Intractable vomiting and severe weight loss in patients following weight reduction surgical procedures
Nitrous oxide administration in cobalamin-deficient patients
Sudden change in tissue osmolarity in critically ill patients or alcoholics
may be present in deficiencies of cobalamin and vitamin E; neuropathy can result from deficiency of B complex vitamins (thiamine, pyridoxine, and cobalamin) and pyridoxine excess; and optic neuropathy may be seen in cobalamin deficiency, vitamin A excess, or a combined deficiency of B complex vitamins, such as in deficiency amblyopia.
Sixth, the underrecognition of nutritional disorders in industrialized countries has led to difficulties in diagnosis, and these deficiencies may be more common than has been clinically appreciated. Although the incidence of WKS has traditionally ranged from 1 to 3 percent, autopsy data suggest a higher incidence, '1' , y and others report thiamine deficiency in up to 17 percent of elderly patients hospitalized for non-neurological reasons. '3 One study of thiamine deficient alcoholics showed that over 50 percent of patients were also riboflavin deficient, and 2 percent had a concomitant deficiency of pyridoxine. '4 Cobalamin deficiency occurs in 5 to 14 percent of ambulatory elderly, [5 , '6 and up to 27 percent of hospitalized elderly develop protein-energy malnutrition (PEM) during their hospital stay. y
Finally, several inherited enzyme deficiency disorders, although not accompanied by a vitamin deficiency may nonetheless be vitamin responsive ( .Table...40-2 ). Homocysteinemia responds to pharmacological doses of folate, cobalamin, and pyridoxine, whereas methylmalonicacidemia responds to cobalamin. Maple syrup urine disease, a branched-chain aminoaciduria, may be responsive to high-dose thiamine which induces the enzyme alpha-ketoacid decarboxylase, promoting metabolism of branched-chain amino acids. Beta-methylcrotonylglycinuria and propionic-acidemia may be responsive to biotin replacement; Hartnup's disease, a disorder of tryptophan metabolism, is also responsive to niacin.
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