Search

A severe and chronic deficiency of vitamin E (alpha-tocopherol) is associated with a characteristic neurological syndrome with typical "clinical," neuropathological, and electrophysiological abnormalities in both humans and experimental animals. Repletion of vitamin E-deficient human subjects with alpha-tocopherol typically halts the progression of the neural signs and symptoms, and in some cases, can result in objective improvement. Electrophysiological parameters provide an objective measure of neural and visual function and improvement of some of these measures has been reported after repletion with vitamin E in humans. In this longitudinal study, the effects of repleting rats with a diet containing 36 mg/kg all-rac-alpha-tocopheryl acetate for 20 wk after they had been receiving a vitamin E-deficient diet for 38 wk was studied. We report significant improvements in growth and a number of electrophysiological parameters of both neural and visual function after repletion. These results confirm the validity of the vitamin E-deficient rat as a model of vitamin E deficiency in humans.

A rat model of vitamin E (alpha-tocopherol) deficiency with similar "clinical," electrophysiological, and neuropathological abnormalities to those seen in man was used to investigate the effects of various amounts and forms of alpha-tocopheryl acetate (alphaTA) on neural and visual function. Electrophysiological techniques provide an objective, non-invasive measure of neural and visual function. These techniques were used in the animal model to determine the minimum dietary requirement of vitamin E necessary to prevent neural and visual abnormalities. They were also used to compare the biological activities of the natural (RRR-) and synthetic (all-rac-) forms of alpha-tocopherol in neural tissues. The results were as follows: (1) Significant differences in neural and visual function were observed between deficient and control rats after approximately 8 months. (2) An intake of 1.0 mg/kg all-rac- or 0.75 mg/kg RRR-alphaTA was observed to marginally protect nerves from vitamin E deficiency. (3) The biological activity of all-rac-alpha-tocopherol in neural tissues was approximately 75% of RRR-alpha-tocopherol. (4) The concentration of free malondialdehyde (an indicator of lipid peroxidation) was significantly increased in tissues from the deficient compared to the control animals. These results are consistent with a deficiency of alpha-tocopherol causing increased lipid peroxidation leading to abnormal neural electrophysiology. They could also be explained by more specific but as yet undefined function(s) of alpha-tocopherol in neural tissues.

Physiological and biochemical studies have been carried out longitudinally over a period of 12 months in vitamin E deficient and control rats to gain an understanding of the mechanism whereby vitamin E conserves normal retinal function. Electroretinographic studies indicated that the primary effect of vitamin E deficiency was on the photoreceptors. Ultrastructural studies, however, did not show any morphological changes to the photoreceptors which could explain receptor dysfunction. A 30-40% loss of vitamin A (retinol) was found to be associated with vitamin E deficiency. This could be corrected by repletion with vitamin E, but there was no associated improvement in visual function. An irreversible loss of the long-chain polyunsaturated fatty acids from the retina, increased lipid peroxidation and alterations in membrane fluidity were also detected during vitamin E deficiency. We suggest that a deficiency of vitamin E leads to changes in the membrane microenvironment, which could affect photo transduction by either impairing the ability of rhodopsin to undergo conformational changes to the active form, or by disrupting the hyperpolarising and depolarising processes of the photoreceptors.

Rats were fed a control or vitamin E (all-rac-alpha-tocopheryl acetate)-deficient diet for 3 or 12 weeks. Serotonin (5-HT), 5-hydroxyindoleacetic acid (5-HIAA), tryptophan, and alpha-tocopherol concentrations were determined in the frontal cortex using HPLC, alpha-Tocopherol concentrations fell significantly to 27% of control values at 12 weeks. Tissue 5-HT, 5-HIAA, and tryptophan concentrations were not significantly altered by the vitamin E-deficient diet at either time point. In vivo microdialysis revealed normal basal and K(+)-stimulated concentrations of 5-HT and 5-HIAA, but extracellular concentrations of tryptophan were significantly decreased after 3 weeks on the vitamin E-deficient diet, which resulted in an increase in the tissue/extracellular ratio and suggested a change in compartmentation. However, after 12 weeks on the deficient diet these values had returned to normal. Results in general indicate that a prolonged and substantial depletion of brain vitamin E can occur without major disturbance of serotonergic function.

A severe and chronic deficiency of vitamin E results in a characteristic neurological syndrome in both man and experimental animals. This is presumed to result from increased oxidative stress arising from a reduction in antioxidant capacity. In this study we have examined parameters of endogenous lipid peroxidation and susceptibility to in vitro oxidative stress of neural tissues and fractions, and some non-neural tissues from 1-year-old vitamin E-deficient and control rats. We have shown: (1) an increase in endogenous lipid peroxidation (thiobarbituric acid reactive substances and malondialdehyde) in neural tissues from vitamin E-deficient animals compared to controls. (2) The following order of susceptibility of neural tissues to in vitro oxidative stress in both vitamin E-deficient and control animals: brain >> muscle > cord > nerve. (3) The susceptibility of different brain regions to in vitro oxidative stress varied in a consistent manner with the cortex, striatum, and cerebellum showing the greatest and brainstem and hypothalamus the least susceptibility. (4) Fractions isolated from myelinated nerves of brainstem showed the following order of susceptibility to in vitro oxidative stress: axoplasmic membranes and organelles > axolemma enriched fraction > whole homogenate > = myelin. These results would fit with the characteristic neuropathology associated with severe and chronic vitamin E deficiency.

alpha-Tocopherol concentrations in brain were reduced to 3% of control levels in rats fed a vitamin E deficient diet for 52 weeks. Vitamin E deficiency resulted in a 19-33% loss of tyrosine hydroxylase (TH) immunopositive neurones in the substantia nigra, but not in the adjacent ventral tegmental area, compared with controls. Vitamin E deficiency, however, did not reduce striatal dopamine concentrations or turnover. When antioxidant defence mechanisms are defective, as in chronic vitamin E deficiency, the nigrostriatal pathway may be affected by oxidative damage and this may have implications for Parkinson's disease.

Four patients with vitamin E deficiency and sensory ataxia were studied using [18F]dopa positron emission tomography. The 2 most disabled patients, who had severe and prolonged vitamin E deficiency due to abetalipoproteinemia, showed reduced [18F]dopa uptake in both putamen and caudate. Putaminal uptake was in a similar range to that seen in Parkinson's disease. Studies of [3H]mazindol binding in the striatum of vitamin E--deficient rats indicated a reduced number of dopamine terminals, which was most severe in ventrolateral striatum. These observations suggest that severe and prolonged vitamin E deficiency results in loss of nigrostriatal nerve terminals, and support the hypothesis that oxidative stress may contribute to the etiology of Parkinson's disease.

Increased concentrations of reactive oxygen species in children with depleted antioxidant defences have been implicated in a cycle of malnutrition, malabsorption, and infection leading to protracted diarrhoea. A rat model of chronic vitamin E deficiency has been used to study the effects of antioxidant depletion on jejunal structure and function in vitro. Basal intestinal short circuit current (Isc), a measure of net electrogenic ion movement across the intestinal epithelium, was greater in chronically vitamin E deficient jejuna than controls, as was the electrogenic secretory response to aminophylline and Escherichia coli STa but not to bethanechol. The galactose stimulated current was also greater in vitamin E deficient jejuna. Indices of lipid peroxidation (concentrations of thiobarbituric acid reactive substances and malondialdehyde) were increased in the vitamin E deficient small bowel. Small intestinal brush border membranes from vitamin E deficient animals displayed changes in both static and dynamic components of membrane fluidity measured by steady state fluorescence polarography. The results of these studies support the hypothesis that oxidative stress in subjects with compromised antioxidant defences results in small intestinal hypersecretion, which could predispose to or perpetuate protracted diarrhoea.

Vitamin E deficiency in rats gives rise to a neuromuscular syndrome that includes a peripheral neuropathy as well as generalised muscle wasting and weakness. This is probably related to damage by oxygen-derived free radicals. In the present study, histological examination of lower limb muscles showed widespread myopathic changes which included the presence of amorphous electron-dense inclusions and tubular aggregates in muscle fibres and muscle fibre necrosis. Histochemical observations suggested a reduction in the activity of oxidative enzymes. The mitochondria showed nonspecific degenerative changes on electron microscopy; no paracrystalline inclusions were observed. Polarographic analysis of isolated muscle mitochondria revealed statistically significant decreases in oxygen utilisation rates with both NADH and FADH2-linked substrates. In confirmation of a generalised respiratory chain abnormality, enzymatic analyses revealed decreases in the activities of complexes I, II/III and IV, although only the decreases in complexes I and IV activities were statistically significant. Measurements of membrane fluidity showed that this is reduced in mitochondria from vitamin E deficient rats, indicating reduced stability of their membranes. The respiratory control ratio, derived from the polarographic results, was also reduced in mitochondria from vitamin E deficient animals, suggesting membrane damage. An altered lipid environment, possibly secondary to a higher level of lipid peroxidation, could result in the inhibition of complexes I and IV. This could also be caused by oxidative damage to the complexes or to mitochondrial DNA. The preservation of citrate synthase activity is against any generalised defect of mitochondrial function. The question as to whether these defects of mitochondrial respiratory chain function are responsible for the muscle fibre damage and necrosis requires further investigation.

1. A vicious cycle of malabsorption and malnutrition has been implicated in the pathogenesis of protracted diarrhoeal disease in infancy. Vitamin E deficiency is common in malnourished infants with protracted diarrhoea. We have studied the effects of chronic vitamin E deficiency on small-intestinal secretion and absorption in the rat. 2. Weanling rats were fed vitamin E-sufficient or -deficient diets for 21 weeks. Jejunal function was studied in vitro in an Ussing chamber after this period. 3. Steady-state isotopic flux experiments in unstimulated tissues demonstrated net Na+ and Cl- secretion in vitamin E-deficient jejuna but net Na+ and Cl- absorption in vitamin E-sufficient jejuna. 4. Basal intestinal short-circuit current was the same in both groups. 5. Cyclic nucleotide and maximal non-neuronal acetylcholine-mediated electrogenic secretion were increased in vitamin E-deficient jejuna. 6. Exogenous 5-hydroxytryptamine (serotonin) induced a smaller increment in electrogenic secretion in vitamin E-deficient jejuna. 7. Vitamin E-deficient jejuna were less responsive to exogenous noradrenaline, resulting in a smaller alpha 2-adrenergic-mediated decrease in intestinal short-circuit current. 8. Fasting for 72h produced a greater increment in intestinal short-circuit current in vitamin E-deficient jejuna. 9. Chronic vitamin E deficiency is prosecretory in the small intestine and may predispose to the perpetuation of protracted diarrhoeal diseases.

We assessed whether patients with familial isolated vitamin E deficiency could discriminate between natural (RRR-) and synthetic (SRR-) stereoisomers of alpha-tocopherol labeled with six (d6) or three (d3) deuterium atoms, respectively. After oral administration of 20 mg of each of the stereoisomers, patients (seven) and controls (seven) had similar concentrations of both in chylomicrons, similar initial increases of both, and similar rates of decrease of d3-SRR-alpha-tocopherol in plasma. Patients and controls differed in their abilities to maintain plasma d6-RRR-alpha-tocopherol concentrations. Controls maintained plasma d6-RRR-alpha-tocopherol concentrations by preferentially secreting it in very low density lipoprotein (VLDL). Three of seven patients did not discriminate between the two stereoisomers and their plasma and lipoprotein d6-RRR-alpha-tocopherol concentrations declined rapidly. The remaining patients were intermediate between non-discriminators and controls in their ability to discriminate and maintain plasma d6-RRR-alpha-tocopherol concentrations. The degree of discrimination between the two stereoisomers in the patients was correlated with the age of onset of the neurologic disability (r2 = 0.64, P < 0.03). Estimates based on the rate of decrease of plasma d6-RRR-alpha-tocopherol in non-discriminators suggest that the entire plasma alpha-tocopherol pool of normal subjects is replaced daily. We suggest 1) that a hepatic alpha-tocopherol binding protein, which preferentially incorporates RRR-alpha-tocopherol into VLDL, is required to maintain plasma RRR-alpha-tocopherol concentrations; 2) that non-discriminators are lacking this protein, or have a marked defect in the RRR-alpha-tocopherol binding region of the protein; and 3) that patients who discriminate, but have difficulty maintaining plasma RRR-alpha-tocopherol concentrations, have a less severe defect, or perhaps a defect in the transfer function of the protein.

Flash electroretinograms, retinal oscillatory and cortical visual-evoked potentials were recorded in 10-month vitamin E deficient rats and in age-matched controls. A significant increase in the latency (P less than 0.0001) and decrease in amplitude (P less than 0.0001) of the electroretinogram a- and b-waves were observed in the vitamin E deficient rats compared with controls. The vitamin E deficient rats also showed a significant delay (P less than 0.002) in early oscillatory potentials. No significant group differences were obtained in the P1 latency or P1-N1 amplitude of the visual-evoked potential; however, the N1 peak was significantly delayed (P = 0.01) in the vitamin E deficient rats. This study shows, for the first time, that the electroretinogram and visual-evoked potential to flash stimulation provide a sensitive index for monitoring the visual effects of vitamin E deficiency in the rat.

Morphological and functional studies have been performed on experimental vitamin E deficient rats. The predominant morphological change was axonal dystrophy and degeneration in the rostral parts of the dorsal columns, particularly in the gracile fasciculi. The dystrophic changes comprised focal axonal swellings containing accumulations of normal and abnormal organelles which included tubulovesicular structures probably derived from the smooth endoplasmic reticulum, mitochondria, dense lamellar bodies, neurofilaments, multifascicular bodies and lysosomes. Similar but lesser changes were observed in distal peripheral nerves. The appearances suggested a disturbance of axonal transport with a defect of 'turnaround' in the distal axons. Studies on the axonal transport of endogenous acetylcholinesterase showed an impairment both of fast anterograde and retrograde transport. The changes were considered to be secondary to the lack of the antioxidant effect of vitamin E as the neurological deficits could be reduced by the concomitant dietary administration of the synthetic antioxidant ethoxyquin and were markedly aggravated by the administration of polyunsaturated fatty acids. It is suggested that the neurological syndrome produced by vitamin E deficiency could be the result of damage to the function of mitochondria and other intra-axonal membranous structures which would interfer both with fast anterograde transport and 'turnaround' and lead to a distal axonal degeneration.

A severe deficiency of vitamin E causes a characteristic neurological syndrome in man and experimental animals. In this study a number of electrophysiological modalities in vitamin E deficient and control rats have been investigated over a period of one year to define the time of onset and severity of the abnormalities associated with vitamin E deficiency in the rat. The mean velocities (n = 10) of the sensory evoked potentials were slower at all time points in the vitamin E deficient rats, with the central conduction velocities being more severely affected than the peripheral. Central conduction velocities, following both tibial and median nerve stimulation, were significantly delayed (P less than 0.005) after 8 months of deficiency. Differences in peripheral conduction following tibial stimulation became significantly delayed (P less than 0.005) after 11 months of deficiency. There were no significant differences in the brainstem auditory evoked potentials or peripheral sensory motor responses between the vitamin E deficient and control rats over the 1 year period. These results in the rat are essentially similar to those previously reported in vitamin E deficient man.

It is now recognized that vitamin E is essential for normal neurological structure and function in both man and experimental animals, with severe deficiency resulting in a characteristic neurological syndrome. The reasons why the neurological system should be particularly susceptible to a deficiency of this fat-soluble vitamin, and the mechanisms involved, are not known. In this review, the neurochemistry, neuropathology, and neurophysiology associated with vitamin E deficiency are described and correlated. A deficiency of vitamin E results in a "distal or dying back" axonal neuropathy which predominantly involves the centrally directed fibers of sensory neurons, with the large caliber myelinated fibers being particularly affected. Both the pathological and electrophysiological studies indicate that the primary abnormality is a degeneration of the axons which then results in a secondary demyelination. The mechanism(s) involved is assumed to involve lipid peroxidation of neuronal membranes as a consequence of a deficiency of the major lipid-soluble secondary (i.e., chain breaking) antioxidant in vivo.

Two adults are described who developed a progressive neurological disorder more than 20 years after the onset of chronic fat malabsorption. The clinical features included dysarthria, cerebellar ataxia, and prominent proprioceptive loss with depressed or absent tendon reflexes. Serum vitamin E was undetectable in both cases. One patient improved clinically and electrophysiologically after oral therapy with vitamin E. The findings in these patients were similar to those in others recently reported with vitamin E deficiency associated with biliary atresia. Electrophysiological observations suggested that the human deficiency state parallels that found neuropathologically in vitamin E-deficient animals.

Neurological syndromes similar to those associated with abetalipoproteinaemia or Friedreich's ataxia developed in four patients with chronic steatorrhoea, two of whom had cystic fibrosis and two chronic cirrhosis of childhood. Serum concentrations of vitamin E were virtually undetectable in all four patients. Substantial clinical improvement occurred in one patient after restoration of normal vitamin E levels by parenteral therapy. The findings suggest that spinocerebellar degeneration may be secondary to severe and prolonged vitamin E deficiency.

Longitudinal studies were carried out over 55 weeks in vitamin E deficient and control rats. It was shown that neurological tissues (brain, cord and nerve) retained a greater percentage of vitamin E (alpha-tocopherol) than other tissues (serum, liver and adipose tissue), and that there was no evidence for compensation by other antioxidant enzyme systems (superoxide dismutase and glutathione peroxidase). An increased uptake of alpha-[3H]tocopherol (150% of controls) was observed in peripheral nerve of deficient animals from 11 weeks, whereas similar increases were not found in brain and cord until 36 weeks. These results were correlated with tests of neurological function which included electrophysiological studies and measurement of axonal transport. Recordings of somatosensory evoked potentials showed a significant delay (P less than 0.001) of central conduction velocity after 40 weeks of deficiency, whereas peripheral conduction was unchanged. After 40 weeks of deficiency, abnormal electromyographic activity of the hind limbs was obtained which was suggestive of chronic partial denervation. By 52 weeks there were significant reductions of both fast anterograde (P less than 0.02) and retrograde (P less than 0.05) transport of acetylcholinesterase in the deficient rats.

The chain-breaking (peroxyl radical-trapping) antioxidant activity of plasma obtained from several patients with a very severe vitamin E deficiency has been measured. The total chain-breaking antioxidant activity in lipid extracts has been shown to be approximately equal to the concentration of vitamin E. For whole plasma there is no significant difference in the concentrations of water-soluble, chain-breaking antioxidants between the E-deficient patients and healthy adults. It is concluded that even in cases of very severe vitamin E deficiency the requirement for this vitamin is not met by some other exogenous or endogenous antioxidant.

A patient with cystic fibrosis and undetectable serum vitamin E concentrations is described who developed a progressive spinocerebellar syndrome and pigmentary retinopathy with abnormal somatosensory and visual evoked potentials (SSEPs and VEPs). In order to assess the relationship between neurological function and serum vitamin E concentrations in cystic fibrosis, 29 unselected patients who had no neurological symptoms were examined neurologically. Ten were randomly selected for neurophysiological assessment by recording SSEPs and VEPs. Electroretinograms (ERGs) were also performed in five cases. The findings were correlated with serum vitamin E concentrations which were unknown to the neurological investigators prior to completion of the study. Only one patient had definite reflex and sensory abnormalities, and the remaining 28 were clinically normal. The ERG was abnormal in two cases, one of whom had abnormal VEPs. SSEPs were normal in all 10 cases. Twenty six patients had serum vitamin E concentrations below the normal range. In two of the three patients who had definite neurological or electrophysiological abnormalities serum vitamin E concentrations were below the median value for the whole group.

Patients with cystic fibrosis tend to have reduced serum concentrations of vitamin E and are therefore at risk of developing the neurological complications associated with vitamin E deficiency. Improved survival in cystic fibrosis has resulted in an increasing number of older patients who may develop hepatobiliary complications which may further impair the absorption of vitamin E. In this study the vitamin E status and results of supplementation with oral vitamin E were compared in adult patients with and without evidence of liver involvement as assessed by routine liver function tests. The serum vitamin E concentrations were reduced below normal in 24 of 25 patients. The mean serum vitamin E concentration was significantly lower (p less than 0.05) in those patients with abnormal liver function. When vitamin E status was assessed as the serum vitamin E/cholesterol ratio, however, there was no significant difference between those patients with normal and abnormal liver function. After supplementation with oral vitamin E, either 10 mg/kg/day for one month or 200 mg/day (equivalent to 3.4 to 4.4 mg/kg/day) for up to three months, there was no significant difference in the vitamin E status between the two groups. The results of this study indicate that in general, patients with cystic fibrosis and abnormal liver function do not require increased supplements of vitamin E compared with those with normal liver function.

Three lines of evidence indicate that vitamin E is important for normal neurological function in man. First, in abetalipoproteinaemia early therapy with vitamin E delays, and may prevent, the development of neurological complications, and in patients with established lesions treatment can arrest or reverse the neuropathy. Secondly, in other chronic disorders of fat absorption with severe vitamin E deficiency, neurological manifestations can be improved by vitamin E. Thirdly, the neuropathological changes observed in vitamin-E-deficient states in man (such as abetalipoproteinaemia, chronic liver disease, and cystic fibrosis) are similar to those reported in vitamin-E-deficient rats and monkeys.

A girl with cystic fibrosis who developed a neurological syndrome probably secondary to vitamin E deficiency at the age of 10 years is described. The severity of the deficiency and the early development of neurological features probably result from reduced intraluminal bile salt concentrations in addition to the pancreatic insufficiency.

The vitamin E status of 146 adults with chronic liver disease was assessed by estimating both their serum vitamin E concentration and the ratio of serum vitamin E to serum cholesterol concentration. Low levels of vitamin E occurred most frequently in patients with primary biliary cirrhosis and other forms of chronic cholestatic liver disease. When a serum vitamin E concentration of 12.3 mumol/l (mean-2 SD of a control population) was taken as the lower limit of normal, 44% of patients with primary biliary cirrhosis and 32% with other chronic cholestatic liver disease had a reduced concentration, indicating a biochemical deficiency of vitamin E. If a vitamin E/total cholesterol ratio of 2.35 mumol/mmol was taken as the lower limit of normal, then 64% and 43% of patients with primary biliary cirrhosis and other chronic cholestatic liver disease, respectively, had a biochemical deficiency of vitamin E. Of the patients with chronic cholestasis and a serum bilirubin concentration greater than 100 mumol/l, 91% had a reduced vitamin E/cholesterol ratio. Twelve patients with primary biliary cirrhosis and severe vitamin E deficiency (serum vitamin E less than 5.0 mumol/l and a vitamin E/cholesterol ratio less than 1.0 mumol/mmol) underwent extensive neurological investigation. Five had a mild mixed sensorimotor peripheral neuropathy, which was not, however, typical of the neurological syndrome associated with vitamin E deficiency. In patients with severe biochemical deficiency of vitamin E (less than 5 mumol/l and less than 1 mumol/mmol total cholesterol), administration of large oral doses of vitamin E only increased serum concentrations to within the normal range in one patient; in the others even weekly parenteral administration over a 3-month period did not correct deficiency. In patients with less severe biochemical deficiency, the serum vitamin E concentration and vitamin E/total cholesterol ratio were restored to normal by oral or intramuscular supplements of the vitamin.

Somatosensory evoked potentials (SEPs) from lumbar and cortical areas and electromyographic activity (EMG) were recorded in 40-42 week vitamin E deficient rats and in age matched controls. A significant increase in the latency (p less than 0.001) of the cortical SEP and a significant reduction in the lumbar to cortical conduction velocity (p less than 0.001) were observed in vitamin E deficient rats compared with controls. No significant differences were obtained in the latency of the lumbar SEP or in the peripheral conduction velocity from the ankle to lumbar region. All the vitamin E deficient rats had abnormal EMG findings (fibrillation potentials, positive sharp waves and polyphasic activity), whereas none of the controls showed any of these signs of dysfunction.