Vitamin C

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Vitamin C

  1. 1. VITAMIN C DR KAUSIK SUR D.C.H,DNB ASSISTANT PROFESSOR DEPARTMENT OF PEDIATRICS VIVEKANANDA INSTITUTE OF MEDICAL SCIENCES RAMAKRISHNA MISSION SEVA PRATISTHAN KOLKATA,INDIA
  2. 2. SOURCES <ul><li>FRESH FRUIT, GREEN LEAFY VEGETABLES </li></ul><ul><li>Amla is the richest source </li></ul><ul><li>BREAST MILK (if mother is on adequate diet) 4-7 mg/100ml </li></ul><ul><li>FRESH COWS MILK/BUFFALOS MILK 2mg/100ml </li></ul><ul><li>SPROUTING PULSES </li></ul>
  3. 4. RECOMMENDED DIETARY INTAKE DAILY INTAKE Mg/day Preterm baby 75 0-6 months 20 6 months- 1 year 40 1 year- adults 40 Pregnancy 40 Lactation 80
  4. 5. FUNCTIONS <ul><li>PRODUCTION OF SUPPORTING TISSUE </li></ul><ul><li>BONE FORMATION (osteoid) </li></ul><ul><li>TEETH FORMATION (dentin) </li></ul><ul><li>CAPILLARY FUNCTIONS (collagen ) </li></ul>
  5. 6. <ul><li>HEMOPOESIS </li></ul><ul><li>Maturation of R.B.C </li></ul><ul><li>Transport of iron in the body </li></ul><ul><li>Helps in conv. Of folic acid to folinic acid and prevent the oxidation of THF </li></ul>
  6. 7. <ul><li>ENZYMATIC FUNCTIONS </li></ul><ul><li>Imp. Role in oxidation of tyrosine </li></ul><ul><li>Phenylalanine metabolism </li></ul><ul><li>Hydroxylation of proline in collagen formation </li></ul><ul><li>Biogenesis of corticosteroids in adrenals </li></ul><ul><li>Hydroxylation of aromatic compounds </li></ul><ul><li>As a cofactor of dopamine B monoxygenase (necessary for nor epinephrine synthesis ) </li></ul><ul><li>Effect on catecholamine biosynthesis </li></ul>
  7. 8. <ul><li>CARBOHYDRATE METABOLISM </li></ul><ul><li>Impaired glucose tolerence can be corrected by large amount of vit.C </li></ul><ul><li>FAT METABOLISM </li></ul><ul><li>Intervention in cholesterol transformation to its principal products of bile acids </li></ul>
  8. 9. <ul><li>ANTIOXIDANT EFFECT </li></ul><ul><li>Important scavenger of free radicles which are derived from oxygen </li></ul><ul><li>METAL ION METABOLISM </li></ul><ul><li>Involved in absorption, mobilization, distribution and intoxication of metal ions </li></ul><ul><li>Helps in transfer of iron from plasma transferrin into tissue ferritin storage of iron in bone marrow, spleen and liver </li></ul>
  9. 10. <ul><li>IMMUNE SYSTEM </li></ul><ul><li>High doses(1gm/day)- increases IgM and C3 levels </li></ul><ul><li>May stimulate lymphocyte transformation and mobility of PMN leucocyte </li></ul><ul><li>BIOSYNTHESIS </li></ul><ul><li>Neurotransmitters </li></ul><ul><li>Carnitine </li></ul>
  10. 11. SCURVY <ul><li>RARE </li></ul><ul><li>6 MONTHS- 2 YEARS </li></ul>
  11. 12. ETIOLOGY <ul><li>Formula and boiled milk fed infants without any vit.C suppl. </li></ul><ul><li>Breast fed infants of mothers deficient in vit.C </li></ul><ul><li>Strict macrotic diet </li></ul><ul><li>Prolonged storage of vit.C containing food products(tin foods) </li></ul><ul><li>PEM </li></ul><ul><li>Vit. C dependency </li></ul><ul><li>Low SE status </li></ul><ul><li>Increased requirement- burn, fracture, febrile illness, surgery, chronic disorders-ra and tb, pregnancy, lactation, thyrotox., Diarrhea </li></ul>
  12. 13. PATHOLOGY <ul><li>SKELETAL CHANGES </li></ul><ul><li>Significant changes occour at growing end of long bones </li></ul><ul><li>Failure of ossification </li></ul><ul><li>Failure of osteoblastic function….Normal balance of productive and destructive processes of bone is altered </li></ul>
  13. 14. <ul><li>Process of provisional calcification continues but destruction of cartilage is disturbed </li></ul><ul><li>Calcified cartilages piles up </li></ul>
  14. 15. <ul><li>PERIOSTEUM- Proliferation of fibroblast </li></ul><ul><li>Loose fibroblastic tissue- hemorrhage can occur easily </li></ul>
  15. 16. <ul><li>Zone of weakness between metaphysis and diaphysis </li></ul><ul><li>Sliping of the diaphysis </li></ul>
  16. 17. <ul><li>TEETH </li></ul><ul><li>Defective collagen formation and chondroitin sulphate </li></ul><ul><li>Defective dentine formation and loosening of teeth </li></ul><ul><li>Gums are swollen, red or blue, tender, bleeds on touch </li></ul>
  17. 18. <ul><li>ANEMIA </li></ul><ul><li>Decrease in iron absorption and storage </li></ul><ul><li>Altered folic acid metabolism </li></ul><ul><li>Bleeding manifestation </li></ul>
  18. 19. <ul><li>HEMORRHAGE </li></ul><ul><li>Impairment of ability of mesenchymal cells to form normal intracellulars substance-collagen tissue of vascular endothelium </li></ul><ul><li>Hemorrhage in skin,mm,subperiosteum,into joints </li></ul><ul><li>ADRENAL FAILURE </li></ul>
  19. 20. CLINICAL TYPES
  20. 21. <ul><li>NEONATAL SCURVY </li></ul><ul><li>Seen in </li></ul><ul><li>newborn babies fed on boiled and diluted cows milk </li></ul><ul><li>Born to mothers with vit c def </li></ul><ul><li>Fever,crying,swelling of knee joint </li></ul><ul><li>X RAY- ringed epiphysis </li></ul>
  21. 22. <ul><li>LATENT SCURVY </li></ul><ul><li>Low plasma ascorbic acid level but no classical manifeatstions like bony changes </li></ul><ul><li>Anorexia,wkness, FTT, irritability,restlessness,freq.RTI, </li></ul><ul><li>Diagnosis- history, blood vit.C level </li></ul><ul><li>X-ray- nonspecific bone atrophy </li></ul>
  22. 23. INFANTILE SCURVY <ul><li>PSEUDOPARALYSIS </li></ul><ul><li>SCORBUTIC ROSARY </li></ul>
  23. 24. <ul><li>LOOSE TETH </li></ul><ul><li>RED, SPONGY SWOLLEN AND BLEEDING GUMS </li></ul>
  24. 25. <ul><li>HEMORRHAGE </li></ul><ul><li>BONE- SUBPERIOSTEAL </li></ul><ul><li>SKIN- PETECHIE </li></ul><ul><li>ECHYMOSIS </li></ul><ul><li>RENAL-HEMATURIA </li></ul><ul><li>GIT-MALENA </li></ul><ul><li>EYE-RETRORBITAL </li></ul><ul><li>CNS- INTRACRANIAL </li></ul>
  25. 26. <ul><li>ANEMIA </li></ul><ul><li>RECURRENT RTI </li></ul><ul><li>DELAYED WOUND HEALING </li></ul>
  26. 27. CHILDHOOD AND ADOLESCENT SCURVY <ul><li>BLEEDING MANIFESTATIONS ARE MORE COMMON( infantile scurvy- more skeletal manifestations) </li></ul><ul><li>Follicular hyperkeratosis and minute perifoolicular hemorrhage at the root of hair follicles around the big joints ( A SIGN OF ADVANCED DEF.) </li></ul><ul><li>After 1-3 months of onset- Dyspnea, bone pain and joint pain (subperiosteal hge) </li></ul>
  27. 28. <ul><li>Advanced cases- ecchymoses and purpura may develop initially at areas of trauma and irritation or in the muscles and subcutaneous tissues </li></ul><ul><li>Joint effusion and hemorrhage </li></ul><ul><li>Splinter hge of nail bed </li></ul><ul><li>Emotional disturbances </li></ul><ul><li>Hairs- fragmented and burried </li></ul>
  28. 29. <ul><li>Extereme depletion state </li></ul><ul><li>Dyspnea </li></ul><ul><li>Edema </li></ul><ul><li>Icterus </li></ul><ul><li>Oliguria </li></ul><ul><li>Neuropathy </li></ul><ul><li>Convulsion </li></ul><ul><li>Hypotension </li></ul><ul><li>Death </li></ul>
  29. 30. RADIOLOGICAL CHANGES <ul><li>EARLY SIGNS </li></ul><ul><li>Ground glass appearance </li></ul><ul><li>Thinning of cortex </li></ul><ul><li>Epiphyseal rarefaction and seperation </li></ul><ul><li>Provisional zone of calcification </li></ul>
  30. 32. <ul><li>ADVANCED SIGNS </li></ul><ul><li>Spur formation </li></ul><ul><li>Scurvy line </li></ul><ul><li>Tremerfield zone </li></ul><ul><li>Corners sign </li></ul><ul><li>Subperiosteal hemorrhage </li></ul><ul><li>Fracture in prov. Zone of calcification or metaphyseal fractutres </li></ul>
  31. 35. LABORATORY DIAGNOSIS <ul><li>BLOOD </li></ul><ul><li>HB% </li></ul><ul><li>ANEMIA TYPING (normocytic normochromic /microcytic hypochromia/megaloblastic) </li></ul><ul><li>WBC COUNT (raised-infections) </li></ul><ul><li>SERUM BILIRUBIN </li></ul><ul><li>PT </li></ul>
  32. 36. <ul><li>FASTING SERUM ASCORBIC ACID LEVEL </li></ul><ul><li>>0.6mg/dl- rules out scurvy </li></ul><ul><li>>0.2 normal </li></ul><ul><li>0.1-.19 low value </li></ul><ul><li><0.1 sugestive of scurvy </li></ul>
  33. 37. <ul><li>PLASMA ASCORBIC ACID LEVEL </li></ul><ul><li>0.7 mg-1.2mg/dl –normal </li></ul><ul><li>0.4-0.7 – mild deficiency </li></ul><ul><li><0.4 – severe deficiency </li></ul><ul><li>Plasma and serum conc. Respond to changes in dietary vitamin c concentration- used for assesment of recent vit.c intake </li></ul><ul><li>Poor indicators of tissue levels </li></ul>
  34. 38. <ul><li>ESTIMATION OF VITAMIN C WHITE CELL PLATELET LAYER </li></ul><ul><li>Le ucocute concentration of vitamin c is a better indicator of body store </li></ul><ul><li>≤ 10µg/10 8 WBC - Deficient </li></ul><ul><li>TISSUE SATURATION TEST </li></ul><ul><li>10mg/kg ascorb. Acid given orally </li></ul><ul><li>First 24 hrs- 80% excreted normally in urine </li></ul><ul><li>0-20% severe deficiency </li></ul>
  35. 39. <ul><li>VITAMIN C TOLERANCE TEST </li></ul><ul><li>I V ascorbic acid 20mg/kg given in NS </li></ul><ul><li>4 hr URINE SAMPLE- urinary excretion of vit c > 1.5 mg/dl-scurvy excluded </li></ul>
  36. 40. COMPLICATIONS <ul><li>Repeated acute RTI </li></ul><ul><li>Adrenal failure </li></ul><ul><li>Haematomyelia </li></ul><ul><li>SUBDURAL HAEMATOMA (rare) </li></ul><ul><li>LIMB SHORTENING AND KNEE FLEXION CONTRACTURES (rare) </li></ul>
  37. 41. TREATMENT <ul><li>LATENT SCURVY- VIT.C 100-200mg/day </li></ul><ul><li>VIT.C RICH DIET </li></ul><ul><li>CLINICAL SCURVY- </li></ul><ul><li>ASCORBIC ACID 500-1000mg loading dose- repeated daily for 1 week </li></ul><ul><li>(I V route in diarrhea, adrenal failure,shock) </li></ul><ul><li>Maintainance dose of vitamin c 50-75 mg/day </li></ul>
  38. 42. <ul><li>DIET- containing fruit, green vegetables, fresh orange juice, tomato juice </li></ul>
  39. 43. SIGNS OF IMPROVEMENT <ul><li>Within 48 hrs- pain, tenderness, apprehensive facies improves </li></ul><ul><li>3-5 days- bleeding gums stop, tenderness of bone disappears, serum bili becomes normal </li></ul><ul><li>10-12 days- ecchymosis and haematoma disappear </li></ul><ul><li>1-2 weeks- radiological response </li></ul><ul><li>1-3 weeks- swelling of bone( may persist more) </li></ul><ul><li>1 month- pigmentary changes of hemorrhage </li></ul>

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