. Metaproteins They are formed during the early stage of protein hydrolysis by
means of acid or alkali, e.g. acid & alkali albuminate.
3. Conjugated- They are formed from proteins usually by the action of heat or
proteins. alcohol, e.g. egg albumin & cooked meat.

b. Secondary derived protein: They are formed during extensive hydrolysis of protein.
They are much different from original protein due to profound hydrolysis.

They are classified into:

1. *highest M.wt. *they are more soluble in water compared to original

Proteosis: protein. *The saturated solution of proteosis can be precipitated out by
addition of ammonium sulfate.
2. Peptones: *lower M.wt than proteosis. *They are readily soluble in water.
*they can be precipitated out by the addition of phosphotungistic acid.
3. Peptides: They are very small hydrolytic fragments of their original proteins.
They are readily soluble in water but they cannot be precipitated out
by addition of ammonium sulfate, e.g. oxytocin.

5
3. Total Parentral Nutrition
**Definitions:

1. Marasmus : It's a chronic disease that develops over months or years as a result of
deficiency in total caloric intake.

2. Kwashiorkor: It's an acute process that can develop within weeks & is associated with
visceral protein depletion & impaired immune function.

3. Mixed marasmic kwashiorkor: It's a severe form of protein calorie malnutrition that
develops when a marasmic patient is subjected to an acute Hypermetabolic stress such
as trauma, surgery & infection.

**Total parentral nutrition [TPN]: It includes the following:

A. Energy sources: {Dextrose}

* Dextrose conc. ≥ 25% till 70% is used & must be administered through central vein
WHY? Because it's hypertonic so allow dilution by blood.

*Dextrose provides 3.4 kcal/g.

Q) How many kcal is provided by Dextrose 50% [500ml bottle]?

500 ml x 50%→ 250 g dextrose
250g x 3.4 kcal→ 850 kcal.

B. Nitrogen source: {Protein}: Solutions that contain a mixture of free essential

& non essential L-amino acids.
*Nitrogen balance: 24 h nitrogen intake……….. How to calculate?

16% of any mixture of common amino acids will consist of nitrogen.

Q1) what is the average weight in gms of nitrogen will be present in 100 ml of 10%
amino acid injection?
100x10/100 = 10g amino acid.
10gx16% = 1.6 g nitrogen.

Q2) what is the average wt in gms of nitrogen will be present in 500 ml bottle 8.5 %
amino acid injection [3 bottles]?
500 ml x 3 x 8.5 % = 127.5 g amino acid
127.5 g x 16 % = 20.4 nitrogen.

N.B. Mixture of dextrose with amino acids & other elements → called 2 in 1
formulations.

*Both Facts & comparisons & the handbood on injectable drugs compare amino acids
in amino acids injection.

6
C. Essential Fatty acids (EFAS): They are available as 10% & 20 % emulsions.
e.g. ** Liposyn:
1. It is a fatty acid emulsion that is used to prevent essential fatty acid deficiency
[EFAD].
2. It provides both linoleic & linolenic acids.
N.B. Deficiency of linoleic acid → diarrhea, dermatitis & hair loss.
3. Its physical appearance is similar to milk.

*Administration:
1. Piggy back method: lipid is in a separate bottle.
2. Total nutrition admixture [TNA]: 3 in 1 Why?
Lipids+ amino acids + dextrose + other elements.
Disadvantages of 3 in 1: the cloudy nature of the product precludes the examination of
the product for fine precipitants.

N.B. 1. Fatty oil emulsions are stabilized by the presence of egg phospholipids so they
are C.I in pts with history of egg allergy.

2. 10% emulsion provides → 1 kcal/ml

20% emulsion provides → 2 kcal/ml

Q) How many kcal is received by patient taking 500 ml bottle of Liposyn 10%?
Ans: 500 kcal

**Extra notes:
1g CHO → 4 kcal
1g protein→4 kcal
1g Fat→ 9 kcal **so fats are better caloric sources on weight bases.

*Fat products for TPN are isotonic so can be administered safely through peripheral or
central vein.

*Ethanol 1g→ 7 kcal………..but not used as TPN why?

1. Rapid infusion→ heart burn or intoxication
2. Pancreatitis.

*TPN formulas must provide sufficient protein calories to convert amino acids present
to lean body mass.

Ratio Non protein calories (NPC) Each gm nitrogen (N)

Ideal 150 1
Range 125-175 1
Burn victims 100 1
*Put (T) or (F):

1. NaCl change pH of the medium (F)

→It is neutral

2. CHO &Fats are alike because they release energy in the cell (T)

7
d. Others: 1. Vitamins:

Vitamin name Comment

A. Fat soluble vitamins:
a. Vitamin A Essential for vision, growth & reproduction.
*− carotene [provitamin A]
b. Vitamin D *regulate calcium & phosphorous homeostasis
*ttt of Rickets, Hypocalcaemia &Hyperparathyroidism.
c. Vitamin E Antioxidant that prevents oxidation of free unsaturated fatty acids. {found
[ tocopherol] in Nuts} {10ppm}
d. Vitamin K Essential for synthesis of clotting factors.
N.B. It is taken orally & is NOT included in TPN solution why?
1. Unstable to light
2. Interfere with anticoagulant therapy
3. IV intake→ potential fatal reactions have been reported.
B. Water soluble vitamins:
a. Vitamin B1 {Thiamine} Used as coenzyme in phosphogluconate pathway & structural component
of nervous system membranes.
*Deficiency: Beriberi with high output cardiac failure.
b. Vitamin B2 {Riboflavin} Coenzyme in oxidative phosphorylation
c. Vitamin B3 {Niacin} Coenzyme in oxidative phosphorylation & biosynthetic pathways.
Deficiency: Pellagra
**↑↑Doses→↓TG
d. Vitamin B5 Its functional form is coenzyme A which is essential for all acylation
{Pantothenic acid} reactions.
e. Vitamin B6 *coenzyme in many enzymatic pathways.
{Pyridoxine} *drugs that induce its deficiency {Isoniazide,cycloserine, penicillamine &
Ethionamide}=anti TB
f. Vitamin B7 {Biotin} *In carboxylation reactions.
*synthesized by intestinal flora so deficiency is rare.
g. Vitamin B9 {Folic acid} Vitamin B12 deficiency causes folate deficiency
h. Vitamin B12 Deficiency: peripheral neuropathy & migaloblastic anemia.
{Cyanocobalamine} Source: animal [liver, egg] & shellfish
*Vitamin C: [antioxidant]
*ascorbic acid → for prevention & ttt of scurvy
*used for prevention & alleviation of common cold symptoms.
*↑ absorption of iron by maintaining it in ferrous state.
2. Trace minerals:

Mineral Comment
Iron *for hemoglobin & myoglobin.
*N.B it is taken orally & not included in TPN solution…..why?
Due to compatibility problems.
*Hemochromatosis: excessive storage of iron by the body
Zinc *For DNA & RNA synthesis.
*Deficiency: pour wound healing, growth retardation, hair loss, dermatitis, diarrhea,
anorexia & glucose intolerance.
Copper Necessary for heme synthesis, electron transport & wound healing.
*Deficiency: anemia & leucopenia.
Manganese For protein synthesis.
Selenium *Antioxidant *Deficiency: muscle spasm & cardiomyopathy
Chromium *for glucose use & potentiate action of insulin
*deficiency: Hyperglycemia
Molybdenum Essential for Xanthine oxidase

8
3. Electrolytes: e.g. Na+, Mg2+, Ca2+, K+, Cl- & phosphorus.
*A common incompatibility occur between potassium phosphate(K 2PO4) & Calcium
gluconate→ ppt …..why? → Because calcium salts such as phosphate & carbonate have
limited H2O so when mixed with phosphate salts →ppt. How to overcome?
**By order mixing or separation.
Order mixing: 1. Mix potassium phosphate with vehicle first.
2. Add calcium gluconate slowly with stirring.

*Potassium phosphate is used as a source of phosphorus not K +.

*Most electrolytes are ordered in terms of milliequivalents, e.g. NaCl, KCl, because
milliequivalents allow direct comparison of ion when different salts are used e.g. 40 mEq
of Na acetate will contain the same weight of Na as 40 mEq of NaCl.
**Exception to above: potassium phosphate as it is ordered in terms of millimole..Why?
Because body phosphate requirements are usually expressed in terms of
millimole/kg/day. Also commercially available phosphate is a mixture of monobasic K+
& dibasic K+ phosphates.
**Drugs for electrolytes imbalance:

1. For potassium M.O.A: Cation exchange resin→ Sodium or calcium ions of the resin are
imbalances: exchanged for potassium ions & other cations) in the GIT; the resin is then
a. Polystyrene sulfonate excreted thus reducing potassium levels→ for ttt of hyperkalemia.
resins: *precautions: Serum potassium concentration <5 mmol/L—C.I.
Obstructive bowel disease—contraindicated.
Sodium restriction→ avoid sodium resin.
Hypercalcaemia, hyperparathyroidism—avoid calcium resin
S.E: Elderly→ fecal impaction In neonates→ C.I→ ↓ gastric motility.
2. Phosphate binders: M.O.A: Bind dietary phosphate in the GIT forming a poorly absorbed
Aluminium hydroxide compound→ ↓absorption of phosphate→  ↓serum phosphate
Calcium carbonate concentration→For ttt of Hyperphosphataemia in chronic renal failure
Lanthanum
Sevelamer
3. Other drugs: May be oral, injection & infusion solutions.

4. Additives: e.g. Insulin

*When low conc. Of insulin is included in LVPs approximately 1/2 insulin will be
adsorbed onto the walls of glass container. {Pharmacist must inform prescriber}.
*Insulin can be measured using:
1. Insulin syringe 2. Tuberculin syringe [has capacity of 1 ml]
CASE STUDY [see book: compounding p: ]
A** Complications associated with administration of TPN:
1) Hyperchloremic metabolic acidosis:
This occurs when total chloride content is high.
*Sources of chloride: 1.amino acids in protein salts.
2. NaCl & KCl: may supply them as Na or K acetate.
2) Hyperosmotic non- ketotic hyperglycemia:
Due to overload of glucose because of rapid infusion.
B **Complications associated with discontinuation of TPN:
Hypoglycemia.
***TPN is stored at 2-80c.

9
4. Vitamins
I. Fat soluble vitamins: → H2O insoluble so better formulated in
mineral oil
1. Vitamin A (Retinol): *Precursor: − Carotene

*Uses:
a-psoriasis b- acne vulgaris (retinoic acid) c- night blindness
d- Skin disease e- reproduction.

N.B. Vit. A does not cross the placenta & it is essential for mucous epithelial cell
production.

*deficiency:
a- night blindness.
b- Keratinization of the epithelial cells of the cornea & all mucous membrane.
c- Loss of appetite.

*toxicity:
1) Hyperostosis (bone hypertrophy) in children. 2) Peeling of the skin.
3) Headache 4) Lymph node enlargement.

*daily requirements: orally or I.M

Child: 1300-2600 IU Adults: 3000 IU

N.B.* Zn is essential for: 1. Maintenance of Vit A in plasma.

2. Mobilization of Vit A from the liver
* Administration of Vit E with Vit A→ increases absorption & tissue storage.
*Cod liver oil {fish oil} contains Vit A & Vit D.
*Vit A must not exceed 10,000 IU
*Vit A is important for vision, growth & reproduction

10
2. Vitamin D (Calciferol):
*precursor: 7-dehydro ergosterol →U.V→ Cholecalciferol (Vit D3)
Ergosterol →U.V→ Calciferol (Vit D2)

*Synthesis: skin cholesterol → UV→ 1st product →liver → calidiol → kidney (-OH in
1 position) → calcitriol (active form).
N.B. One alpha: Vit D with OH in  position (active).

*Uses: 1- has parathyroid hormone like action: → ttt of hyperparathyroidism

a. ↑GIT absorption of Ca2+
b. ↑ tubular reabsorption of Ca2+
c- ↓ mobilization of Ca2+from bone to blood→ ↑ deposition of Ca2+in bones.
Other uses of Vit. D: Rickets & Osteomalacia

N.B. Ca2+/PO4-3 is affected by:

1. Vit D: as above.
2. Calcitonin→ [↓ Ca2+in blood]:
*↓ reabsorption [tubular] of Ca2+ & PO43-
*↓ metabolism of Ca2+& PO43- from bones.
3. Parathormone [PTH]:→ [↑Ca2+ in blood]:
*↑ tubular reabsorption of Ca2+ &↑ excretion of PO43-.
*↑Mobilization of Ca2+ &PO43- from bone to blood (Ca 2+#PO4-3).

*deficiency: is due to diet deficiency or inadequate exposure to sunlight.

In children→ rickets
In adults: osteomalacia "soft bones" & hyperparathyroidism.

*Toxicity:
-Hypercalcimea - MI
- Mental retardation -Deposition of Ca2+ in soft tissue
- Increases digitalis toxicity -Constipation
-Stop the growth.

11
*Daily requirement: 400 IU
For Rickets: 4000-40,000
N.B. *Vit D is completely absorbed from GIT & depend on hepatic & biliary
function, so drug that increases hepatic microsomal enzymes (e.g.anticoagulants,
barbiturates, rifampicin & antidepressants)→ cause Vit D deficiency.
*Lasix (furosemide) is C.I in Vit D deficiency because it causes hypocalcaemia
(↓↓Ca2+).

3. Vitamin E (−tocopherol/ butylated hydroxy toluene):

*present naturally in green vegetables, eggs & meat.

*Uses: 1. Increases absorption of Vit A.

2. Antioxidant (reducing agent) in oily solutions
3. Carried in plasma - lipoprotein.
*deficiency:
a. anemia b. muscular dystrophy
c. male sterility d. habitual abortion in females.

*Toxicity: Safe in very high doses.

*daily requirements: 5-10 IU/day.

N.B.
*Vit E is Contraindicated with minerals as Ca2+& iron.
*Vit E is soluble in fixed oil, ether & chloroform.
*Put (T) or (F): Vit E isn't proved to be essential for reproduction in man but
Vit A is important (T).

4. Vitamin K: Vit K1 phytoquinone→ plant origin.

Vit K2 menaquinone→ bacteria origin in GIT.
Vit K3 menadione→ synthetic origin (H2O soluble).

*Uses: essential for production of prothrombin in the liver.

*Deficiency:
In infant: hemorrhagic anemia & kernicterus, increase bilirubin.
In adult: decrease liver function→ Jaundice.

N.B. *Antidote of vitamin K is Coumarin (Dicumarol).

*Excessive antibiotic use→ decrease normal flora→ decrease Vit K + synthesis→
deficiency of Vit K.

12
II. Water soluble vitamins:
1. Vit B1 (Thiamine): co-enzyme in CHO metabolism, present naturally in
yeast & liver. It is thermolabile.
Q.Complete : the heat labile portion of Vit B complex is……………….
*Deficiency: causes Beri-Beri disease "wernicke's syndrome or Korsakoff's
syndrome" (peripheral neuritis) → its symptoms:
-Mental disorder - fatigue -tachycardia
-Heart edema -Low conc. of HCl.
*Toxicity: not marked (safe).
*Daily requirement: adult> 0.6 mg →4-5mg.
Child: 0.4 mg
*Uses: 1. Beri-Beri treatment.
2. Diabetes mellitus (peripheral neuritis).
3. Neuralgia 4. Mental disorder.

2. Vit B2 (Riboflavin):
*An (H+) carrier which play an important role in energy metabolism in
respiratory chain.
*It is absorbed from upper GIT & never given alone but in combination with
other Vit B complex.
*deficiency:
1. Chelosis: cracks in the corner of the mouth.
2. Glossitis: tongue inflammation.
3. Photophobia: due to corneal vascularization.
4. Keratitis.
5. Embryo toxicity in pregnant female.
*Daily requirement: Child>0.6 mg & Adult > 1 mg orally. IM, SC.

3. Vit B3 (Nicotinic acid or Niacin):

*Occurs in 2 forms: Nicotinic acid & Nicotinamide

+
*It is (H ) carrier coenzyme for protein metabolism & production of energy ATP
(in respiratory chain).

*Side effect of Vit B3:

-flushing & V.D.
- Hyperglycemia & hyperuricemia
-Hypocholesterolemia.

*deficiency: mainly causes Pellagra which is characterized by:

1. Dermatitis. 2. Weakness 3. Neuritis
4. CNS confusion 5. Photosensitivity 6. GIT irritation
7. Subclinical pellagra→ schizophrenia.

*Daily requirements: Child > 4 mg

Adult > 6 mg → 45 mg.

13
4. Vitamin B6 (Pyridoxine):
1. for amino acid metabolism: Tryptophan →Vit B 6→ Nicotinic acid.
2. Co enzyme essential for GABA production in the brain which is the main
neurotransmitter inhibitor to prevent convulsion.

*deficiency: 1. Epileptic convulsion 2. Peripheral neuritis

3. Iron deficiency anemia 4. Dermatitis.

*Drug interactions with Vit B6:

1. Oral contraceptives: deplete B6 should be supplied
2. Pregnancy: deplete B6
3.Hydralazine, INH, Penicillamine→ decrease tryptophan metabolism.
4. L-dopa: increases metabolism of Vit B6 by increasing synthesis of decarboxylase
enzyme (which converts L-Dopa→ dopamine).

5. Vit B12 (Cyanocobalamine): →Oral preparations are of no value.

1. Maintenance of myelin sheath in the nervous tissue (its deficiency→ neurological
signs).
2. Important for synthesis of epithelial cells & normal growth.
**It needs an intrinsic factor for its absorption from GIT; it is glycoprotein in nature
(its deficiency is called pernicious anemia).

Q) How to differentiate between pernicious anemia due to deficiency of intrinsic factor

or due to deficiency of Vit B12?
By Schilling test: →using radioactive cobalt "CO57 or CO58".
Take Vit B12+CO57 or CO58:
1. If CO57 appear in feaces (not absorbed) → so pernicious anemia due to lack of
intrinsic factor & Vit B12.
2. If CO57 appear in urine (absorbed) → so pernicious anemia due to lack of Vit B 12
alone.
** Pernicious anemia "Addison's pernicious anemia" → due to decrease in intrinsic
factor in GIT.
-Leads to peripheral gastric mucosal atrophy, Glossitis, achlorohydra (↓ HCl secretion)
& leads to megaloblastic anemia.
ttt by: Vit B12 IM or S.C inj. 1000mg/ml → NEVER I.V

6. Vitamin B9 (Folic acid):

*essential for synthesis of purine & pyrimidine bases.
*Used in megaloblastic anemia beside Vit B 12.
*Not use folic acid because it masks signs of Vit B 12 deficiency.
*Folic acid antimetabolite (Methotrexate) → used as anticancer.

7. Vitamin B7 (Biotin):
*synthesized by bacterial flora or taken with food.
*involved in some fatty acid synthesis & many carboxylation reactions.
*Consumption of egg white only →leads to biotin deficiency.

14
8. Choline:
*synthesized in the body from Methionine amino acid.
*It is essential for phosphatidyl choline synthesis which is involved in lipid transport &
Ach synthesis.

9. Vitamin B5 Pantothenic acid (panthenol):

*It is converted to Co A enzyme which is essential for Ach synthesis & fatty acid
metabolism.
*It is used locally to heal wounds.

10. Vitamin C (Ascorbic acid):

*it has lactone structure
*Present in green vegetables & citrus fruits.
*Level in females > males & smoking decreases Vit C level in blood.

*Importance:
1. Essential for collagen synthesis in the connective tissue.
2. important in oxidation-reduction reaction (redox) & cellular respiration.
3. used as reducing agent: used in ttt of Meth-heamoglobinemia.
4. Antidote for alcohol overdose because it activates alcohol dehydrogenase enzyme
which is essential for alcohol metabolism.

N.B. Vit C gives false +ve result with Clinitest (which depends on reduction of alkaline
CuSO4 by glucose in urine).

*Deficiency: Scurvy disease: → Gum bleeding, lesions in teeth, bones & blood vessels.

*Toxicity:
1. Stones in the urinary tract. 2. Diarrhea.
3. Ingestion of 10 gm daily then withdrawal →Frank symptoms or scurvy.
N.B. Scurvy appears in new born whose mothers ingest high amount of Vit C.
Dose: Child > 20mg/day
Adult > 150mg/day

Q) The least stable of the H2O soluble vitamins is: Ascorbic acid.

15
5. Clinical Laboratory Tests
A. Hematological tests:
1. RBCs:
a. Hematocrit {HCT} or Packed cell volume {PCV}:
*Measure by % the volume of packed RBCs in whole blood sample after centrifugation
{provide indication about number & size of RBCs}.
Low HCT → anemia, overhydration or blood loss.
High HCT → polycythemia (↑ Erythrocytes) or dehydration.
*Its normal value= 3x Hb value (normally 45%).

b. Hemoglobin test (Hb test): *Measures the gms of Hb contained in 100 ml (1 dl) of
blood so estimate oxygen carrying capacity of RBCs.
N.B. Hb value: depends on number of RBCs & amount of Hb in each RBCs.
*Normal value: *Male: 14-18 gm/dl *Female: 12-16 gm/dl.

c. RBCs indices {wintrobe indices}: provide information about RBC size & Hb conc.
N.B. Anisocytosis: variation in RBCs' size e.g. Mixed folic acid & iron deficiency
anemia. Poikilocytosis: variation in RBCs' shape e.g. Sickle cell anemia.

1. Mean Cell volume {MCV}: → normal value: 90 ± 10 fl.

* It is the ratio of HCT to RBCs count (HCT% X10/ RBCs count in millions) → average
RBC size & reflects any Anisocytosis.
*If Low (↓) MCV → Microcytic anemia (low RBC size) →due to iron deficiency <80 fl.
* If High (↑) MCV → Macrocytic anemia (high RBC size) →due to Vit B12 or folic acid
deficiency.
2. Mean cell Hb conc. [MCHC]: average conc. of Hb in an average RBC.
Low MCHC {Hypochromic} → e.g. iron deficiency.
3. RBC distribution width {RDW}:
* ↑RDW : found in factor deficiency {e.g. iron, folate, Vit B12}
* normal RDW : e.g. anemia of chronic disease.

d. Reticulocyte count (immature cell count):→ it is measure of immature RBCs

* High RC → hemolytic anemia, acute blood loss or factor deficiency (e.g. iron or folic à).
* Low RC → drug induced Aplastic anemia (bone marrow suppression).

e. Erythrocyte sedimentation rate (ESR):→results from alteration in plasma proteins.

Normal: *Male 0-20 mm/hr *Female 0-30 mm/hr
↑ESR → acute or chronic infection, tissue necrosis, malignancy & rheumatoid arthritis.
** ESR is used to: 1. Follow clinical course of disease.
2. Demonstrate the presence of occult organic disease.
3. Differentiate between angina pectoris & Myocardial infarction:
Angina pectoris: → no change in ESR. MI: → ↑ ESR value.
N.B. No of RBCs of healthy person : 5x106/ mm3 or 5x1012/L
*It is the highest count among all plasma cells.
*In case of patient that has sensitivity →Test requires: Complete blood picture with
differential WBCs.

16
2. WBCs' count "Leukocytes": →4000-11,000 mm3

If *↑count → Leukocytosis: with bacterial infection, leukemia or tissue necrosis.

*↓count → Leukopenia: with bone marrow depression
**WBCs types:
A. Granulocytes: a. Neutrophiles: → 50-70%
*Chemotaxis: Neutrophiles phagocytize & degrade many types of particles & serve as
body's 1st line of defense.
*Neutrophilic Leukocytosis: in systemic infections, burns, fever, chemotaxis, exercise,
gout & drugs e.g. Epinephrine & Lithium.
*Neutropenia (low number of neutrophils): in bone marrow depression, mumps &
measles or Idiosyncratic drug.
b. Basophiles (mast cells):→0.3% → *stain deeply with blue basic dye.
*(↑) → myolegenous leukemia. *If low→ not distinguished.
c. Eosinophils: → stain deep red with acid dye.
* (↑) → in allergy, hay fever or post infection.

B. Agranulocytes:
a. Lymphocytes→    cells.
* (↑) →Lymphocytosis : →viral infection.
* (↓) → Lymphopenia → deplo disease, HIV disease & AIDS.
**Epstein Barr virus→ atypical lymphocyte infectious mononucleosis.
b. Monocytes "Phagocytic cells":
* (↑) →Monocytosis → in T.B, subacute bacterial endocarditis & during recovery phase
of some acute infections.

3. Platelets "Thrombocytes" →blood clotting (150,000-300,000 mm3)

*Thrombocytopenia (low Thrombocytes): → in purpura & some drugs e.g. Quinidine,
sulfonamides & maybe with Heparin.
N.B *Agranulocytosis= Leukopenia=Neutropenia→ ↓ in polymorphonuclear
leukocytes. It is accompanied by necrotic lesions of mouth & throat.
N.B *Leukocytes →  interferon *Fibroblasts →  interferon
*T- lymphocytes →  interferon.

B. Myocardial Infarction (MI):

1. Ck-MM: found in skeletal muscle.

2. Ck-BB: found in brain.
**Cardiac Troponins [I, T, C]: *New method to identify myocardial cell injury.

17
*They possess superior specificity in situations where +ve false elevation of Ck-MB
occurs {especially Troponin T}.

C. Liver Function tests:

a. Enzymes:
1. ALT [SGPT] → Serum glutamic-pyruvic transaminase→ more specific.
*↑ liver & heat damage.
2. AST [SGOT]→ Serum glutamic-oxaloacetic transaminase→ more sensitive.
↑ In: * CHF after 8hours & MI.
*Severe hepatitis & mild cirrhosis.
3. Alkaline phosphatase [ALP]: N.B. ALP also↑ with increased osteoblastic activity e.g.
Paget's disease, hyperparathyroidism, osteomalacia & bile duct obstruction.
4. Thymol turbidity test

b. Serum bilirubin:

*Serum bilirubin is required as:

1. Total [conjugated & unconjugated.
2. Direct [conjugated only]
* ↑ serum bilirubin→ deposition in tissues → Jaundice.
Causes

Hemolysis: biliary obstruction: Liver cell necrosis

* ↑ conjugated so↑ *↑ total. ↑direct: because inflammation
total *↑ direct. causes some bile block.
bilirubin *↑ indirect: ↓liver capacity to
conjugate.
*Urine color is normal. *urine color is dark Dark urine.
*may be: e.g. viral hepatitis.
Intrahepatic: e.g. chlorpromazine.
Extrahepatic: e.g. biliary stone.
N.B.* Direct Van den Bergh test: → measure conjugated bilirubin.
By performing test in aqueous medium so only more soluble conjugated bilirubin is measured.
*Indirect Van den Bergh test: → measure unconjugated bilirubin.
By performing test in alcoholic medium→ Total Bilirubin→ then subtract from direct→ Indirect.
*Bromosulphalein [BSP] excretion test: It's the measure of excretory function of the
Liver…………………………….HOW?
BSP dye is injected IV→ normal Liver will remove 95% of the dye in 45 min.

c. Serum proteins: Albumin→↓ in liver disease→ compensatory ↑ in globulin level

18
D. Urine analysis:
1. pH: normally acidic.
* Alkaline urine : 1. Proteus infection
2. Alkalosis 3. Acetazolamide use [CA inhibitor].

2. Specific gravity:
↑: D.M→ glucose in urine.
Nephrosis→ protein in urine.
↓: Diabetes insipidus.

E. Renal function test: [BUN-Serum creatinine &creatinine clearance]

N.B. Azotemia: excessive retention of nitrogenous waste products [BUN & Creatinine].
1. Renal Azotemia [uremia] → renal disease.
2. Prerenal Azotemia → dehydration, excessive protein take, hemorrhagic shoc k.
3. Postrenal Azotemia→ ureteral or urethral stones or tumors & prostatic obstructions.
**Creatinine clearance normal value: 75-120 ml/min.

**Some diagnostic agents:

Agent Used for Technique

1. Azuresin: Detection of 1. Gastric secretion stimulant [caffeine] is given 1 hr
achlorohydria. before administration of Azuresin.
2. If gastric secretion is normal, HCl displaces the dye
from resin & then dye is absorbed & excreted in
urine.
2. Congo-red: Detection of amyloidosis Dye injected IV→ if it disappeared from blood →
indicate retention by amyloid deposits.
3. Evans blue: Estimation of blood ----------
volume.
4. Phenosulfon Determination of kidney IM or IV: 80% of dye is excreted within 2hrs
phthalein: function. [normal].

5. Excretory function of IV: 95% should be eliminated in 45 min in normal

Bromosulphalein: liver. individuals.

6. Barium Used to render the Characteristics:

sulfate: intestinal tract opaque 1. Taken rectally [enema] or orally, depending on
for X-ray. portion of GIT to be x-rayed.
2. Insoluble in H2O→ little danger of toxicity due to
systemic absorption "least soluble".

19
6. Drug Metabolism :
*Biotransformation pathways:
A. Phase I reactions introduction of polar function groups in the
molecule by oxidation, reduction & hydrolysis.
1. Oxidation:
i. Occurs in the liver, intestinal mucosa, lungs & kidneys.
ii. Takes place by Cytochrome P450 enzymes (CYP 450).

Type of Reaction pathway

reaction
1. Aromatic
hydroxylation
2. Aliphatic
hydroxylation:
3. Olefinic
hydroxylation:
4. Benzylic
hydroxylation:
5. Allylic
hydroxylation:
6.
Hydroxylation
 to a carbonyl:
7. Oxidative
deamination:
8. N-
dealkylation:
9. N- Oxidation:

10. O-
dealkylation:
11. S-
dealkylation:
12. S-
Oxidation:

13.
Desulfuration:
14.
Dehalogenation:
15. Oxidation of
Alcohols:
16. Oxidation of
Aldehyde:

20
2. Reduction:
1. Carbonyl reduction:

2. Azo-reduction:

3. Nitro-reduction:

3. Enzymatic hydrolysis:
1. Ester hydrolysis by esterase:

2. Amide hydrolysis by
amidase:

B. Phase ii metabolism: conjugation reactions to give very polar

rapidly eliminated metabolite. There are 6 conjugation reactions:

Pathway Active moiety Enzyme Example

1. Glucouronidation: Glucouronic acid Glucouronyl transferase -OH -NR2
-COOH -SH
2. SO4 Conjugation: PAPS: phospho-adenosine Sulfatransferase -OH
5 phospho-sulfate Amylamin
3. Acetic acid Glycine/ glutamine + active N- acyl transferase -COOH
conjugation: drug (drug+ Co ASH)
Co enz A
4. Glutathione GSH Glutathione -X (halogens: Cl, F, Br, I
conjugation S- transferase Epoxide
(keep cell integrity)
5. Methyl SAM Methyl transferase -OH, SH, NH2
conjugation: S-adenosyl methionine
6. Acetylation conj. Acetyl co A N- Acetyl transferase NH2, NHNH2
SO2 NH2, CONH2

Important Notes:
*Bioactivation: prodrug→ active drug in the body.

*Usually metabolites have low O/W partition coefficient:

↓ oil solubility & ↑ water solubility.

*Functional group metabolism occurs in Phase I.

21
22