Effect of Giardiasis upon Vitamin A Metabolism

Átírás

1 Parasit. Hung Effect of Giardiasis upon Vitamin A Metabolism Dr. Magda EMBER László MINDSZENTY Institute for Public Health and Epidemiology, Szeged Almost without exception, publications dealing with nutritional disorders make the point that statistical data are based on severe cases of avitaminosis. According to specialists of FAO and WHO, a true picture cannot be obtained from these data, because they take no account of.the less severe forms of vitamin deficiency,of which a diagnosis can be established only by biochemical methods. In the WHO Chronicle (1965) there is a report on the geographical incidence of vitamin deficiencies (32). On the map of this report i t would seem that avitaminosis does not exist in Hungary. At best this is true only for primary avitaminosis. In most cases vitamin A deficiency is (l6),the result of a diet poor in vitamins and proteins and is called primary vitamin A deficiency. Vitamin A deficiency can also occur in secondary form for even i f the vitamin source is adequate certain individuals develop hypovitaminosis as a result of infection, fever or other disease. In these cases the hypovitaminosis is mostly subclinical. The present investigation deals with secondary vitamin A deficiency caused by giardiasis. * Paper presented at the Vllth International Congress of Nutrition, Hamburg, August

2 Only a few facts about the importance of Glardia lamblia (Lambl i a intestinalis) are summarized here. Clinical symptoms of the disease in Hungary were adequately described as early as 1937 (30), when malabsorption and anorexia were emphasized. Clinical observations suggest that the average duration of the infection is from 2 to 3 years (12). KATSAMPES et al. (8) observed a defective absorption of vitamin A in children infected with G. lamblia; X-ray examinations (19)»electronmicroscopic and biopsy studies (29, 33), carried out in various clinico-pathological states.of giardiasis, consistently prove that this protozoon adhering to the small intestine causes malabsorption, with a resultant decrease in the levels of vitamins A and D and subsequent retardation of growth. According to MAXARA (12) the incidence of giardiasis in childhood is 5 to 20 per cent;however, he stresses that this level can be as high as 50 to 80 per cent in children living in communities, and infection occurs mostly at that age when the vitamin storage is at its lowest and requirement is highest.according to MOORE (15) there is l i t t l e information on how much vitamin A a child can store. I f the pathogenicity of G. lamblia is considered a possible cause of v i tamin A malabsorption, earlier results (4, 5) are not surprising, namely that a significant difference could be observed in the vitamin A status of infected and uninfected children who had been living in state homes for many years an-d who had been fed on the same diet. The authors gave evidence that this difference was due to G. lamblia infestation. With the present investigation the authors wished to establish whether vitamin A deficiency occurs in healthy cyst carriers" and whether i t is a secondary result of giardiasis. Materials and Methods The existence of giardiasis in two state homes - one in Szeged and one in Szegvár (Southern Hungary) - was determined by the direct smear technique, using iodine stain; at the same time

3 the vitamin A status and the value of serum carotene were determined from venous fasting blood. All measurements were taken at the same relative time on the days before and after completion of treatments and dietary supplementations. Determination of the vitamin was carried Out "by the TEA-colour reaction (5, 17). The beta-carotene content of carrots used for supplementation of diet was determined by KRAMER'S method (9). The physicians of these state homes had not observed any clinical symptoms in the children,hence they had not considered the possibility of giardiasis before our investigations. Taking uninfected children as comparative controls, living in state homes we tried, in different ways, to influence the vitamin A status of the infected children: a. / with vitamin A administration, b. / with raw carrot administration, c. / with administration of antiparasitic drugs, and d. / with the combination of drug and vitamin administration. In addition, we had the opportunity to carry out investigations for 6 weeks on 10 infected children, as against four, who were used as controls,and again on 10 infected subjects for 3 years. The main purpose of our observations was to establish a relationship between vitamin A status and reinfestation after treatments. Results a./ Ten infected children receiver 150,000 I.U. vitamin A* daily on two consecutive days without therapy (E i g. 1). On the fourth day of experiment following treatment the vitamin A level was s t i l l high in comparison with that of the control but later had fallen again to the starting level.in agreement with * Egyesült Gyógyszer- és Tápszergyár (Budapest), 50,000 I.IT. axerophth. per capsules.

4 500 SVA IU/400ml << 11 il SS r - «O k N m «H M 5 o fi T Days-Napok CZI Infected Children - Fertőzött gyermekek 3 Uninfected Children - Nem fertőzött gyermekek ESS Uninfected Adults - Nem fertőzött felnőttek Fig. l - l. ábra Effect of Oral Administration of Vitamin A upon the Vitamin A Status of Children. The serum vitamin A (SVA) concentration is higher in infected children than in healthy children on the day following administration (absorption time is deficient). After a further 2 days the SVA of infected children falls to its former level. Per os adagolt A vitamin hatása az SVA-ra. Az adagolást követő napon a fertőzöttek SVA szintje magasabb,mint az azonosan supp- Jementált egészséges egyéneké. (Az absorptio kóros.) Két ujabb nap elteltével a cystahordozók SVA-ja a kiindulási értékre esett vissza.

5 the results of KATSAMPES s et al. (8) vitamin A tests, we found that absorption efficiency was impaired in patients infected with G.L. However with a healthy control child, whose hypovitaminosis was not due to giardiasis, the vitamin level remained normal after supplementation. Thus, supplementation by ixself does not bring about improvement of the vitamin A status, a finding characteristic of secondary hypovitaminosis (16). b. / In the early spring months children living in state homes could obtain only carrots as a natural source of carotene. A group of ten infected patients was given, besides their daily food, 6 mg of beta-carotene in the form of grated carrots over a four day period. However, this caused no significant change in the vitamin A status (median: from 4-2,8 IU/lOO ml to 51,0 IU/100 ml); on the other hand there was a significant increase in the level of serum carotene (median:'from 63,0 /ig/loo ml to 152,0 g/loo ml); indicating that giardiasis disturbs the conversion of beta-carotene to vitamin A. c. / Of 29 infected children 21 were treated with atabrine 8 with imidazole derivatives. Recovery from the parasitic infection was checked by repeated examinations of the stools. Without any dietary change successful treatment with both drugs resulted in a significant increase in the vitamin A status (median: from 52,5 IU/100 ml to 90,0 IU/lOO ml) (P i g. 2). In four cases in which treatment was not effective, the vitamin A status re mained unchanged. As a result of successful therapy, the level of serum carotene f e l l in relation to the rise in vitamin A (P i g. 3). Dotted lines in the'figure refer to the volunteer who received the same therapy as infected subjects. Future investigations w i l l seek to determine whether the results are caused by the change in the ratio of the active-inactive pigments (14). GUGGENHEIM (15) reported that when rats were given prolonged treatment with atabrine, an anti-malarial drug, hepatic storage of vitamin A was adversely affected. d. / Ten children received a combined cure, namely, after treat-

6 SVA Vt X)ml ABCDEFGH I No cysts present in stool - Cysták a székletben nincsenek VWk Cysts present in stool - Cysták a székletben Pig ábra Changes in Yitamin A Status Children Cured by Antiparasitic Drugs (atabrine or imidazole derivatives). A-Z represent successfully treated patients, a-d patients s t i l l carrying cysts. Az SVA változása gyógykezelés (atebrin, i l l. imidazol származék) hatására. A-Z jelölteknél nem lehetett cystát kimutatni a kezelés után,mig a-d kezeiteknél a cystahordozás még fennmaradt.

7 SC BgttÛrri S\A IMOOml Daus-Napok I, 1, 1, 1, I, î, I, *, ^ Pre- Post- Pre- Posttherapy -Infected. Children - Fertőzött gyermekek ÙC -Ù, Healthy Patient - Egészséges egyén Pig ábra Inverse Changes in the Levels of Serum Carotene (SC) and of Vitamin Á (SVA) in Children after Effective Treatment with Atabrine.The broken line represents a human volunteer treated with atabrine whose SVA did not alter. His diet contained neither vitamin A nor carotene during treatment. Az SC és az SVA ellentétes változása eredményes atebrin kura hatására. A kura nem befolyásolta az SVA értéket önként jelentkezett egészséges egyénnél, akinek étrendje a kura alatt nem tartalmazott sem A vitamint, sem karotint.

8 ment with atabrine on the sixth and seventh day of the experiment they were given' daily 150,000 IU vitamin A. We observed that the increase in their vitamin A status (median:from 61,0 IU/100 ml to 93,0 IU/100 ml) was similar to that of those children who were treated only with drugs. This suggests that recovery from giardiasis brought about an improvement in absorption time. The results of observations made over longer periods are summarized in F i g. 4 and F i g. 5 The patients in these cases were treated by atabrine. The serum vitamin A (SVA) levels of the subjects listed in F i g. 4 increased after treatment and remained constant throughout the observation. With two patients Sz. L. (1955) and K. J. (1957) reinfestation occurred, and depressed the higher level of SVA reached earlier. The SVA levels of the controls did not change during the period of observation. The SVA levels of the patients shown in F i g. 5 also altered considerably during the period of several years of observation. The results obtained with two patients (K. B. /1957 arid G. J. /1956/) are especially noteworthy; these subjects were not infected at the beginning of our investigations, however, i t can readily be seen that their SVA levels decreased following in festation; after succesful treatment, normal vitamin A metabolism was re-established. Discussion The authors verified and analysed the secondary vitamin A deficiency caused by giardiasis. I t is important not only because of its special symptomatology, but also because i t decreases the host's T-esistance, thus rendering him susceptible to other

9 SVA IU/100ml JPH m^ji - D u «956) 150] P] m «..n n n n «953) 130] BL»I_JLJ3 D 0 ( n n m M-.^n 11 n n «957? m Ks ml i._ T n n n (1955) l n n 15ö 8 : 1 îola^j] U M (4955) 150] BM slm^p 0 Q (1950 «I n n K B 50ÍJLJJ LT D Ll «957) 150] n SzL BJ IMJJ I m (1955) sol l^n n n mm] 130] SzL " 30LD Q_Q imn m B F SA 50LO 0 H (1957) 150] BS 150] OL lî a. _ =^ I I û- q û i, c: û ST * 9 If 50-LD Fl «957) Days-Napok March April May Hónapok Pig ábra Treatment - Kezelés No cysts present in stool - Cysták a székletben nincsenek Cysts present in stool - Cysták a székletben Changes Observed in the SYA Level During 6 Weeks after Treatment with Atabrine. Control children received no treatment. (The f i gures in brackets indicate, the year of birth of the children.) Az SYA változása gyógykezelés hatására. A kura utáni változás 6 héten keresztül megfigyelve. Kontrolnak választott egészséges gyermekek nem részesültek kezelésben. (Feltüntettük a születési évszámot.)

10 -^v Treatment - Kezelés (Q SYA during infestation - SYA a fertőzöttség alatt UBS SYA without infestation - SYA a fertőzöttség után Fig ábra Changes Observed between the Years in the SYA Level of Patients Infested by G. lamblia. The treatment with the antiparasitic - d"rug~~tas"bed for 5 days. Az SVA változásának megfigyelése állami gyermekotthonban G. lamblia infestatioban, között. A kezelés esetenként - 5" napos kúrát jelent antiparazitás gyógyszerrel.

11 diseases. Since it occurs mainly among preschool children, causing an inflammation in the upper region of the small intestine that may last from 2 to 3 years, it is a significant condition in this age group. With these facts in mind we attempted to remedy the impairment of vitamin A metabolism caused by giardiasis. More detailed and elaborate experiments are needed to elucidate the mechanism (probably enzymic) by which infestation disturbs vitamin A metabolism. One reason why our work cannot be compared with cli nical findings is that the children involved in our study were considered healthy by their physician. The change in vitamin A status cannot be attributed to an adequate hospitalisation diet as has been claimed by PALUMBO et al.(20) for we made no alte rations whatsoever in the usual everyday diet of the state homes. Fortunately a number of well-known scientists (l, 6, 7, 18, 21, 28, 31) have carried out extremely valuable work on the-meta,- bolism of vitamin A, and most of the metabolic steps are known. ROELS (22) expresses surprise that although an adult person's yearly vitamin A requirement costs no more than 5 US cents, the fight against vitamin A deficiency presents such a great problem all over the world. With people suffering from giardiasis an even greater amount would not suffice to bring the low vitamin A status back to normal, even with large doses of vitamin A supplement. Since MAKARA (12) estimates that there are approximately 300 million people in the world who are suffering from giardiasis this should be considered a universal problem. Of the 300 million infected persons 1 million live in Hungary. Most of them are under 6 years of age.as our investigations have shown, in our country these people receive vitamin A in vain, for whether it is in its natural form,or given therapeutically they cannot utilize i t. According to ROELS's calculations (22), to supply 1 million person with vitamin A costs dollars per year. Each year this sum would be spent to not effect as far as the vitamin supply of the population is concerned.

12 Vitamin A deficiency, as we have learned (2, 10, 11, 13, 23, 24), is a world problem. In cases of secondary vitamin A deficiency, considerable progress could be made by screening and by removal of infected individuals from communities.both pediatricians and nutritionists should be in no doubt about the importance of giardiasis, which has an even greater importance in children's homes.. Acknowledgement The authors thank Prof.O.WISS, of Hoffman-La Roche and Company, Basle, for generous gifts of vitamin A preparations and betacarotene. We are grateful to Mrs. L i l i L. HUNYADY, Mrs. Melinda H. PÁLMAI, Mrs. Edit K. SZILÁGYI and Mr. G.PETHEŐ for technical assistance, to Mr. L. BERÉNYI for preparing the figures. We are especially indebted to Dr. G. MAKARA for his valuable help, friendly advice, constructive criticism, and continuous encouragement. Summary In two state homes for children the vitamin A level of G. lamblla-infested,symptom-less children was lower than that of those free from infestation. Vitamin A supplementation given to ten children receiving no curative treatment caused only temporary improvement in their vitamin A status ; beta-carotene administration to another group of 10 children, though increasing the level of serum carotene (from 63,0/g to 152,0 /*g), did not alter the vitamin status. Successful treatment with antiparasitic drugs raised the vitamin A status of 25 children from a serum value of 52,5 IU/100 ml to 90,0 IU/100 ml expressed in medians. The vitamin A status of 10 cured children who received vitamin supplementation as well did not reach a higher value than that of patients who had received drugs ai one.

13 Observations made over a longer period suggest that there is a direct relationship between the serum vitamin A level and giardiasis. The results provide evidence for the pathogenicity of G.lamblia and give an insight into the patho-mechanism of vitamin A malabsorption. EMBER, M. MINDSZENTY, L.: Giardiasis hatása az A vitamin anyagcserére Két állami nevelőotthonban tünetmentes Giardia cystahordozók serum A vitamin értéke alacsonyabb volt,mint a közösségben élő egészséges gyerekeké. 10 fertőzött gyerek napi H.JL A vitamint kapott A vitamin kapcsula" formájában, két egymást követő napon. A-serum A vitamin szint csak átmeneti emelkedést mutatott. Nem okozott változást a serum A vitamin értékben az a napi 6 mg beta-karotin sem, amelyet 10 másik fertőzött gyerek kapott 4 egymást követő napon keresztül. Significans emelkedést mértünk ezzel szemben a serum karotin értékében (63,0 mikrogramról 152,0 mikrogramra, medianban kifejezve). A parazitaellenes gyógykezelés hatására 25 gyermek serum A vitamin szintje megemelkedett 52,5 N.E./lOO ml-ről 90, N.E./lOO ml értékre (mediánban kifejezve). Nem emelkedett magasabbra annak a 10 gyermeknek a serum A vitamin szintje sem, akik a parasita elleni therapián kivül,a vitamint is kaptak. Hosszú időn át tartó megfigyelésünk (6 hét,ill.3 év) is azt bizonyitja,hogy a reinfestatio magával hozza a serum A vitamin szint újbóli csökkenését. Vizsgálatainkkal a G. lamblia pathogenitását kivántuk bizonyítani, de betekintést nyertünk az A vitamin anyagcserébe is. R e f e r e n c e s 1./ AMES, S.R.: Fat Soluble Vitamins. Ann. Rev. Biochem. 27: (1958).

14 2. / ARROYAVE, G., WILSON, D., MENDEZ, J., BÉHAR, M. and SCRIM- SAW, N.S.: Serum and liver vitamin A and lipids in protein malnutrition. Amer. J. Clin. Nutrit. 9: (1961). 3. / AWDEH, Z.L.: The separation of vitamin A from carotenoids in micro samples of serum. Ann. Biochem. 10: 156 (1965). 4. / EMBER, M. and MINDSZENTI, L. :. Effect of giardiasis upon hlood levels of vitamin A. Proc. 1st. Int. Congr. Parasit. Roma 1964, p (Pergamon, Oxford 1966.) 5. / EMBER, M., JÍN0SSY, G. és MINDSZENTY, L.: Összefüggések a giardiasis és a vér A vitamin szintje között. Budapesti Vitamin Napok. Budapest / GANGULY, J. and KRINSKY, N.J.: Yitamin A-alcohol in plasma and liver. Biochem. J. 54: (1953). 7. / GLOOR, U.andWISS, 0.: Fat-soluble vitamins. Ann.Rev. Biochem. 33: (1964). 8. / KATSAMPES, O.P., McCOORD, A.B. and PHILLIPS, W.A.: Yitamin A absorption test in cases of giardiasis. Amer. dis. Child. 6J_: (1944). 9. / KRAMER, M. and SZŐKE, S.: Personal communication (1964). 10. / LASTER, L. and INGELFINGER, F.J.: Intestinal absorption. New Engl. J. Med. 264: , , (1961). 11. / LEITNER, Z.A.: Yitamin A. Proc. of the Nutrition on Society Conference on Yitamin A (1950). Cit.: Brit. J. Nutr. 5,: (1951). 12. / MAKARA, G.G.: Epidemiology and control of protozoon infections other than amoebi-asis. WHO Training Course on Enteric Infections. Budapest / McLAREN, D.S.: World hunger some misconceptions. Lancet, (1963). 14. / McLAREN, D.S.: Present knowledge of the role of vitamin A in health and disease. Trans. Roy. Soc. Trop. Med. Hyg., 60: (1966). 15. / MOORE, T.: Vitamin A. Elsevier, Amsterdam / MOORE, T.: Pathology of vitamin A deficiency. Vitam. Horm. N.Y. 18: 499-^14 (I960).

15 17. / NEELD, J.B. and PEARSON, W.N.: New méthode of serum vitamin A analysis. J. Nutr. 79: (1963). 18. / OLSON, J.A.: The absorption of beta-carotene and its conversion into vitamin A. Amer. J. clin. Nutr. 9_: (1961). 19. / PETERSON, G.M.: Intestinal changes in Giardia lamblia Infestation. Amer. J. Roentgenol. 77: (1957). 20. / PALUMBO, P.J., SCUDAMORE, H.H. and THOMPSON, J.H.: Relationship of infestation with Giardia lamblia to intestinal malabsorption syndromes. Proc. Mayo Clin. 37: (1952). 21. / PITT, G.A.J, and MORTON, R.A.: Pat-soluble vitamins. Ann. Rev. Biochem. 31: (1962). 22. / ROELS, O.A.: Present knowledge of vitamin A. Nutr. Rev. 24: (1966). 23. / SAI, P.T.: The challenge of African nutrition.israel, med. Sei. '1: (1965). 24. / SCRIMSHAW, N.S.: Malnutrition in children. J. Amer. diet. Ass. 42: (1963). 25. / SOBEL, A.E.: Pat-soluble vitamins. Vitam. Horm. N.Y. 10: (1952). 26. / TAKANO, J. and YARUIEY, J.H.: Giardiasis. Bull. John's Hpk. Hosp. 116: (1965). 27. / VÉGHELYI, P. és MAKARA, G.: A gyermekkori giardiasis. Gyógyászat, 77: (1937). 28. / WALE, G.: Receptor mechanism in human vision. Proc. 13th Int. Physiol. Congr. Tokyo (pp Excerpta Med. Pound. Amsterdam 1965.) 29. / WHO Chronicle: 19: 468 (1965). 30. / YARDLEY, J.H., TAKANO, J. and HENDRIK, T.R.: Giardiasis. Bull. John's Hpk. Hosp. 115: (1964). Received: Magda EMBER M.D., L. MINDSZENTY Institute for Public Health Chemist and Epidemiology, Szeged, Tolbuchin sugárút 71.