Severe Folate Deficiency Research Articles

Olanzapine and pancytopenia with severe folate deficiency

To the editor: Olanzapine, a thienobenzodiazepine serotonin-dopamine antagonist, is a recent atypical antipsychotic agent, with a structural and pharmacologic profile similar to that of clozapine. Although clozapine is effective in refractory schizophrenia, its use is limited by the occurrence of hematologic adverse effects, such as agranulocytosis, which occurs in 0.5–2% of treated patients [1]. Many studies have suggested a better hematologic safety profile for olanzapine, but impaired granulocytopoiesis and thrombocytopenia have recently been reported [2-6]. No case of pancytopenia with megaloblastic anemia has been described with the use of olanzapine. We report a case of pancytopenia with severe folate deficiency in a schizophrenic patient treated with olanzapine. A 56-year-old man, who worked as a painter, was a heavy smoker, had bad dental health, and a history of chronic psychosis was hospitalized on 11 August 2008 with severe pancytopenia, suggested by purpura. He had been living with his brother and had been treated for many years with haloperidol decanoate (3 mg every 3 weeks), loxapine (100 mg/day), amisulpride (800 mg/day), tropatepine (10 mg/day), diazepam (10 mg/day), and clorazepate (50 mg/day). Because of recent worsening of his psychotic symptoms, olanzapine was introduced (20 mg/day) in May 2008. The laboratory data on admission and during the early period of hospitalization are shown in Table 1. The hemogram and reticulocyte count revealed pancytopenia with macrocytic normochromic aregenerative anemia. The folate plasmatic level was dramatically decreased, total protein and cobalamin were slightly decreased, and renal and hepatic functions were normal. Shortly after admission, only olanzapine was discontinued. The patient received probabilist cobalamin supplementation with no immediate hematologic improvement. On 14 August, he began to receive intravenous folate supplementation (50 mg/day). Ten days later, a huge reticulocyte crisis was observed, whereas the white blood cell and platelet counts were significantly increased (Table 1). Meanwhile, the results of bone marrow aspiration confirmed the diagnosis of megaloblastic anemia. The patient was supplemented with folic acid over 2 weeks. Because the medical staff decided against restarting olanzapine, the loxapine dosage was increased to 150 mg/day with a good response. Computerized tomography imaging showed hepatic abnormalities consistent with portal hypertension. On 4 September, the macrocytic anemia recovered and folate supplementation was discontinued. One month after admission, gastric endoscopy revealed grade I peptic esophagitis without esophageal varix. The biopsies were all negative, thus ruling out celiac disease. At this time, his laboratory data only showed a slight macrocytosis with no anemia. At the 3-month follow-up, olanzapine had not been restarted and the patient had a perfect clinical examination, despite discontinuation of folate supplementation. F. Maurier : J.-F. Guichard Department of Internal Medicine, Vascular Medicine and Clinical Immunology, Ste Blandine Hospital, Metz, France

Folate deficiency in women of reproductive age in nine administrative regions of Ethiopia: an emerging public health problem

Objective: To investigate the country-wide extent of folate deficiency and risk factors in Ethiopian women.Design: Cross-sectional study.Methods: Multistage cluster sampling and systematic sampling were used to select 970 women aged 15 to 49 years from nine accessible regions of Ethiopia. Demographic and health information was collected via questionnaire. Biological samples were collected by medical technologists. Outcome measures: demographic and health variables, food frequency, haemoglobin status, ferritin status and folate status.Results: Mean ± SD plasma folate was 5.57 ± 3.84 ng/mL. Forty-six per cent of women had severe folate deficiency (≤ 4 ng/mL) and 21.2% had marginal folate deficiency (> 4–6.6 ng/mL) with unequal prevalence across the country. Severe folate deficiency was higher in women who were unmarried (p = 0.002), had parity of 4–6 (p = 0.001), used oral contraceptives (p = 0.01), had no illnesses (p = 0.001), had intestinal parasites (0.001), followed lower plant food diets (0.001), followed lower animal product diets (0.001), had no anaemia (0.001) and had no iron deficiency (0.001). In logistic regression analysis, only low plant food diets (p = 0.001) and iron deficiency (p < 0.001) retained their significance with regard to folate deficiency. The odds for developing folate deficiency was 0.9 times less likely among those with higher plant food intake (AOR-0.9;95%CI – 0.72–1.2) and 0.2 times less likely among those with adequate iron (AOR-0.2;95%CI – 0.17–0.34).Conclusions: Folate deficiency is widespread in Ethiopian women, emphasising the need for sustainable folate intake through dietary diversification and appropriate public health measures.

Folate Receptor Alpha Defect Causes Cerebral Folate Transport Deficiency: A Treatable Neurodegenerative Disorder Associated with Disturbed Myelin Metabolism

Sufficient folate supplementation is essential for a multitude of biological processes and diverse organ systems. At least five distinct inherited disorders of folate transport and metabolism are presently known, all of which cause systemic folate deficiency. We identified an inherited brain-specific folate transport defect that is caused by mutations in the folate receptor 1 (FOLR1) gene coding for folate receptor alpha (FRalpha). Three patients carrying FOLR1 mutations developed progressive movement disturbance, psychomotor decline, and epilepsy and showed severely reduced folate concentrations in the cerebrospinal fluid (CSF). Brain magnetic resonance imaging (MRI) demonstrated profound hypomyelination, and MR-based in vivo metabolite analysis indicated a combined depletion of white-matter choline and inositol. Retroviral transfection of patient cells with either FRalpha or FRbeta could rescue folate binding. Furthermore, CSF folate concentrations, as well as glial choline and inositol depletion, were restored by folinic acid therapy and preceded clinical improvements. Our studies not only characterize a previously unknown and treatable disorder of early childhood, but also provide new insights into the folate metabolic pathways involved in postnatal myelination and brain development.

Folate deficiency presenting as pyrexia: a case report

Folate deficiency is an uncommon cause of pyrexia. We describe the case of a 29-year-old male who presented with a pyrexial illness subsequently attributed to megaloblastic anaemia secondary to severe folate deficiency, after exclusion of other infective or inflammatory causes. A temperature chart documenting the course of the patient's pyrexia is presented and potential pathophysiological mechanisms are proposed. Folate deficiency is a reversible cause of pyrexia that should be considered in any patient who presents with a pyrexial illness of unknown cause.

Folic acid deficiency optic neuropathy: A case report

IntroductionNutritional optic neuropathies are uncommon and can be associated with gradual visual loss and optic atrophy or sudden vision loss and optic disc swelling.Case presentationA 44-year-old woman presented with a 4-week history of progressive visual loss and was noted to have bilateral retrobulbar optic neuropathy. No other clinical abnormality was noted. Investigations revealed severe folate deficiency with normal vitamin B12 levels. Her alcohol and tobacco consumption was moderate and subsequent correction of folate levels with oral supplementation has led to improvement in her visual acuity.ConclusionThis case highlights an unusual presentation of folic acid deficiency that may present to the general physician.

The Reduced Folate Carrier (RFC) Is Cytotoxic to Cells under Conditions of Severe Folate Deprivation: RFC AS A DOUBLE EDGED SWORD IN FOLATE HOMEOSTASIS

The reduced folate carrier (RFC), a bidirectional anion transporter, is the major uptake route of reduced folates essential for a spectrum of biochemical reactions and thus cellular proliferation. However, here we show that ectopic overexpression of the RFC, but not of folate receptor alpha, a high affinity unidirectional folate uptake route serving here as a negative control, resulted in an approximately 15-fold decline in cellular viability in medium lacking folates but not in folate-containing medium. Moreover to explore possible mechanisms of adaptation to folate deficiency in various cell lines that express the endogenous RFC, we first determined the gene expression status of the following genes: (a) RFC, (b) ATP-driven folate exporters (i.e. MRP1, MRP5, and breast cancer resistance protein), and (c) folylpoly-gamma-glutamate synthetase and gamma-glutamate hydrolase (GGH), enzymes catalyzing folate polyglutamylation and hydrolysis, respectively. Upon 3-7 days of folate deprivation, semiquantitative reverse transcription-PCR analysis revealed a specific approximately 2.5-fold decrease in RFC mRNA levels in both breast cancer and T-cell leukemia cell lines that was accompanied by a consistent fall in methotrexate influx, serving here as an RFC transport activity assay. Likewise a 2.4-fold decrease in GGH mRNA levels and approximately 19% decreased GGH activity was documented for folate-deprived breast cancer cells. These results along with those of a novel mathematical biomodeling devised here suggest that upon severe short term (i.e. up to 7 days) folate deprivation RFC transport activity becomes detrimental as RFC, but not ATP-driven folate exporters, efficiently extrudes folate monoglutamates out of cells. Hence down-regulation of RFC and GGH may serve as a novel adaptive response to severe folate deficiency.

Cough mixture abuse as a novel cause of folate deficiency: a prospective, community-based, controlled study

Cough mixture abuse has been reported to cause severe folate deficiency and neurological defects. We carried out a prospective case-controlled survey to confirm this association and define the incidence and severity of the problem. A total of 57 cough mixture abusers and 47 other substance abusers (controls) were studied. When compared with controls, cough mixture abusers had a high incidence of low folate levels that could only be detected by screening.

Homocysteine-Lowering Action Is Another Potential Cardiovascular Protective Factor of Aged Garlic Extract1–3

We investigated hypohomocysteinemic action as a cardiovascular protective property of aged garlic extract (AGE). Hyperhomocysteinemia was induced in rats by feeding folate-depleted diets. Plasma folate concentrations of 5, 24, and 202 nmol/L were detected in rats fed a folate-deficient L-amino acid diet containing succinyl sulfathiazole, an AIN-93G folate-deficient diet, and an AIN-93G folate-sufficient diet, respectively. Plasma concentrations of total homocysteine were elevated to the highest level (32 micromol/L) by severe folate deficiency and to a moderate level (9 micromol/L) by mild folate deficiency, compared with the lowest level of (5 micromol/L), noted for the folate-sufficient group. The addition of AGE to the severely folate-deficient diet decreased plasma total homocysteine concentration by 30%. Hyperhomocysteinemia caused by mild folate deficiency remained unaltered by AGE supplementation. The reduction in total homocysteine of the severely folate-deficient rats was accompanied by a proportional decrease in protein-bound and free homocysteine, resulting in an unchanged protein-bound:free homocysteine ratio. AGE added to the diet did not alter plasma concentrations of other aminothiol compounds: cysteine, glutathione, and cysteinylglycine. These data, together with increased S-adenosylmethionine and decreased S-adenosylhomocysteine concentrations in the liver, suggest that the hypohomocysteinemic effect of AGE most likely stems from impaired remethylation of homocysteine to methionine and enhanced transsulfuration of homocysteine to cystathionine. More importantly, in addition to its cholesterol-lowering potential, blood pressure-lowering effect, and antioxidant property, a hypohomocysteinemic action may be another important cardiovascular protective factor of AGE.

Severe folate deficiency in pregnancy with normal red cell folate level

We report here a case of megaloblastic anaemia in late pregnancy, which leads us to question whether folate supplements should be recommended in the UK routinely throughout pregnancy and not just in the preconception period and first trimester.

Folate Deficiency Alters Melatonin Secretion in Rats

The final step of melatonin (MLT) synthesis is methylation of N-acetyl-serotonin, with S-adenosylmethionine as a methyl donor provided by a metabolic pathway involving sulfur-containing amino acids (homocysteine and methionine). Remethylation of homocysteine to methionine requires folate. The present study was undertaken to test the influence of folate deficiency on MLT secretion. Severe folate deficiency was induced in rats by feeding them a synthetic diet containing (per kg diet) 0 mg folate and 10 g succinylsulfathiazole. Control rats were fed the same diet containing 8 mg folate/kg. After 4 wk, erythrocyte folate concentrations were significantly lower and plasma homocysteine levels were greater in folate-deficient rats than in controls. Pineal MLT concentration and urinary excretions of MLT, 6 sulfatoxymelatonin (the main hepatic MLT metabolite) and methoxylated catechol compounds were lower in the folate-deficient group than in the controls, whereas plasma catecholamine concentrations did not differ. Decreases generally were more marked at wk 2 than at wk 4 for the urinary metabolite excretions. These findings indicate that folate deficiency dramatically alters MLT secretion in rats.

Severe Folate Deficiency Impairs Natural Killer Cell–Mediated Cytotoxicity in Rats

Dietary folate deficiency enhances, whereas folate supplementation suppresses, the development of several cancers. This study investigated the effect of folate deficiency on natural killer cell (NK)-mediated cytotoxicity, which is important in immune surveillance against tumor cells. In Experiment 1, severe folate deficiency was induced in rats by feeding an amino acid-defined diet containing 0 mg folate and 10 g succinylsulfathiazole/kg diet. Control and folate-supplemented rats were fed the same diet containing 2 (basal requirement) and 8 mg folate/kg diet, respectively. Severe folate deficiency at the end of wk 5 was associated with 20% growth retardation, a 60% reduction in lymphocyte counts and significantly impaired NK-mediated cytotoxicity compared with the control and folate-supplemented groups (P < 0.02). The lesser degree of severe folate deficiency achieved by wk 4 was not associated with impaired NK-mediated cytotoxicity. Folate supplementation at 4x the basal requirement did not significantly enhance NK-mediated cytotoxicity at either time point. In Experiment 2, moderate folate deficiency was induced in rats by feeding the same diet without succinylsulfathiazole. NK-mediated cytotoxicity in the moderately folate-deficient rats (without growth retardation or lymphopenia) was not significantly different from that in controls. Although severe folate deficiency may have adverse effects on NK-mediated cytotoxicity, moderate folate deficiency, a degree of depletion associated with an increased risk of several cancers, appears not to affect NK-mediated cytotoxicity in rats. Furthermore, a modest level of folate supplementation above the basal requirement does not enhance NK-mediated cytotoxicity. These data collectively suggest that NK-mediated cytotoxicity is not a likely mechanism by which folate status modulates carcinogenesis.

Occurrence of hyperhomocysteinaemia in cardiovascular, haematology and nephrology patients: contribution of folate deficiency.

We investigated the contribution of plasma folate deficiency to hyperhomocysteinaemia in selected patient groups. Based on our observations, we have determined a lower folate reference interval cut-off using homocysteine as a metabolic marker of folate deficiency. Four hundred and twenty-five consecutive plasma specimens from cardiology (n = 120), haematology (n = 190) and nephrology (n = 115) patients were analysed for homocysteine and plasma folate concentrations. Healthy volunteers were used as controls (n = 117). We observed elevated homocysteine values above our upper reference limit of 13 micromol/L in 20.1%, 28.4% and 74.8% of the cardiology, haematology and nephrology patients, respectively. All but 1.9% of the patients had plasma folate values greater than the lower reference interval limit (3.4 nmol/L) for our folate assay. The percentage of patients from cardiology and haematology clinics who were hyperhomocysteinaemic and had folate values > 15 nmol/L was 5.0% and 4.2%, respectively. In contrast, 58% of our nephrology patients with folate values > 15 nmol/L were hyperhomocysteinaemic. In all three groups, an inverse relationship was found between folate and homocysteine. The folate/homocysteine ratios in the patient groups were approximately one-third of the values observed in our control group. Folate deficiency appears to be the primary cause of hyperhomocysteinaemia in our cardiology and thrombosis patients. However, severe folate deficiency appears to be uncommon. The majority of our nephrology patients are hyperhomocysteinaemic without an apparent folate deficiency. We conclude that raising the lower reference interval cut-off for folate to 15 nmol/L would help to identify individuals at risk for hyperhomocysteinaemia in our non-uraemic patient population. Increasing folate supplementation to maintain a plasma concentration above 15 nmol/L in cardiac, thrombosis and renal patients would greatly reduce the occurrence of hyperhomocysteinaemia in these patients.

Nutritional folate deficiency augments the in vivo mutagenic and lymphocytotoxic activities of alkylating agents

To investigate the interaction of folate deficiency and alkylating agents in vivo, weanling Fischer 344 rats were maintained for 5 weeks on a folate replete, moderately folate deficient, or a severely folate deficient diet. Mutant frequencies at the HPRT locus in splenic lymphocytes were 1.2+/-0.6, 1.9+/-1.1, and 6.4+/-4.0 x 10(-6), respectively (P < 0.01). N-nitroso-N-ethylurea (ENU), 100 mg/kg body weight, was much more mutagenic with progressive folate deficiency (5.0+/-2.4 vs. 16.2+/-7.3 vs. 39.2+/-21.0 x 10(-6)), suggesting a synergistic interaction (P << 0.01). Neither moderate nor severe folate deficiency significantly enhanced the mutagenic effects of cyclophosphamide, 50 mg/kg body weight (18.0+/-7.9 vs. 6.0+/-2.8 vs. 28.5+/-28.2 x 10(-6)). The number of cloning cells/ spleen were reduced 68% in moderately folate deficient rats and by 87% in severely deficient animals (P < 0.05). The combination of folate deficiency and cyclophosphamide reduced the total number of cloning cells further, but ENU alone, or in combination with folate deficiency, did not. These findings indicate that folate deficiency increases the risk of somatic mutations and is lymphocytotoxic in rats. Folate deficiency enhances the mutagenic but not the lymphotoxic effects of ENU, while it increases the lymphotoxic but not the mutagenic activity of cyclophosphamide. Correction of folate deficiency may decrease the immunologic and genetic damage caused by some alkylating agents.

Severe folate deficiency masquerading as the syndrome of hemolysis, elevated liver enzymes, and low platelets

Although folate deficiency is common in pregnancy, progression to megaloblastosis is not. Hemolytic anemia, thrombocytopenia, and coagulopathy due to folate deficiency may mimic the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP). Two women presented in the second trimester with abdominal pain and severe thrombocytopenia. These symptoms were misinterpreted in the first woman as the HELLP syndrome, leading to an emergency cesarean delivery. Subsequent investigation revealed folate deficiency; treatment resulted in rapid normalization of all abnormalities. In the second woman, folate deficiency was diagnosed antenatally. Treatment allowed continuation of the pregnancy to term. The serious complications of folate deficiency make a strong case for supplementation in pregnancy. Careful scrutiny of clinical and laboratory findings may help discriminate the HELLP syndrome from its mimics, avoiding preterm delivery.

Dietary nickel and folic acid interact to affect folate and methionine metabolism in the rat.

A previous experiment using rats indicated that dietary nickel (Ni), folic acid, and their interaction affected variables associated with one-carbon metabolism. That study used diets that produced only mild folate deficiency. Thus, an experiment was performed to determine the effect of a severe folate deficiency on nickel deprivation in rats. A 2 x 2 factorially arranged experiment used groups of six weanling Sprague-Dawley rats. Dietary variables were nickel, as NiCl2-6H2O, 0 or 1 microgram/g and folic acid, 0 or 4 mg/kg. All diets contained 10 g succinylsulfathiazole/kg to suppress microbial folate synthesis. The basal diet contained < 20 ng Ni/g. After 58 d, an interaction between nickel and folate affected the urinary excretion of formiminoglutamic acid (FIGLU) and the liver concentration of S-adenosylmethionine (SAM). Because of this, it is proposed that the physiological function of nickel is related to the common metabolism shared by SAM and FIGLU. Possibly the physiological function of nickel could be related to the tissue concentration of 5-methyltetrahydrofolate (MTHF) or tetrahydrofolate (THF).

Folate deficiency inhibits pancreatic amylase secretion in rats

Previous studies have suggested that the metabolism of methyl groups is an important factor in the function of the exocrine pancreas. Ethionine, an inhibitor of cellular methylation reactions, produces hemorrhagic pancreatitis when administered to mice fed a choline-deficient diet. Glycine N-methyltransferase, an enzyme which regulates the ratio of S-adenosylmethionine to S-adenosylhomocysteine, is particularly abundant in the exocrine pancreas. Since de novo synthesis of methyl groups requires the participation of folate coenzymes, we investigated the effect of folate deficiency on pancreatic exocrine function. Rats were fed an amino acid-defined folate-deficient diet or the same diet supplemented with folate ad libitum. A third group received the folate supplemented diet pair-fed to the deficient group. After 3 and 5 wk, pancreatic amylase secretion was measured in perfused duodenal segments of anesthetized animals before and after cholecystokinin injection. Pancreatic secretion was significantly reduced in the deficient group compared with the pair-fed control group after 5 wk. These results indicate that severe folate deficiency impairs pancreatic exocrine function.

Severe Folate Deficiency Causes Secondary Depletion of Choline and Phosphocholine in Rat Liver

It has previously been shown that choline deficiency causes depletion of hepatic folate concentration in rats. Two separate experiments were undertaken to investigate the converse phenomenon: whether folate deficiency would lead to depletion of hepatic choline. In Experiment 1, severe folate deficiency was induced in rats by feeding an amino acid-defined diet containing (per kg diet) 1.4 g choline, 0 mg folate and 10 g succinylsulfathiazole. Control rats were fed the same diet containing 8 mg folate/kg. After 4 wk, plasma and hepatic folate concentrations were significantly depleted in the severely folate-deficient rats compared with controls (P < 0.001), and hepatic choline and phosphocholine concentrations were 65 and 80% lower, respectively (P < 0.001). In Experiment 2, moderate folate deficiency was induced in rats by feeding the same diet as described above, but with the succinylsulfathiazole omitted. After 24 wk, significant systemic folate deficiency was present in the moderately folate-deficient rats compared with controls (P < 0.001). A modest reduction (36%, P = 0.087) in hepatic choline concentration was observed in the moderately folate-deficient rats compared with controls. No significant differences in hepatic phosphocholine concentrations were detected between the two groups. These results indicate that severe folate deficiency causes secondary hepatic choline deficiency in rats.

Fallbeispiel einer alimentationsbedingten Anämie durch Folsäuremangel

Because of anaemia and dystrophy a girl was admitted to hospital. By bone marrow aspiration the diagnosis of a megalocytic anaemia was established. The determination of folic acid revealed a severe folate deficiency caused by education problems with consecutive malnutrition. Under folic acid replacement therapy and intensive talks with the parents the girl recovered from her illness and after change of nutrition she developed well without any further folic acid replacement.

Severe folate deficiency and pancytopenia in a nutritionally deprived infant with homocystinuria caused by cystathionine beta-synthase deficiency

Severe folate deficiency and pancytopenia in a nutritionally deprived infant with homocystinuria caused by cystathionine beta-synthase deficiency

Methotrexate effects on folate status and the deoxyuridine suppression test in rats

Methotrexate (MTX) was administered to rats to produce marked folate deficiency to develop an experimental model for studying folate coenzyme abnormalities. Male Sprague-Dawley rats were fed control and experimental, folate-deficient diets, with or without MTX (0.1 mg/100 g body wt) i.p. every other day for 2 wk. The MTX-treated rats developed severe folate deficiency signs, including diarrhea and impaired growth. Cytological features of megaloblastic anemia seen in peripheral blood in the folate-deficient group (FD)+MTX rats were RBC macroovalocytosis, anisocytosis and elevated neutrophil lobe counts, in comparison to both MTX-untreated FD and control rats. Urinary formiminoglutamic acid (FIGLU) excretion was elevated and RBC folate depressed in these FD+MTX rats. The dU suppression test in isolated lymphocyte cultures showed abnormal and higher [ 3H]thymidine uptake by DNA in both MTX-treated and untreated FD groups at 11 wk, but only in FD-MTX at 5 wk; this was associated with lower plasma folate values. Thus, these results indicate that MTX-treated rats have a more severe folate deficiency than that produced by a folate-deficient diet alone.