Helicobacter PyloriInfection–Related Pancytopenia in a Young Boy
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Deficiency of vitamin B12 (VitB12), also known as cobalamin, and Helicobacter pylori infection are commonly seen in our region. Inadequate dietary intake of VitB12, lack of intrinsic factor (IF) se...Keywords:
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Helicobacter
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Ethylenediaminetetraacetic acid
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Although pancreatic enzymes clearly degrade R binder, a nonintrinsic factor binder, the full scope of the pancreatic role in cobalamin absorption remains the subject of debate. Therefore the direct effect of pure human pancreatic juice (PPJ) on ileal cobalamin absorption in the absence of intrinsic factor was studied. PPJ significantly enhanced cobalamin uptake in guinea pig ileal loop perfused in vivo. It did not do so in the jejunum. This PPJ activity in the ileum was further stimulated by enteropeptidase and inhibited by aprotinin. The intestinal mucosa remained intact during our study by morphologic and inulin clearance criteria and behaved normally with respect to intrinsic factor and nonintrinsic factor binders. Since no intrinsic factor was present in the perfusate, PPJ must directly enhance cobalamin uptake by the ileum, perhaps promoting cobalamin attachment to receptor sites for subsequent transport by intrinsic factor. PPJ thus seems to affect cobalamin absorption at several levels. Previous studies have established its interaction with luminal R binders and with bile. The findings now indicate that pancreatic juice may have an additional, more direct role in promoting cobalamin absorption in the ileum.
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The sections in this article are: 1 Types of Cobalamin 2 Dietary Sources and Requirements 3 Biological Reactions and Deficiency Manifestations 4 Cobalamin-Binding Proteins 4.1 Definition 4.2 Specifity of Structure and Binding 4.3 Site of Production, Synthesis, and Secretion 4.3.1 Intrinsic Factor 4.3.2 R Protein 4.3.3 Transcobalamin II 4.4 Structure, Function, and Congenital Abnormalities 5 Intestinal Absorption of Cobalamin 5.1 Gastric Phase 5.2 Intestinal Luminal Phase 5.3 Mucosal Phase 5.4 Studies on Ileal Receptor 5.5 Passive Absorption and Absorption in Neonatal Period 5.6 Uptake and Fate of Intrinsic Factor 5.7 Measurement of Cobalamin Absorption and Body Stores 5.7.1 Absorption 5.7.2 Body Stores 6 Disorders of Cobalamin Absorption
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To investigate the fate of intrinsic factor and cobalamin during cobalamin absorption, we incubated enterocytes isolated from guinea pig ileum for periods of up to 30 min with 57Co-labeled cyano-cobalamin bound either to human intrinsic factor or to rabbit intrinsic factor biosynthetically labeled with [35S]methionine. When the labeled complex was incubated for 30 min with isolated ileal cells under conditions that block cellular metabolism, virtually all cellular radioactivity could be removed by washing the cell surface with EDTA or acid. In contrast, washing removed only half the radioactivity from cells incubated at 37°C in O2. When residual cellular radioactivity was extracted and analyzed by gel filtration, 80-94% of both the 35S and 57Co radioactivity eluted in the same fractions as the original complex. The remaining 6-20% eluted as free [57Co]cobalamin or [35S]methionine. To examine events occurring after 30 min, we instilled into tied-off ileal loops of intact guinea pigs radiolabeled intrinsic factor-cobalamin complex and extracted nondissociable radioactivity 2-4.5 h later. The proportion of extracted 57Co eluting as free cobalamin increased to 39-46%, that eluting as intrinsic factor-cobalamin complex declined to 22-45%, and 9-34% now eluted as a macromolecule that reacted with antitranscobalamin II antibody but not antiintrinsic factor antibody. Extracted 35S radioactivity eluted in several peaks in addition to the intrinsic factor peak. These findings suggest that (a) after reversible attachment of intrinsic factor-cobalamin complex to its ileal surface receptor, an energy-dependent process prevents removal of the complex from the cell surface by EDTA or acid; (b) cobalamin dissociates from intrinsic factor and, as suggested by previous workers, binds to a molecule antigenically similar to transcobalamin II; and (c) intrinsic factor is slowly degraded and forms breakdown products that are detectable in ileal extracts.
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An 18-year-old French Canadian student presenting with a severe normocytic anemia, had undetectable serum cobalamin but normal gastric acidity and no evidence of generalized malabsorption. The gastric juice contained a normal quantity of intrinsic factor. Serum anti-intrinsic factor blocking antibodies were not present. Absorption of radiolabelled cobalamin given orally in the Schilling test was decreased but this was corrected by using hog intrinsic factor. Patient gastric juice bound cobalamin normally but did not promote uptake of this vitamin by homogenates of guinea pig intestinal mucosa. A family study showed normal cobalamin absorption for all tested subjects, as well as two α-hemoglobin gene deletions in the father and a single α-gene deletion in the patient. The cobalamin malabsorption is likely due to a defect of the patient's intrinsic factor at the ilea! receptor sire.
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A ligand assay specific for cobalamin that uses mouse stomach as the source of intrinsic factor has been developed. When mouse stomach extract incubated with radiocobalamin is fractionated by gel chromatography, the radioactive complex elutes as a single peak with apparent molecular weight of 54,900. Formation of the complex is greater than 98% inhibited by human anti-intrinsic factor antibody. When the equivalent of 10,000 pg/ml of cobinamide is added to serum, the apparent cobalamin concentration detected averages 8.5 pg/ml. Correlation with the Lactobacillus leichmannii microbiologic assay results in the regression equation y = 0.97x + 20. In six patients who had megaloblastic anemia the serum cobalamin by the mouse intrinsic factor ligand assay ranged from 0 to 9 pg/ml. Because the primary source of intrinsic factor is free of R proteins, there is no need for extensive purification of the extract. The assay is sensitive, precise, and accurate, and no more difficult to perform than other conventional ligand assay procedures.
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The effects of canine gastric and pancreatic intrinsic factors on uptake and subcellular localization of cobalamin have been investigated in vivo to determine whether these proteins could mediate the physiological absorption of cobalamin in the dog. Cyano [57Co]cobalamin was introduced into ileal loops in dogs under general anesthesia, either free (control) or bound to gastric or pancreatic intrinsic factor. At 2 h, total uptake of cobalamin by ileal mucosa was significantly enhanced after prior binding to either gastric or pancreatic intrinsic factor compared with controls. Displacement of receptor-bound cobalamin with EDTA showed that enhanced total uptake reflected increased internalization of cobalamin by both proteins. Findings after reorienting sucrose density gradient centrifugation of ileal mucosa from loops containing intrinsic factor-cobalamin complexes were consistent with a major lysosomal and perhaps endosomal localization of internalized cobalamin, in agreement with results after oral administration of cobalamin. In marked contrast, cobalamin was recovered predominantly in the soluble fractions and was not associated with particulate subcellular organelles in ileal mucosa from control loops. These findings suggest that both gastric and pancreatic intrinsic factors can promote the physiological absorption of cobalamin by receptor-mediated endocytosis in the dog.
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Ligand binding activity of intrinsic factor-cobalamin receptor (IFCR) was determined in homogenates and isolated brush-border membranes (BBM) of ileum and kidney from dogs exhibiting simple autosomal recessive inheritance of selective cobalamin malabsorption (Fyfe, J. C., Giger, U., Hall, C. A., Jezyk, P. F., Klumpp, S. A., Levine, J. S., and Patterson, D. F. (1991) Pediatr. Res. 29, 24-31). IFCR activity of affected dog ileal homogenates was 3-4-fold higher than normal whereas IFCR activity in affected dog kidney homogenates was one-tenth of normal. The recovery of IFCR activity in the BBM of ileum and renal cortex of affected dogs was 30- and 20-fold less than normal, respectively. The dissociation constant (Kd) for intrinsic factor-cobalamin was similar in BBM of both tissues and was the same in affected and normal dogs. In the affected dog ileal BBM, activities of alkaline phosphatase and sucrase-isomaltase and vesicular transport of glucose and Na(+)-taurocholate were normal. Immunoblots showed no IFCR cross-reactive material in the ileal or renal BBM of affected dogs. IFCR purified by affinity chromatography from kidney of both normal and affected dogs had an Mr = 230,000. However, amino acid analysis revealed that the affected dog IFCR had more lysine than the normal, and protease cleavage of the purified IFCRs revealed different peptide maps. Asparagine-linked oligosaccharides of both proteins were sensitive to peptide N-glycosidase F cleavage, but only the affected dog IFCR was endoglycosidase H sensitive. These results suggest that cobalamin malabsorption in this canine family is caused by inefficient BBM expression of IFCR due to a mutation of IFCR and its retention in an early biosynthetic compartment.
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The purpose of these studies was to determine whether gastric intrinsic factor and the ileal intrinsic factor receptor participate in the process of cobalamin absorption in the dog. Physicochemical analysis of gastrointestinal fluids and mucosal extracts obtained 3-5 h after cyano[57Co]-cobalamin was fed to dogs demonstrated that 1) all cyano-[57Co]cobalamin became bound to proteins during intraluminal transport; and 2) mucosal cyano[57Co]cobalamin in the extract of the ileal mucosa was bound to intrinsic factor, to intrinsic factor coupled to receptor protein, and to proteins with properties similar to R protein and transcobalamin II. A significant fraction of the cyano[57Co]cobalamin in the mucosal extract was membrane bound and, upon solubilization with Triton X-100, was found to contain immunoreactive intrinsic factor that, however, could no longer couple to the isolated receptor. The formation of the complex of cobalamin with intrinsic factor and the receptor protein and the selective accumulation of cobalamin in the ileum indicate that the intrinsic factor-mediated mechanism for absorption of this vitamin is active in the dog.
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