Treatment of severe neutropenia with high-dose pyridoxine in a patient with chronic graft versus host disease and squamous cell carcinoma: a case report

Abstract

IntroductionThe differential diagnosis of neutropenia includes medications, infections, autoimmune diseases, and deficiencies of Vitamin B12 and folate. The association of Vitamin B6 deficiency with severe neutropenia is a rare finding.Case presentationA 51-year-old Caucasian woman presented with fever and profound neutropenia (48 neutrophils/uL). Her clinical history included non-Hodgkin lymphoma, in remission following treatment with allogeneic bone marrow transplantation, quiescent chronic graft-versus-host disease, and squamous cell carcinoma of the skin metastatic to cervical lymph nodes. Medications included atenolol, topical clobetasol, Ditropan (oxybutynin), prophylactic voriconazole, prophylactic valganciclovir, Soriatane (acitretin), and Carac (fluorouracil) cream. The bone marrow was hypocellular without metastatic cancer or myelodysplasia. Neutropenia did not respond to stopping medications that have been associated with neutropenia (valganciclovir, voriconazole and Soriatane) or treatment with antibiotics or granulocyte colony stimulating factor. Blood tests revealed absence of antineutrophil antibodies, normal folate and B12 levels, moderate zinc deficiency and severe Vitamin B6 deficiency. Replacement therapy with oral Vitamin B6 restored blood vitamin levels to the normal range and corrected the neutropenia. Her cervical adenopathy regressed clinically and became negative on scintography following Vitamin B6 therapy and normalization of the blood neutrophil count.ConclusionSevere pyridoxine deficiency can lead to neutropenia. Screening for Vitamin B6 deficiency, along with folate and Vitamin B12 levels, is recommended in patients with refractory neutropenia, especially those with possible malabsorption syndromes, or a history of chronic-graft-versus host disease. Severe neutropenia may facilitate progression of squamous cell carcinoma.

Micronutrient Alterations During Continuous Renal Replacement Therapy in Critically Ill Adults: A Retrospective Study

“…Pyridoxine is required for nucleic acid and protein synthesis. Low vitamin B 6 concentrations have been associated with inflammation, severe neutropenia, and high oxidative stress . Vitamin B 6 deficiency has been implicated in critically ill patients with refractory seizures .…”

“…Low vitamin B 6 concentrations have been associated with inflammation, severe neutropenia, and high oxidative stress. 16,17 Vitamin B 6 deficiency has been implicated in critically ill patients with refractory seizures. 18 For critically ill surgical patients, higher plasma concentrations of pyridoxine have been shown to be associated with better glucose response when compared with those with inadequate vitamin B 6 levels.…”

Effects of vitamin B6 metabolism on oncogenesis, tumor progression and therapeutic responses

“…50,[54][55][56] This notion has been substantiated in multiple clinical scenarios in which the immunological status of immunodeficient cancer patients was consistently ameliorated by the supplementation of PN. 92,93 In the 1990s, Tryfiates et al 59 investigated the clinical relevance of their preclinical observations, indicating that the conversion of vitamin B6 differs in malignant versus normal cells as well as in tumor-bearing versus healthy rodents. Thus, besides being found in the serum and neoplastic lesions of tumorbearing rats, adenosine-N6-diethylthioether N1-pyridoximine 5 0 -phosphate could be detected in cultured human cancer cells as well as in the blood and tumor tissue of cancer patients.…”

Dietary Supplements in People with Metastatic Cancer Who Are Experiencing Malnutrition, Cachexia, Sarcopenia, and Frailty: A Scoping Review

“…The 48 articles were classified into the following categories: full text peer-reviewed manuscripts (n = 38), conference abstracts (n = 8), and clinical trial registrations (n = 2). Of the full text peer-reviewed manuscripts, the majority reported on randomized controlled trials (RCTs) (n = 18) [34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51], followed by quasi-experimental trials (n = 15) [52][53][54][55][56][57][58][59][60][61][62][63][64][65][66], retrospective cohort observational studies (n = 2) [67,68], and case studies (n = 3) [69][70][71]. Conference abstracts reported on RCTs (n = 3) [72][73][74], quasi-experimental trials (n = 4) [75][76][77][78], and a case study (n = 1) [79].…”

“…Vitamins included in studies were vitamin A (n = 2) [44,54], B1 (n = 1) [76], B6 (n = 2) [70,76], B9 (n = 4) [46,60,61,68], B12 (n = 1) [60], C (n = 2) [44,54], D (n = 4) [40,59,62,64], and E (n = 3) [39,44,54]. Minerals included were calcium (n = 2) [62,64], iron (n = 2) [68,79], and selenium (n = 1) [75].…”