Case Study 2 The Dangers of Special Nutrients

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A 33-year-old white woman experienced severe fatigue and malaise for 2 weeks that intensified over the previous 3 days. She came to an emergency department complaining of the above symptoms plus fever, nausea, and abdominal pain. Because of a history of depression she had received paroxetine and fluphenazine for many months but she discontinued these drugs 2 weeks earlier. At the time of this admission she was off all medications except an over-the-counter "natural product" for weight loss. Although she weighed only 90 lbs and was 5 ft 3 in. tall, she was trying to lose weight and had succeeded to the extent of a 10-lb. loss over the past 2 weeks. Later on she was diagnosed with an eating disorder and psychiatric counseling was begun.

At this time her blood pressure was low at 94/62, heart rate was elevated, and temperature slightly low. Sclera were icteric. Clinical findings plus laboratory data revealed a host of abnormalities including anemia, hemolysis, hepatic dysfunction, renal failure, and thrombocytopenia. Relevant laboratory data are

Hemoglobin

6 g/dL

Platelets

15,000/mm3

AST

1274 U/L

ALT

992 U/L

Bilirubin

3.7 mg/dL

LDH

7879 U/L

BUN

152 mg/dL

Creatinine

5.3 mg/dL

Urine output

150 mL/day

Because of the hemolysis and low hemoglobin, preliminary diagnoses of thrombotic thrombocytopenic purpura or hemolytic uremic syndrome were made, but the patient had no fever nor mental status changes and other findings were not consistent with these diagnoses. During the first 3 days of hospitalization the patient's hepatic function improved. Her renal function, however, remained poor. She had proteinuria, glycosuria, and red and white cells in the urine. She was, therefore, dialyzed repeatedly. Her urine output began to increase by the 11th day after admission.

Her illness was eventually traced to a metal in her over-the-counter diet aid.

What is a possible identity of this metal?

a) Lead b) Mercury c) Chromium d) Sodium

Sodium in the metallic form is too reactive to be present. As a cation it is very nontoxic and is, of course, widespread in commercial products. Lead and mercury are well-known to be very toxic and their inclusion in medicinal products is rare and, on those occasions when they are present, it is in very low amounts. One cannot, of course, absolutely rule out the accidental inclusion of lead or mercury in a specific batch or bottle of a medicinal. Chromium is an essential element. It is also a popular nutritional supplement particularly in the form of chromium picolinate. In this form it is represented as contributing to effective weight loss, lower blood sugar, and improved cholesterol profile. The recommended daily allowance is 50 to 200 |g. This lady was using 1200 to 2400 |g per day of chromium picolinate for at least the previous 4 months. Normal chromium plasma concentrations equal 0.1 to 2.1 |g/mL (Chromium VI) and her plasma concentration was 4.6 |g/mL 24 hours after admission. Her high level of chromium consumption is believed to be the cause of her many symptoms at admission.

This patient was finally discharged after 26 days of hospitalization with a final diagnosis of liver and renal disease due to chromium toxicity. One year after discharge her liver and kidney function were normal on the basis of serum biochemistry testing.

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