Diseases associated with VAD

We identify children and adults with Bitot`s spots when they attend charitable primary health care centers of this institution and of its sister NGO, Howrah South Point, that are located in several urban and semi urban slums of Kolkata and Howrah as well as in some villages around Kolkata. These children and adults don’t attend the primary health care centers for their Bitot`s spots but to consult a doctor for a doctors consultation regarding their individual symptoms and diseases. The Bitot`s spots of these patients are observed as a part of the regular physical examination and they have not been noticed by the patients themselves in before.

This work is an opportunity to observe associations between physiologic and pathologic conditions of man and Vitamin A Deficiency (here represented by Bitot`s spots). Certain diseases are known to be associated with Vitamin A Deficiency, for example malnutrition, maldigestion and malabsorption, diarrhea, measles, chronic liver diseases, tuberculosis and HIV. Other conditions may be associated to Vitamin A Deficiency, and any such an association may broaden the understanding of the pathophysiology of these conditions or of the pathophysiology of Vitamin A Deficiency.

Between January 2009 and March 2011, we screened all (more than 10.000 consecutive) patients attending the primary health care centers for the presence of Bitot's spots and we recorded the clinical diagnosis of 109 consecutive patients found to have with Bitot`s spots up to two different diagnosis of each patient with Bitot`s spots as some patients of this cohort had more than one clinical diagnosis. We analyzed the diagnosis of these 109 patients with Bitot`s spots for clusters of same diagnosis.

A girl with Bitot`s spots attending a primary health care center

Among the 109 consecutive patients having Bitot`s spots, children as well as adults, the following clusters of diagnosis were identified:  

Altogether there were 14 patients with mental retardation and / or seizure disorder among the 109 patients with Bitot`s spots. In some of these patients, both diseases (mental retardation and seizure disorder) were present. Three of the 11 patients with mental retardation had concomitant seizure disorder, and three of the patients with seizure disorder had also mental retardation.

Persons with mental retardation may be at risk for Vitamin A Deficiency due to their dependency on others to feed them. As they are not contributing to the family income, their environment may wrongly tend to perceive them as less valuable and may offer them less valuable food.

It is our observation that mental retardation is often associated to profound poverty of the family. Poverty may affect negatively the fetal life and the birth of persons who later on are found to have mental retardation. Poverty may lead to under use of certain health interventions like use of iodized salt in areas of iodine deficiency or under use of health services that support children. It might be difficult to disentangle the effect of the poverty of a family on the nutritional status of persons with mental retardation from the effect of mental retardation itself on nutrition.

It is a further limitation of this work that the diagnosis of mental retardation has been made by an experienced general physician according to obvious clinical signs of the patients only, without use of mental performance tests and scales.

The patients with seizure disorder usually were on long-time treatment with anticonvulsant drugs at the time of the observation of their Bitot`s spots. Some of these patients used the anticonvulsant drug Valproat that is known to interfere with retinol metabolism. Further observations will clarify whether the use of Valproat is associated with Bitot`s spots in patients with seizure disorder from this population at risk for Vitamin A Deficiency.

A boy with mental retardation and a Bitot`s spot

 
The chronic liver diseases seen in association with of Bitot`s spots were mostly specified as alcohol-toxic hepatitis and liver cirrhosis. There were two additional patients with an acute liver disease and Bitot`s spots, who were not counted in the cluster of the chronic liver diseases.

We note that diseases like diarrhea and measles didn’t form a cluster in the list of the diagnosis of the patients with Bitot`s spots in our setting. After intense immunization efforts, measles is rare nowdays in the urban slums of Kolkata and Howrah.