This document discusses vitamin K deficiency. It notes that vitamin K is required for the post-translational carboxylation of coagulation factors and other proteins. Vitamin K deficiency can cause hemorrhage and is seen in neonates, people with small bowel diseases or resections, and those on long-term antibiotic therapy. Prolonged prothrombin time indicates deficiency, which is treated with vitamin K supplementation.

1. - Dr.Akif A.B

2.  What type of Anemia is seen in Vitamin B6 deficiency
??

3.  Microcytic hypochromic anemia
 Vitamin B6 is involved in 1st step of heme synthesis
(Aminolevulinate synthase)
 Vitamin B6 is also required for conversion of
Homocysteine to Cystathione.

4.  Burning feet syndrome is caused by which Vitamin
deficiency ??

5.  Vitamin B5 (Pantothenic acid)

6.  Higher intake of which vitamin is associated with
renal stones ??

7.  Vitamin C
 >2gm/day
 Vitamin C is metabolised to Oxalate and over intake can
precipitate Renal stones
 Formation of renal stones have been seen only if there is
Primary renal disorder.
 Can produce Iron overload due to increase Iron absorption

8.  Pseudotumour cerebri is caused due to which
vitamin toxicity ??

9.  Chronic Vitamin A Toxicity

10.  Tea and coffee can lower levels of which Vitamin in
body ??

11.  Thiamine B1
 As tea and coffee contains Thiaminases, it can destroy
Thiamine in body.
 Raw fish and shell fish also contains Thiaminases.

12.  Vitamin K is required for activation of which
Coagulation factors ??

13.  Factor 2,7,9,10
 Protein C and S
 Osteocalcin and matrix GLA protein

14.  Casal’s necklace is caused by which vitamin deficiency
??

15.  Niacin deficiency

17.  Riboflavin deficiency
 Magenta Tongue, Angular cheilosis, Seborrhoea and
cheilosis
 Flavin Mononucleotide and Flavin Adenine
Dinucleotide (FMN and FAD)
 Coenzyme for metabolism of Carbohydrate, fats and
proteins.

19.  Use of Antibiotic decreases levels of which Vitamin ??

20.  Vitamin K
 Antibiotics inhibits bacteria of Gut which produces
Menaquinone

21.  Keshan disease is caused by deficiency of which
Mineral ??
 Menky kinky hair disease ??

22.  Selenium
 Cardiomyopathy
 Menky’s disease : X-linked metabolic disturbances of
copper metabolism characterised by Mental
retardation, low copper levels and low ceruloplasmin
levels.

23.  Triad of Wernicke’s Encephalopathy ??

24.  Ophthalmoplegia
 Horizontal nystagmus
 Cerebellar ataxia
 Plus memory loss or confabulations : Korsakoff’s
Psychosis

25.  Pellagra is caused by ??
 What is Hartnup disease ??
 Which Anti-TB drug can precipitate Pellagra ??
 4 D’s of Pellagra ??

26.  Niacin deficiency
 Hartnup disease is a congenital defect of Intestinal and
kidney absorption of Tryptophan
 Isoniazid is a structural analogue of Niacin
 4 D’s of Pellagra : Diarrhoe + Dementia + Dermatitis +
Death
 Vitamin B6 and Riboflavin helps in conversion of
Tryptophan to Niacin

27.  High output cardiac failure is caused due to which
Vitamin deficiency ??

28.  Thiamine
 Wet beri beri
 Presents with Cardiac manifestations : High output
cardiac failure, Cardiomegaly, Tachycardia
 Dry Beri Beri
 Presents with Peripheral neuropathy.

29.  Lab diagnosis of Thiamine deficiency ??

30.  Transketolase activity measured before and after
administering Thiamine Pyrophosphate
 >25% increase in activity is suggestive of Thiamine
Deficiency.

31.  42-year-old woman
 20-year history of Crohn's disease
 presents with a complaint of low energy levels and hair loss.

 Her Crohn's disease is moderately well controlled, with episodic
diarrhoea and abdominal pain, and has not required intestinal
resection.
 The patient says that she does not feel like she is having a 'flare' of her
Crohn's disease, and there are no rashes or other symptoms.
 On physical examination, her hair is mildly thin, stomatitis is noted,
but the physical examination is otherwise normal.

32.  An 8-year-old boy from an underdeveloped rural community is seen by a
health practitioner.
 He is noted to be below the fifth percentile for height, and has been doing
poorly in school.
 On nutritional assessment the boy's mother reports that his diet consists
mainly of locally produced grains and vegetables that are not fortified, and that
meats are rarely available.
 The mother also reports that he does not have much energy, but there are no
other specific complaints and physical examination is unremarkable.
 Review of the boy's growth chart shows that height had been stable at the
thirtieth percentile until his last visit at the age of 4 years old.

33. Zinc Deficiency
- Dr. Akif A.B

34.  10-40% is absorbed from small intestine.
 Direct relationship with protein metabolism.
 Absorption is inhibited by Phytates, fibres as well as
dietary iron.
 A RCT showed that standard iron supplements doesn’t
interfere with Zinc absorption.

35.  0.5-1 mg/day is excreted in stools daily.
 Serum Zinc concentration = 70-120mcg/dl
 60% loosely bound to albumin
 30% tightly bound to macroglobulin.
 Primary store : Liver and Kidney
 Mostly Intracellular bind to Metalloproteinases.

36.  11 mg/day for males
 9mg/day for females

37.  Activates many enzyme system
 Carbonic Anhydrases, Dehydrogenases, Alkaline
phosphatases and Carboxypeptidases.
 Plays a role in growth, Tissue repair, wound healing
and synthesis of Testicular hormone.

38.  Impaired phagocytic function
 Lymphocyte depletion
 Decreased immunoglobulin production
 Reduction in the T4+/T8+ ratio
 Decreased interleukin (IL)-2 production

39.  Inhibits secretory effect of Cholera toxin and Heat
labile enterotoxins
 Direct inhibitory effect on Enteropathogenic E-coli

40.  Meat
 Milk
 Sea foods
 Legumes
 Nuts
 Cereals
Less available for absorption

41.  Inadequate intake
 Breastfeeding : Breast milk has low zinc content.
 Crohn’s Disease : Decreased absorption
 Cystic fibrosis
 Sickle cell anemia
 Due to renal tubular damage leading to increased urinary
excretion.

42.  Drugs
 Penicillamine , Ethambutol, Thiazide and certain
antibiotics.
 Liver diseases
 Due to Hypoalbuminemia

43.  Increased risk of infection.
 Stomatitis : Non specific
 Fatigue
 GI Symptoms : Nausea, vomitings, diarrhoea
 Short stature

44.  Bone fractures due to osteopenia
 Impaired glucose tolerance
 Hypogonadism
 Alopecia
 Hypogeusia

45.  Autosomal Recessive disease
 Partial defect in Zinc absorption.
 Due to mutation of SLC39A4 on chromosome 8.
 Diarrhoea, Alopecia, Dermatitis, depression , irritability.
 Growth retardation and delayed sexual maturation.
 Frequent infections.
 Characteristic erythematous vesico-bullous dermatitis.

47.  Serum Zinc levels : <60mcg/dl
 May be low in hypoalbuminemia
 Serum Zinc levels is very insensitive, as it can be
normal in patients with mild Zinc Deficiency
 Albumin level as poor correlation with Zinc levels,
so if there is suspicion of Zinc deficiency and if Zinc
levels are low , patient should be treated despite of
Serum albumin levels.

48.  Zinc level in Lymphocyte or neutrophils is more
sensitive.
 Zinc level in either lymphocytes (<50 mcg/1010 cells)
 Granulocytes (<42 mcg/1010 cells)
 Depressed serum alkaline phosphatase

49.  Vitamin D or A deficiency
 Hypothyroidism
 Depression
 Vitamin B12 or folate deficiency
 Iron deficiency

50.  1-2mg/kg/day of elemental Zinc.
 3mg/kg/day for Acrodermatitis Enteropathica.
 Usual supplementation dose is : 20-40mg/day
 Higher doses may be required in severe deficiency due
to increased GI loss or malabsorption.

51.  Usually treatment is given for 3-6 months.
 Acrodermatitis enteropathica
 Requires life long supplementation
 Stoppage has been associated with recurrence of disease
 As skin manifestations are due to enzyme deficiency,
topical Zinc has no role.
 Monitor serum copper levels in long term therapy as
Zinc competes with copper for absorption.

52.  WHO recommends zinc supplementation for infants
and children with acute diarrhea in resource-limited
countries .
 The supplements are given at a dose of 20 mg/day for
children
 10 mg/day for infants younger than 6 months old, for
10 to 14 days.

53.  Intake of 10 times the normal supplementation
doesn’t produce any symptoms.
 Chronic ingestion of high dose Zinc can cause
Copper deficiency.
 Acute ingestion of 1-2 gm Zinc sulphate can cause
nausea, vomiting, GI erosions and renal tubular
necrosis.

54.  Prophylactic supplementation of Zinc to < 5years of
age children has known to decrease chances of
Pneumonia and diarrhoea when compared to placebo
in many trials.

56.  Vitamin K1 - Phylloquinone : vegetable source
 Vitamin K2 - Menaquinone : Bacterial source and
Liver

57.  Required for post translation carboxylation of :
 Factor 2,7,9,10
 Protein C and S
 Osteocalcin in bone
 Matrix GLA protein of
Vascular smooth muscle.
Importance is not known

58.  Green leafy vegetables
 Soyabean oil
 Liver

59.  Hemorrhage
 Neonates are more prone due to decreased fat stores ,
immaturity of Liver, poor placental transport and
decrease content in breast milk.
 Intracranial, skin and GI bleeding can occur 1-7days
after birth.
 Thus Vitamin K 0.5-1 mg is given I.M at birth

60.  Vitamin K deficiency can be present in small bowel
disease, Small bowel resection and biliary obstruction.
 Prolonged antibiotic therapy can decrease GI bacteria
and cause decrease menaquinone levels.
 Anti-obesity drug Orlistat can cause Vitamin K
malabsorption.

61.  Causes prolonged Prothrombin time
 Treated with 10mg Vitamin K .
 In chronic deficiency 1-2mg/day oral intake or 1-2mg
i.m weekly.