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Enhanced nickel sensitivity in iron deficiency anemia

Authors:
BSaravana Karthikeyan
BSaravana Karthikeyan
BSaravana Karthikeyan
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Divya Vinayachandran at SRM Institute of Science and Technology
Divya Vinayachandran
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Abstract

As dentists, there is a high possibility for us to come across cases with undiagnosed iron deficiency anemia. We must be alert never to overlook the various oral manifestations and should consider the possibility of nickel sensitivity when presented with a case of iron deficiency anemia concurrent with chronic urticaria.
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© 2017 Indian Journal of Public Health | Published by Wolters Kluwer - Medknow 215
Letter to Editor
Sir,
We are writing with reference to your review article in
the January–March 2017 issue on “directly observed iron
supplementation for control of iron deciency anaemia.”[1]
The article is well written and the suggestion of directly
observed iron supplementation may denitely prove fruitful.
We, as oral diagnosticians, come across several cases with
undiagnosed iron deciency anemia. We would like to share
our experience with a patient with iron deciency anemia
who also had a unique manifestation. Iron deciency anemia
continues to be the most common nutritional disorder in the
world. In India, it is considered as a severe public health
problem with a prevalence of ≥40%.[2] The oral diagnostician
encounters cases often reporting with the complaint of burning
sensation of the oral mucosa. This is attributed to the iron
deciency which affects the normal functioning and turnover
of the epithelial cells causing atrophy of the oral mucosa.[3] We
encountered a case of iron deciency anemia with an infrequent
history of chronic urticaria. She had a long-standing history of
constantly being on and responding well to antihistamines. The
frequency and severity of urticaria coincided with consumption
of green leafy vegetables, chocolates, and nuts, which she
restricted herself from. Previous patch testing revealed no
positive results. Proper iron therapy eventually improved
her hemoglobin prole and eventually reduced the episodes
of urticaria. Interestingly, the foods which precipitated the
episodes of urticaria are rich in nickel.[4] Nickel sensitivity is
a possibility to be considered in patients with iron deciency
anemia presenting with chronic urticaria.[5] The human
body retains approximately 3%–6% of the total amount of
dietary nickel absorbed. This is enhanced in iron deciency
anemia. The divalent metal transporter protein presents on the
surface of the intestinal enterocytes, absorbs, and transports
dietary iron, in the unavailability of which, it binds to other
divalent cations. This is of signicance in patients with nickel
allergy, developing iron deciency anemia. Adequate iron
supplementation eventually limits the absorption of nickel,
which along with a low nickel diet is recommended for patients
with iron deciency anemia and nickel sensitivity.
Therefore as dentists, there is a high possibility for us to come
across cases with undiagnosed iron deciency anemia. We
must be alert never to overlook the various oral manifestations
and should consider the possibility of nickel sensitivity when
presented with a case of iron deciency anemia concurrent
with chronic urticaria.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
V. C. Divya1, B. Saravana Karthikeyan2
1Senior Lecturer, Department of Oral Medicine and Radiology,
SRM Kattankulathur Dental College and Hospitals, SRM University,
Kancheepuram, 2Reader, Department of Conservative Dentistry and
Endodontics, SRM Ramapuram Dental College and Hospitals, SRM University,
Chennai, Tamil Nadu, India
Address for correspondence: Dr. V. C. Divya,
Department of Oral Medicine and Radiology, SRM Kattankulathur
Dental College and Hospitals, SRM University, Kattankulathur,
Kancheepuram, Tamil Nadu, India.
E‑mail: drdivyavc@gmail.com
RefeRences
1. Bairwa M, Ahamed F, Sinha S, Yadav K, Kant S, Pandav CS. Directly
observed iron supplementation for control of iron deciency anemia.
Indian J Public Health 2017;61:37-42.
2. World Health Organization. Worldwide Prevalence of Anemia 1993-
2005. WHO Global Database on Anemia. Available from: http://
www.who.int/nutrition/publications/micronutrients/anaemia_iron_
deciency/9789241596657/en/. [Last accessed on 2017 Aug 01].
3. Wu YC, Wang YP, Chang JY, Cheng SJ, Chen HM, Sun A. Oral
manifestations and blood prole in patients with iron deciency anemia.
J Formos Med Assoc 2014;113:83-7.
4. Pizzutelli S. Systemic nickel hypersensitivity and diet: Myth or reality?
Eur Ann Allergy Clin Immunol 2011;43:5-18.
5. Sharma AD. Benet of iron therapy in the management of chronic
Urticaria due to nickel sensitivity. Indian J Dermatol 2010;55:407-8.
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How to cite this article: Divya VC, Karthikeyan BS. Enhanced nickel
sensitivity in iron deciency anemia. Indian J Public Health 2017;61:215.
© 2017 Indian Journal of Public Health | Published by Wolters Kluwer - Medknow
Enhanced Nickel Sensitivity in Iron Deficiency Anemia
[Downloaded free from http://www.ijph.in on Monday, September 18, 2017, IP: 182.72.180.102]
... Sir, We appreciate that the reader's letter [1] has taken great interest in this topic of paramount public health concern in developing countries. It is evident that there are multiple reasons behind iron deficiency anemia in population. ...
... [3] "How the role of nickel sensitivity should also be considered in such scenario?," authors of letter [1] should provide an explicit explanation for consideration of readers. A study by Antico and Soana reports that this is nickel associated urticaria [4] which responds to iron therapy/supplementation. [2] Available literature is inconclusive to establish the relationship between oral intake of nickel rich foods and nickel allergy syndrome. ...
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... As described in a case report by Divya et al. a patient's symptoms of urticaria were correlated with the consumption of green leafy vegetables, chocolates and nuts (i.e., foods rich in Ni). After proper Fe therapy, urticaria reduced and hemoglobin concentrations improved in the patient [72]. ...
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Iron (Fe) is fundamental to life on earth. In the human body, it is both essential and harmful if above threshold. A similar balance applies to other elements: calcium (Ca), magnesium (Mg), and trace elements including copper (Cu), zinc (Zn), lead (Pb), cadmium (Cd), mercury (Hg), and nickel (Ni). These elements share some proteins involved in the absorption and transport of Fe. Cu and Cd can inhibit Fe absorption, while excess of Fe may antagonize Cu metabolism and reduce ceruloplasmin (Cp). Excessive Fe can hinder Zn absorption and transferrin (Trf) can bind to both Zn and Ni. Ca is able to inhibit the divalent metal transporter 1 (DMT1) in a dose-dependent manner to reduce Fe absorption and low Mg concentrations can exacerbate Fe deficiency. Pb competitively inhibits Fe distribution and elevated Cd absorption reduces Fe uptake. Exposure to Hg is associated with higher ferritin concentrations and Ni alters intracellular Fe metabolism. Fe removal by phlebotomy in hemochromatosis patients has shown to increase the levels of Cd and Pb and alter the concentrations of trace elements in some types of anemia. Yet, the effects of chronic exposure of most trace elements remain poorly understood.
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... In rats, nickel toxicity may consequences in decreases of all kinds of blood cells by hampering the activity of the bone marrow . Nickel deficiency has not been made known to be a concern in humans, despite this; it may cause biochemical changes, such as reduced Fe resorption that directs to anemia (Divya and Karthikeyan, 2017). Immunotoxicity: Nickel can be responsible for noticeable immune and allergic reactions (Dearman and Kimber, 1992;Kimber and Dearma, 1994;Guimaraens et al., 1994;Das et al., 2008). ...
NICKEL ESSENTIALITY, TOXICITY AND THE MECHANISM OF TOXICITY IN ANIMAL
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Nickel is one of the prevalent heavy metal pollutants. The sources of this pollutant are both natural as well as anthropogenic. The ongoing increase of the modern technology is gradually increasing the demand for nickel-containing product. The use of nickel in modern technology is gradually increasing that result in hastened consumption of nickel-containing product. Nickel compounds contaminate our environment during its manufacturing as well as its usage. Their rapid accumulation in different locations of the earth is hazardous. Human society is ultimate facing various adverse effects of nickel toxicity along with all other creatures on the earth. Though, as a micronutrient nickel is important for normal functioning of the animal system but at the elevated concentrations it causes various adverse effects. Through this review article efforts are being made for an analysis of the existing situation related to essentiality, effect and mechanism of nickel toxicity on animals. The investigation at the current scenario is extremely crucial for the realization of the extent of the crisis linked to nickel as an environmental toxicant to accelerate awareness and search for remedy.
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... In rats, nickel toxicity may consequences in decreases of all kinds of blood cells by hampering the activity of the bone marrow . Nickel deficiency has not been made known to be a concern in humans, despite this; it may cause biochemical changes, such as reduced Fe resorption that directs to anemia (Divya and Karthikeyan, 2017). Immunotoxicity: Nickel can be responsible for noticeable immune and allergic reactions (Dearman and Kimber, 1992;Kimber and Dearma, 1994;Guimaraens et al., 1994;Das et al., 2008). ...
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Full-text available
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Nickel pollutant, one of the important widespread heavy metal pollutants starts from natural as well as anthropogenic sources. At present, it is a fact that nickel is an essential element vital for the healthy growth of plants. It plays a crucial responsibility for the activities of certain enzymes, for substantiating proper redox state of a cell and many other physiological, biochemical and growth responses. The use of nickel in modern technology is gradually increasing that result in hastening consumption of nickel-containing product. Nickel compounds arrive in the environment during its manufacturing as well as its use. Their rapid accumulation in different locations of the earth is responsible for widespread nickel pollution. This review presents an analysis of the existing situation related to essentiality, effect and mechanism of nickel toxicity in plants. The investigation of the current scenario is extremely crucial for the realization of the extent of the crisis linked to nickel as an environmental toxicant.
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Directly observed iron supplementation for control of iron deficiency anemia
Article
Full-text available
  • Jan 2017
  • Indian J Publ Health
Anemia is major public health problem affecting 1.6 billion people worldwide. The poor compliance of iron supplementation remains main contributor for high prevalence of anemia. The current paper reviewed the effectiveness of direct observation of oral iron supplementation on anemia. A systematic search was performed through electronic databases and local libraries. Search strategies used subject headings and key words “directly observed” and “iron supplementation.” Searches were sought through April 2014. A total of 14 articles were included in the study. Findings were presented in three categories. First, all of those reported an improvement in compliance of iron supplementation. Second, reduction in the prevalence of anemia was reported by all and third, all except one reported increased blood hemoglobin level. Directly observed an iron supplementation is an effective approach for prevention and management of anemia in vulnerable groups. However, larger trials are needed before
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Systemic nickel hypersensitivity and diet: Myth or reality?
Article
  • Feb 2011
Unlabelled: Nickel is a very common metal contained in many everyday objects and is the leading cause of ACD (Allergic Contact Dermatitis). Nickel is present in most of the constituents of a normal diet, but some food groups are usually considered to be richer. However, the nickel content of specific food can vary widely, depending on many factors. Thus, the daily intake of nickel is also highly variable both among different populations and in a single individual, in different seasons and even in different days. Measuring precisely the daily intake of nickel from food and drinks is extremely difficult, if not impossible. The relationship between ACD and contact with nickel is undisputed and widely confirmed in literature. The situation is different for systemic nickel allergy syndrome (SNAS). The SNAS can have cutaneous signs and symptoms (Systemic Contact Dermatitis or SCD) or extracutaneous signs and symptoms (gastrointestinal, respiratory, neurological, etc.).The occurrence of SCD as a systemic reaction to the nickel normally assumed in the daily diet is very controversial. A rigorous demonstration of the relationship between SCD and nickel is extremely difficult. In particular, further and larger studies are needed to assess the reality and the prevalence of nickel urticaria. With respect to nickel-related gastrointestinal symptoms, as well as chronic fatigue syndrome, fibromyalgia, headache, recurring cold sores and recurrent infections in general, the data available in literature are not conclusive and the studies lack the support of clear, first-hand evidence. With respect to respiratory disorders, the role of food nickel and the effectiveness of a dietary treatment have been assumed but not proven. In fact, the usefullness of a therapeutic low-nickel diet is controversial: rare, if not exceptional, and limited to very sporadic cases of SCD. Additionally, the quantitative and qualitative composition of a low-nickel diet presents few certainties and many uncertainties. The low-nickel diets suggested in literature are highly variable, both in the extension of the restrictions and in their details--and the differences are not marginal. Conclusion: an evaluation of the data presented by medical literature about SNAS and its relationship with oral nickel does not allow to draw final conclusions. In the absence of genuine certainty we can only conclude that further and broader studies, more rigorously conducted, are needed.
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