Topics:

• Introduction
• Chemistry
• Absorption, transport and storage
• Co-enzyme functions
 •Water soluble
Introduction •Also called as pterol-
glutamic acid
•active form:THF
Chemistry Chemistry
 Diet: polyglutamate
↓ folate conjugase
(Present in duodenum
Absorption,t and jejunum)

ransport and Monoglutamate

↓
storage Cell: tetrahydrofolate
(THF)
Storage: in liver as
polyglutamate(10-12mg)
Dyhydrofolat reductase

Function
as co-enzyme
PTetrahydrofolate reductase

[One carbon
matabolism]
One carbon matabolism
One carbon Doner: histdine, glycine, serine
One carbon accepted for the synthesis of:
»amino acids(glycine, serine)
»purines
»thymidylate
»cholin
● Homocysteine is converted into methionine this step
essential for the repeated use in one carbon metabolism
● Vit-B12 is also essential for this step .
Vitamin B9 Manifestations
By Your Name
 ● Reduced DNA Synthesis

Manifestations ● Macrocytic Anaemia

● Hyperhomocysteinemia

● Neural Tube Defect

Reduced DNA Synthesis
Due to the deficiency of Folate,
There is reduction in the THFA
content in the body and inhibition of
Thymidylate synthase enzyme

Hence dUMP is not converted to

dTMP leading to unavailability of
dTTP for DNA synthesis

This leads to arrested cell division

Rapidly dividing cells in bone marrow and intestinal mucosa are most
affected
 Macrocytic Anaemia
It is a consequence of reduced DNA
synthesis due to folate deficiency,

During RBC formation, DNA

synthesis is reduced but protein
synthesis continues.

This leads to to accumulation of haemoglobin in RBC precursors.

This asynchorny between the maturity of nucleus and cytoplasm leads to immature looking
nucleus and mature eosinophilic cytoplasm in the bone marrow cells.
Reticulocytosis is often seen.

These abnormal RBCs are destroyed in spleen by hemolysis

This hemolysis decreases RBCs lifespan.

Reduced generation of RBC and increased hemolysis leads to anaemia

 Hyperhomocysteinemia
Hyperhomocysteinemia refers to the condition where there is greater than 15 micromol/L
of homocysteine in the blood. This condition is present in a wide range of diseases, and in
many cases, it is an independent risk factor for more serious medical conditions.

Elevated levels of homocysteine have been associated with increased cardiovascular,

cerebrovascular, and thromboembolic diseases
 Neural Tube Defect

NTDs occur when the neural tube does not

close properly. The neural tube forms the early
brain and spine. These types of birth defects
develop very early during pregnancy, often
before a woman knows she is pregnant.

Folic acid deficiency leads to Neural tube defect

 SOURCES
● Yeast
● Green leafy vegetables (eg. Spinach,Broccoli)
● Cereals
● Pulses
● Oil seeds
● Egg

MILK IS A POOR SOURCE FOR FOLIC ACID.

RECOMMENDED DIETARY
ALLOWANCE
Requirement of Free Folate: 200µg/day

In Pregnancy: 400µg/day

During Lactation: 300µg/day

 FOLATE DEFICIENCY

Folic Acid deficiency is very common in India &

is perhaps the most commonly seen vitamin
deficiency.
 CAUSES
● Pregnancy: Due to increased requirement
● Disease: Conditions that affect absorption in
GIT can cause folate deficiencies. They include:

• Celiac disease
• Gluten induced enteropathy
• Resection of jejunum
● Drugs: Anticonvulsant drugs
(hydantoin,dilantin,phenobarbitone) will inhibit
intestinal enzymes that absorbs monoglutamate
form of folic acid resulting in reduced folate
absorption.

● Hemolytic Anemia: As requirement of folic acid

becomes more,deficiency is manifested as
hemolysis.

● Dietary Deficiency: Absence of vegetables in

● Folate Trap: It is a condition when deficiency of
Vitamin B12 causes inactivation of folate(Vit.B9).
 Folic Acid Therapy

Therapeutic dose is 1 mg of folic acid per day orally. Folic

acid alone should not be given in macrocytic anemia,
because it may aggravate the neurological manifestation
of B12 deficiency.
So, folic acid and vitamin B12 are given in combination to
patients. Regular supplementation of folic acid may
reduce the incidence of birth defects, cardiovascular
diseases and cancers.
 Toxicity of Folic Acid

Doses over 1 mg may cause renal problems.

Since solubility of folic acid is low, large

doses should not be given parenterally, as there is
danger of crystallization in kidney tubules leading to
renal damage.
SULFONAMIDES:
structure similar to PABA

competitively inhibit the enzyme responsible

for the incorporation of PABA into dihydropteroic
acid, the immediate precursor of folic acid

CLINICAL IMPORTANCE:

When sulfonamides are given, microorganisms cannot synthesize

folic acid and hence their growth is
inhibited.
Thus sulphonamides are very good antibacterial agents,
 IRON(Fe)
-Topics-
1: Distribution of iron
2: Requirement of iron
3:Sources of iron
4: Factor influencing Absorption of iron
1. Destribution of Iron
►Total body iron content is 3-5gm (75%in
blood+rest in liver,BM,muscle)

►Iron present is all cells

►Blood contain 14.5gmHb/100ml
►75%iron=Hemoglobin
►5%iron = myoglobin
►15%iron=ferritin
2.Requirement of iron
►Daily requirement of iron in
(adult=20mg/day but only 1-2mg is
absorbed
Children (13-15yr)=20-30mg/day
Pregnent women=40mg/day)
►Note=Transfer of iron from mother
to fetus occurs mainly in the last
trimester of pregnancy
►In first three month of life iron intake
is negligible because milk is poor
source of iron
►During this time child is dependent on
the iron reserve received from mother
during pregnancy
3.Source of Iron

►Leafy vegetables are good source of

iron=20mg/100gm
►Pulses(10mg/100gm)&Cereals(5mg/100gm)
►Liver and Meat contain good quantity of iron
►Jaggery is good source of iron
►Milk is a very poor source of iron(0.1mg/100gm)
4: Factor influencing Absorption of
Iron
►Iron is absorbed by upper part of
duodenum
►(1)Reduced form of iron

-Fe++ form(ferrous)is absorbed but

Fe+++(ferric)is Not absorbed in our body
►(2) Ascorbic acid
-Ferric(Fe+++). Ferrous(Fe++)
-This reaction is catalyse by •gastric HCL
•Ascorbic acid
•cysteine
•-SH group protein
-about 50-70mg of Ascorbic acid per day will be
Sufficient for normal iron absorption
(3) Interfering substance

►Iron absorption is decreased by

•phytic acid(cereals)
•oxalic acid(leafy vegetables)
By forming insoluble iron salt
~That Reason out of 20mg iron intake
. Only 1mg is absorbed
(4) Other minerals

•calcium
•copper
•Lead
•phosphates will inhibit iron absorption
-1 atom Of lead inhibit 1000 atoms of iron
IRON
ABSORPTION AND REGULATION
IRON KINETICS
FACTORS INVOLVED.

1. FACTORS FAVOURING ABSORPTION

A. Vitamin C
B. Gastric HCl
C. Cysteine
D. Gastroferrin, a glycoprotein in gastric juice is believed to bind iron and
facilitate its uptake in duodenum and jejunum.
2. FACTORS INHIBITING ABSORPTION
E. Tea (diminishes absorption by > 60%)
F. Coffee (reduced absorption by > 35%)
G. Phytates, found in corn, soya products, grains, and bran (producing
insoluble complex)
H. Oxalates found in spinach and chocolates
INDIAN DIET VS WESTERN DIET
● An average indian diet (heme iron) contains more than
20mg of iron.
● But the phytates and oxalates present reduce iron
absorption.
● In contrast, western diet(non heme iron), even though
iron content is about 10mg, about 2mg is absorbed.
IRON HOMEOSTASIS & MUCOSAL BLOCK
THEORY
● Iron is perhaps the only nutrient whose
homeostasis is maintained by regulation at
level of absorption and not by excretion.
● Iron is said to be a ONE-WAY ELEMENT
because the body pool is mainly regulated
by absorption and utilization.
● Duodenum and jejunum are the sites of
absorption.
MUCOSAL BLOCK THEORY/GARNICK’S THEORY

● When iron stores in the body are depleted, absorption

is enhanced. When adequate quantity of iron is stored,
absorption is decreased. This is referred to as mucosal
block of regulation of absorption of iron.
● About 1-2 mg of iron enters body daily from dietary
absorption.
● Iron is absorbed in following 3 steps;
1. Luminal phase
2. Mucosal cellular phase
3. Basolateral phase
REGULATION
Hepcidin, a small peptide produced by liver cells regulates iron
absorption.

Its production decreases in anemia and is increased during

hemosiderosis.

It reduces synthesis of both divalent metal transporter and

ferroportin.
TRANSPORT OF IRON

● Transport form of iron is transferrin. It is synthesized

in liver. Normal plasma level of transferrin is 250
mg/100 ml
● One molecule of transferrin can transport 2 ferric
atoms. Total iron binding capacity (TIBC) in plasma is
400 mg/100 ml; this is provided by the transferrin.
This protein bound iron (serum iron) is about 120
mg/dl.
STORAGE, CONSERVATION & EXCRETION

● IRON IS STORED AS FERRITIN & HEMOSIDERIN.

● Hemosiderin is usually seen in states of iron overload
or when Fe is in excess, when the synthesis of
apoferritin and its uptake of Fe are maximum.
● SINCE ITS A ONE WAY ELEMENT, VERY LITTLE IS
EXCRETED.
● Loss of iron in male is <0.5 mg/day.
● Loss of iron in female is about 1 mg/day.(upto
menopause)
 IRON
METABOLISM
DISORDERS AND
TREATMENT
IRON DEFICIENCY ANEMIA

● ABOUT 70% OF INDIANS ARE IRON DEFICIENT AND

85% OF PREGNANT WOMEN SUFFER FROM IRON
DEFICIENCY ANEMIA.
● MICROSCOPE APPEARANCE:MICROCYTIC
HYPOCHROMIC ANEMIA.
● ANEMIA RESULTS WHEN HEMOGLOBIN LEVEL IS
BELOW 12g/dl.
CAUSES
● LACK OF ABSORPTION
● HOOKWORM INFECTION
● REPEATED PREGNANCIES
● CHRONIC BLOOD LOSS
● NEPHROSIS
● LEAD POISONING
CLINICAL MANIFESTATIONS

● PATIENT BECOMES UNINTERESTED IN

SURROUNDINGS (APATHY).
● PROLONGED ID CAUSES ATROPHY OF GASTRIC
EPITHELIUM LEADING TO ACHLORHYDRIA.
● ATROPHY OF EPITHELIUM IN ORAL CAVITY AND
ESOPHAGUS CAUSES DYSPHAGIA TERMED
PLUMMER-WILSON SYNDROME.
LABORATORY FINDINGS

● SERUM IRON LEVEL IS REDUCED IN IRON

DEFICIENCY ANEMIA.
● SERUM FERRITIN LEVEL SHOW SLOW DECLINE AND
TRANSFERRIN SATURATION CONTINUES TO FALL.
● TOTAL IRON BINDING CAPACITY(TIBC) IS ELEVATED
IN HYPOCHROMIC ANEMIAS.
TREATMENT

● ORAL IRON SUPPLEMENTATION IS THE TREATMENT OF

CHOICE.
● 100mg OF IRON + 500mg OF FOLIC ACID ARE GIVEN TO
PREGNANT WOMEN AND 20mg OF IRON + 100mg OF FOLIC
ACID TO CHILDREN.
● IRON TABLETS ARE GIVEN WITH VITAMIN C AND VITAMIN E
TO CONVERT IT INTO FERROUS FORM FOR EASY
ABSORPTION AND ALSO TO PREVENT FREE RADICAL
GENERATION.
IRON TOXICITY

● HEMOSIDEROSIS: IRON EXCESS IS CALLED

HEMOSIDEROSIS. HEMOSIDERIN PIGMENTS ARE GOLDEN
BROWN GRANULES, SEEN IN SPLEEN AND LIVER.
● HEMOSIDEROSIS OCCURS IN PERSON RECEIVING
REPEATED BLOOD TRANSFUSIONS.
● NOWADAYS, COMPONENT SEPARATED PLASMA IS
AVAILABLE WHICH ELIMINATES RISK OF
HEMOSIDEROSIS.
● PRIMARY HEMOSIDEROSIS: IT IS ALSO CALLED AS
HEREDITARY HEMOSIDEROSIS. IT IS AN AUTOSOMAL
RECESSIVE CONDITION.
● DUE TO MUTATION IN GENE HFE-1, IRON
ABSORPTION IS INCREASED.
● IRON VESSELS: COOKING IN IRON VESSELS INCREASES
THE AVAILABILITY OF IRON.
● BANTU SIDEROSIS: BANTU TRIBE IN AFRICA IS PRONE
TO HEMOSIDEROSIS BECAUSE OF THE STAPLE DIET,
CORN, IS LOW IN PHOSPHATE CONTENT.
● HEMOCHROMATOSIS: IN LIVER HEMOSIDERIN
DEPOSITS LEAD TO CELL DEATH AND CIRRHOSIS.
● PANCREATIC CELL DEATH LEAD TO DIABETES.
● DEPOSITS UNDER THE SKIN CAUSES YELLOW-
BROWN DISCOLORATION, WHICH IS CALLED
HEMOCHROMATOSIS.
● THE TRIAD OF CIRRHOSIS, HEMOCHROMATOSIS,
DIABETES ARE REFERRED TO AS BRONZE’S DIABETES.
HEMOSIDEROSIS HEMOCHROMATOSIS
Vitamin - B12

Introduction
 Vitamin B12

- Vitamin B12 is also known as cobalamin, extrinsic

factor (EF) of castle and antipernicious anemia factor.

- Dorothy Hodgkin suggested its structure by X- Ray

diffraction studies.

- Later Robert Woodward synthesized B12 and proved

the structure
Vitamin B12
Structure
 Different Forms

CYANOCOBALMIN
- When cyanide is added to R position, that molecule is
called CYANOCOBALMIN

- The CN group has no physiological function, it is only

a laboratory artifact.

- Oral preparations are in this form.

 HYDROXYCOBALMIN

- When hydroxyl group is attached at R position, it is

called hydroxycobalmin.
- Injectable preparations are in this form.

ADENOSYLCOBALMIN
- Vitamin B+ATP → Ado-B (5'-deoxy-adenosylcobala
min) + CN +PPi + Pi
- This is the major storage form seen in liver.
METHYLCOBALMIN
- When the methyl gmap replaces adenosyl group, it is
known as methylcobalamin

- This is the major form seen in blood as well as in

cytoplasm of cells.

- The Ado-B12 and methyl B12, are the functional

coenzymes in the body.
 RDA
Recommended
dietary
allowance
 RDA
► Children – 0.5 – 1.5 μg / day
AGE RDA
0 – 6 Month 0.4 μg / day
7 – 12 Month 0.5 μg / day
1 – 3 Year 0.9 μg / day
4 – 8 Year 1.2 μg / day
 Recommended Dietary
Allowance

Adult 1 – 2 μg / day
Pregnancy and 3 μg / day
Lactation
Dietary Sources
►Animal Origin are the only sources for
Vitamin B₁₂.
►Rich Sources :
►Liver
►Kidney
►Milk
►Curd

►Fish
►Eggs
►Pork
Dietary Sources
► Vitamin B₁₂ is synthesized only by micro
organisms.
► Plant cannot synthesize.
► Animal obtain B₁₂ either by eating Foods or
from the intestinal bacterial synthesis.
► Small quantities of vitamin B₁₂ , synthesized
by bacteria on the surface of fruit.
ABSORPTION OF
VITAMIN B12
202
2
REǪUIRES TWO PROTEINS

● INTRINSIC FACTOR
(SECRETED BY THE PARIETAL
CELLS)

● COBALOPHILIN
(SECRETED IN SALIVA)
PowerPoint
PROTEIN VIT B12 + PEPTIDES
S
VITAMIN B12 + COB
COMPLEX
complex hydrolyzed by trypsin and
releases vit b12

VIT B12(2X) + IFIF-B12

one molecule of if can

combine with 2 molecules of
b12. this
IF-B12 complex is attached to
specific receptors on mucosal cells.
B12 is absorbed from ileum , while folic acid is
in jejunam.
TRANSPORT AND
STORAGE OF B12
● IN THE BLOOD , METHYL B12 IS PREDOMINANT

● TRANSCOBALAMIN , A GLYCOPROTEIN , IS THE

SPECIFIC CARRIER , STORED IN LIVER CELLS
AS ADO-B12 FORM WITH TRANSCORRIN.

● GENERALLY B COMPLEXES ARE NOT STORED IN

THE BODY BUT B12 IS AN EXCEPTION

● WHOLE LIVER CONTAINS ABOUT 2mg OF VITAMIN

B212 , WHICH IS SUFFICIENT FOR AB 2 TO 3 YEARS.

● SO VIT B12 DEFICIENCY IS SEEN ONLY

AFTER GASTRECTOMY
Deficiency
Manifestations
of Vit. B12
● Folate trap
● Megaloblastic
Anemia
● Homocystinuria
● Achlorhydia
● Demyelination
 ● Due to demyelination,
both sensory and motor
Subacute tracts are affected,
hence the name.
Combined ● Romberg’s Sign Positive
● Babinski’s Sign Positive
Degeneration ● Unsteady gait
● Paresthesia of
extremities
● Loss of position sense
 ● Serum B12
● Peripheral Smear
Assessment of
● Schilling Test
Vit. B12 ● FIGLU Excretion
Deficiency Test
Schilling Test
Radioactive labeled (Cobalt-60) vitamin B12, 1 ug is given orally. Simultaneously,
an intramuscular injec- tion of unlabeled vitamin B12 is given, in order to saturate
tissues with normal vitamin B12. So, radioactive vitamin B12 will not bind to body
tissues. Therefore, the entire absorbed radioactivity will pass into the urine. The
patient's urine is then collected over the next 24 hour to assess the absorption. In a
normal person, the ingested vitamin B12 will be absorbed into the body. Since the
liver receptors for vitamin B₁₂ are saturated by the injection, much of the in- gested
vitamin B₁₂ will be excreted in the urine. In patients with pernicious anemia or with
deficiency due to impaired absorption, less than 5% of the radioactivity is detected in
urine. If an abnormality is found, the test is repeated, with radioactive vitamin plus
intrinsic factor given orally, and urine is collected for 24 hour. In pernicious anemia,
there is lack of intrinsic factor, so that the first test is abnormal; but the second test
is normal
Treatment
● Eating B12 rich ● Even after that
products like some neurological
seafood, poultry, symptoms due the
meat, egg etc. or deficiency could be
B12 supplements permanent.
may improve some
symptoms.
● If macrocytic anemic is treated with folic acid
alone, the anemia may improve, but associated
neurological symptoms are aggravated.
● Hence, all macrocytic anemias are generally
treated by giving both folate and vitamin B12.
● Therapeutic dose of B12 is 500 to 1,000 µg by
intramuscular injections, and of B9 is 1mg per
day orally.
Some other points….
Homocysteine in blood helps in maintaining lining
of blood vessels and clot formations. High levels of
homocysteine (homocystinuria) may lead to
damage to lining of blood vessels and more easy
clot formation than normal leading to myocardial
infarction or ischemia. Hence, B12 and Folate are
protective against ischemic heart disease.
CLINICAL CASES
A 10-year-old girl presented with excessive tiredness,
poor appetite, inability to concentrate and tingling
sensations. On examination, there was pallor.
Laboratory examination revealed decrease in
hemoglobin, ferritin and MCV. Total iron binding
capacity (TIBC), transferrin and ROW were increased.
What is the likely diagnosis?
A 47-year-old female is brought to the emergency department with
complaints of malaise, vomiting and fatigue. The patient reveals
alcohol abuse for the last 10 years. She has been to rehab on
several occasions for alcoholism but has not been able to stop
drinking. She denies cough, fever, chills, upper respiratory
symptoms. She reports feeling hungry. On physical examination,
she appears malnourished but in no distress. Her physical
examination is normal. Her blood count revealed a normal white
blood cell count but also showed anemia with large red blood
cells. Other tests were normal. What is the most likely cause of her
anemia? What is the molecular basis for the large erythrocytes?
A 38-year-old vegetarian female presented to her doctor with
fatigue and tingling/numbness in her extremities (bilateral). The
symptoms were gradually getting worse over the last year. She
reported frequent episodes of diarrhea and weight loss. On
examination. she was pale with tachycardia. Her tongue was
beefy red. Neurological examination revealed numbness in all
extremities with decreased vibration senses. The CBC
demonstrated megaloblastic anemia. What is the most likely
diagnosis? What is the most likely underlying problem for this
patient? What are the two most common causes of
megaloblastic anemia and how would this patient's history and
examination differentiate the two?