VITAMIN C

D R. Z A R R I N K H A L I Q

A P-B I O C H E M I S T RY
 LEARNING OBJECTIVES
 Discuss Biochemical role of Vitamin C in microcytic anemia.
 Discuss haemoglobinopathies & their biochemical + genetic basis
with special emphasis on Sickle cell anemia, Thalassemia and
Methemoglobinemia.
 Discuss following types of anemia on basis of signs & symptoms
+ laboratory data:
Hypochromic microcytic
Normochromic microcytic
Normochromic normocytic
Macrocytic (Megaloblastic)
Vitamin
C
 ASCORBIC ACID

 The active form of vitamin C is Ascorbic acid.

 Alkalies destroy Vit C  hence,

its absorption is decreased
in achlorhydria (Absence of HCl).
 Ascorbic acid is reduced form.
 Dehydroascorbic acid is oxidized form.
** Both have vitamin activity.
** Both are metabolically active.
 Biosynthesis of Vitamin C

Vitamin C cannot be synthesized by humans

because they lack the enzyme L-gulonolactone
oxidase.
Recommended Dietary Allowance (RDA)

Infants 30 mg /day
Adults 75mg/day
Pregnant women 100mg/day
Lactating women 150mg/day
 Sources

 Guava
 Milk is deficient in it.
 Citrus fruits
 Tomatoes
 An ounce of orange
 Green chillies
juice has about 22
 Onions mg of ascorbic acid.
 Spinach
 Cabbage
 Metabolism of Vitamin C

 Absorbed readily from small intestine.

 Widely distributed throughout body.
 Normal human plasma contains approx. 0.6-1.5 mg/100mL.
 Can cross placental barrier.
 It is secreted in milk.
 Oxidized to oxalic acid in body, and excreted in urine.
 Biochemical Functions
• Powerful antioxidant  Reducing action  Protect cells
• Act as co-enzyme
• Collagen formation (important for skin, gums, & blood
vessels)
• Enhances iron absorption
• Supports the immune system
• Aids in wound healing
Role of Vitamin C as Anti-oxidant

◦ Vitamin C neutralizes Reactive Oxygen Species

(ROS)

◦ Reactive Oxygen Species (ROS)

◦ OH (hydroxy radical),
◦ O2- (superoxide radical),
◦ H2O2 (hydrogen peroxide),
◦ HO2 (hydroperoxyl radical)

◦ ROS attack phospholipids & proteins embedded in membranes

◦ R0S oxidize LDL & Red Blood Cells (RBCs)
 Co-Enzyme Activity of
Vitamin C

Vitamin C is a co-enzyme for:

 Cu –containing Hydroxylases

 Iron containing hydroxylases

 Cu containing hydroxylases

1. Dopamine β-hydroxylase:
Involved in synthesis of catecholamines
(Norepinephrine & Epinephrine) in adrenal medulla
and CNS.
2. Peptidylglycine hydroxylase:
Involved in synthesis of hormones like oxytocin, ADH
& CCK.
 Iron containing hydroxylases
1. Proline and lysine hydroxylases:
Are required for post-translational modification of
procollagen to collagen.
Proline hydroxylase is also required in formation of
osteocalcin and the C1q component of the
complement system.
2. Aspartate β-hydroxylase:
It is required for post-synthetic modification of the
precursor of protein C.

3. Trimethyllysine & γ-butyrobetaine hydroxylases:

These are required for the synthesis of carnitine.
 ROLE OF VITAMIN C

A. Role in tryptophan metabolism:

Vit C is required as a co-enzyme for a hydroxylation reaction in
biosynthesis of serotonin from tryptophan.
B. Role in tyrosine metabolism:
Vit C is required as a co-enzyme for hydroxylation reactions
resulting in production of homogentisic acid & malonyl
acetoacetic acid from tyrosine.
Reducing action of Vitamin C
Absorption of iron:
Ascorbic acid helps reduce ferric (Fe+3) to ferrous
(Fe+2). It helps absorb iron from the intestine & its
utilization.
Electron transport chain:
it also takes part in oxidation-reduction reaction systems
coupled with cytochromes, NAD+, NADP+, and FAD.
 Association of Vitamin C &
Folic acidTH4
Reduction of folic acid:
The reduction of folic acid to tetrahydrofolic acid needs
presence of ascorbic acid. This reaction is necessary
for the utilization of folic acid in body. Ascorbic acid
deficiency in infants has been associated with
megaloblastic anemia due to non-utilization of folic
acid.
Treatment of Methemoglobinemia:
Due to its reducing property ascorbic acid is of some
use in treatment of methemoglobinemia.
Scurvy: Deficiency Disease of
Vitamin C
Deficiency of vitamin C Scurvy.
Occurrence:
 In artificially fed infants  Low content of Vit. C in
cow’s milk & destruction of it on boiling +
pasteurization
 Elderly people living alone
 Alcoholics
 Drug addicts
 Sign & Symptoms of Vit C
Deficiency
 Sore & spongy gums
 Loose teeth
 Fragile blood vessels
 Hemorrhages below periosteum & skin
 Swollen joints & weak bones
 Delayed wound healing
 Anemia (Microcytic hypochromic)

Many symptoms due to defective connective tissue production.

 Vitamin C linked Scenario

A 45 years old male who has been a

chronic smoker for the past 10 years
presented to OPD with complaints of
swollen gums that bleed on touching. On
blood complete exam he was found to be
suffering from anemia.
 Scenario of Vitamin C

A middle age widower living alone consumes a

diet exclusively composed of tea, toast, &
sausages. He is suffering from lethargy and
tiredness and notices purplish bruises on his legs.
He also develops swollen gums which bleed on
touch. He goes to the doctor, where on general
examination he is found to be anemic.
Vitamin C Related Scenario
A child with dark purplish spots on the legs, swollen joints, and
gingivitis with tooth loss was brought to the pediatrician in a Hospital.
He also had a history of epistaxis. On investigation, no abnormality
was found in bleeding and clotting time.
PYRIDOXINE
(B6)
 PYRIDOXINE
(Vitamin B6)
 Vitamin B6 is a collective term for:
 Pyridoxine
 Pyridoxal
 Pyridoxamine

 All derivatives of pyridine.

 Differ only in nature of the functional group.
 SOURCES

 Pyridoxine occurs primarily in plants

 Pyridoxal and Pyridoxamine are found in foods obtained from
animals.

All three compounds can serve as precursors

of biologically active coenzyme, pyridoxal phosphate (PLP).
PYRIDOXIN FAMILY
 PYRIDOXAL PHOSPHATE
(PLP)
 PLP functions as a coenzyme for a large number of enzymes,
particularly those catalyzing reactions involving amino acids,
For example,
 In transsulfuration of Homocysteine (Hcy) to cysteine
 In synthesis of dopamine & serotonin
 PLP is also required by glycogen phosphorylase.
PLP SERVED REACTIONS
Clinical indications for pyridoxine

 Isoniazid  Drug commonly used to treat tuberculosis

 Isoniazid interferes with Pyridoxine metabolismDecreasing

functional vitamin B6 deficiency.
 B6 supplementation is essential to prevent peripheral neuropathy.

 Dietary deficiencies in pyridoxine are rare.

 Dietary deficiencies seen in newborn infants fed on formulas low in

B6, in women taking oral contraceptives, and in those with alcoholism.
 TOXICITY
 Vitamin B6 is the only water-soluble vitamin with significant toxicity.

 Neurologic symptoms (sensory neuropathy) occur:

 At intakes above 500 mg/day 

 Nearly 400 times the recommended dietary allowance (RDA)
 Over five times the tolerable upper limit (UL).
 ANEMIAS
Microcytic anemia  Characterized by smaller-than-normal red blood cells
(MCV < 80 fL), often due to impaired hemoglobin synthesis.
Iron deficiency anemia  Most common cause of anemia.

Certain vitamins play key roles in development or prevention of microcytic

anemia.
 Pyridoxine (Vitamin B6)
 Vitamin C
 Vitamin K
 MCV criteria
(Imp. Slide)
Criteria for MCV (Mean Corpuscular Volume) values: Used
to classify RBCs as microcytic, normocytic, or macrocytic.
This helps in diagnosing types of anemia.

 MCV ranges b/w 80-100 fL  Normocytic

 Values below 80 fL  Microcytic anemia
 Values above 100 fL  Macrocytic anemia
 Type of Anemia Signs & Symptoms Lab Data Common Causes
Hypochromic - Fatigue, pallor, weakness - ↓ Hb, ↓ Hct Thalassemia
Microcytic - ↓ MCV (<80 fL)
Iron deficiency anemia
- Brittle nails, pica - ↓ MCH/MCHC Chronic blood loss
(craving non-food items), (hypochromia)
spoon-shaped nails - ↑ TIBC
(koilonychia) - ↓ serum ferritin
- Irritability, poor
concentration
Normochromic - Similar to hypochromic - ↓ Hb Sideroblastic anemia
Microcytic anemia but often less - ↓ MCV (mildly low) (e.g., B6 deficiency)
severe - Normal MCH/MCHC
- Fatigue, pallor (normochromic)
- No specific signs - ↑ serum iron
- Ring sideroblasts in
marrow
Normochromic - Fatigue, pallor - ↓ Hb, ↓ Hct Anemia of chronic disease
Normocytic - Dyspnea on exertion - Normal MCV (80–100 fL)
- Possibly signs of - Normal MCH/MCHC Acute blood loss
underlying disease (e.g., - Normal or ↓ reticulocyte Aplastic anemia
renal disease, infection) count CKD
Macrocytic (usually - Fatigue, pallor - ↓ Hb Megaloblastic anemia
normochromic) - Glossitis (smooth, beefy - ↑ MCV (>100 fL) (B12/folate deficiency)
tongue) - Hypersegmented Alcoholism
- Neurologic symptoms (in neutrophils Liver disease
B12 deficiency): - ↓ serum B12 or folate Hypothyroidism
 Role of Pyridoxine in Anemia

 Vitamin B6 is a coenzyme in heme synthesis

 B6 is used in first step catalyzed by δ-aminolevulinic acid (ALA) synthase.
 It facilitates synthesis of aminolevulinic acid (ALA) from glycine and
succinyl-CoA.
 This is a crucial step in production of heme (the iron-containing part of
hemoglobin).
 Effect of Vit B6 Deficiency
Leads to sideroblastic anemia
Sideroblastic anemia  A type of microcytic anemia 
characterized by iron accumulation in mitochondria 
developing red cells = ring sideroblasts in bone marrow.
Despite sufficient iron, lack of heme synthesis causes
microcytosis.
 Role of Vitamin C in Anemia
 Enhances absorption of non-heme iron in intestine
 Vit C reduces ferric (Fe³⁺) to ferrous (Fe²⁺) form  more absorbable.
 Helps in mobilizing iron from storage & its incorporation into ferritin.
 Deficiency effect:
 Can lead to functional iron deficiency, contributing to microcytic anemia due to
impaired iron absorption, even if dietary iron is adequate.
 Also contributes to fatigue and poor wound healing, common symptoms in anemia.
 Role of Vitamin K in Anemia
Vitamin K is not directly involved in hemoglobin synthesis or RBC formation.
Main role of Vit. K is in clotting factor synthesis (Factors II, VII, IX, and X).
Clinical note:
Severe vitamin K deficiency can lead to bleeding
Chronic blood loss could secondarily cause iron deficiency anemia, which
may be microcytic.
Role of Vit K is indirect in microcytic anemia.
 LO for
HAEMOGLOBINOPATHIES

Discuss haemoglobinopathies with their

biochemical + genetic basis
with special emphasis on
Sickle cell anemia, Thalassemia &
Methemoglobinemia.
 Haemoglobinopathies

 Group of inherited disorders

 Affecting structure or production of hemoglobin

(Hb)

 These disorders arise from mutations in genes

encoding globin chains (α or β)
 SICKLE CELL ANEMIA
Biochemical Basis:
• A point mutation in the β-globin gene (HBB gene).

• Substitution of valine for glutamic acid at position 6 (Glu6Val).

• Alters the hemoglobin structure (HbS)  Polymerization under low

oxygen tension.

• HbS polymerizes → distorts RBCs into sickle shape → reduced flexibility

→ vaso-occlusion and hemolysis.
 Clinical Features of Sickle Cell
Anemia:
Genetic Basis of Sickle Cell Anemia:

•Autosomal recessive inheritance.

•Homozygous (HbSS) → full-blown disease.

•Heterozygous (HbAS) → sickle cell trait (usually

asymptomatic).
 Clinical Features of Sickle Cell
Anemia:
 Chronic hemolytic anemia

 Painful vaso-occlusive crises

 Splenomegaly, increased infection risk

 Dactylitis Dactylitis refer to swelling of a finger or toe, causing it to

resemble a sausage  Usually seen in Sickle cell disease.
 Stroke in children
Lab Findings of Sickle Cell Disease

 Sickled RBCs on peripheral smear.

Hb electrophoresis: predominance of HbS.

Increased reticulocyte count.

 THALASSEMIA
Biochemical Basis:

Imbalance in the production of α or β globin chains →

ineffective erythropoiesis.

α-Thalassemia: Decreased α-globin production → excess β chains.

β-Thalassemia: Decreased β-globin production → excess α chains

→ RBC damage.
 Types of Thalassemia

α-Thalassemia:
 1 gene deletion: Silent
 2: Trait
 3: HbH disease
 4: Hydrops fetalis (lethal)

β-Thalassemia:
 Minor: One defective allele → mild anemia
 Major (Cooley's anemia): Both alleles defective → severe
anemia, needs transfusion
Clinical Features of Thalassemia

•Microcytic hypochromic anemia.

•Bone deformities due to marrow expansion.

•Splenomegaly, growth retardation.

•Iron overload due to repeated transfusions.

 Lab Findings of Thalassemia

 Microcytic hypochromic anemia

 Hb electrophoresis:
 β-Thal major: ↑ HbF, ↓/absent HbA

 Target cells, Nucleated RBCs

 METHEMOGLOBINEMIA
Biochemical Basis:

 Oxidation of Fe²⁺ (ferrous) in hemoglobin to Fe³⁺ (ferric) → forms

methemoglobin.

 Methemoglobin cannot bind oxygen → impaired oxygen delivery to

tissues.
 Genetic Basis of
Methemoglobinemia

 Congenital forms:
• Mutations in cytochrome b5 reductase (enzyme reducing MetHb
back to normal Hb).

• Hemoglobin M disease (mutant globin stabilizes Fe³⁺).

 Acquired forms:
• Exposure to oxidizing agents (e.g., nitrates,
sulfonamides, benzocaine).
 Clinical Features of
Methemoglobinemia
Cyanosis unresponsive to oxygen therapy.

Chocolate-colored blood.

Headache, fatigue, shortness of breath.

Severe cases  neurological deficits, death.

Lab Findings of Methemogloinemia

 Normal PaO₂ but low O₂ saturation

 ↑ MetHb levels (>1%)

 Cyanosis without respiratory distress

 SUMMARY OF HAEMOGLOBINOPATHIES

Genetic
Condition Inheritance Key Effects Clinical Features
Mutation

Sickle Cell β-globin Hb Pain crises,

AR
Anemia (Glu6Val) polymerization anemia

α or β-globin Anemia, bone

Thalassemia AR Globin imbalance
mutations deformities

Cytochrome b5
Methemoglobin AR / AD / Cyanosis, low O₂
reductase or Fe³⁺ in Hb
emia acquired delivery
HbM

A R = AU T O S O M A L R E C E SS I V E

A D = AU T O S O M A L D O M I N A N T