Clinical Cases of Minerals

Dr Ashish Anjankar

Case Scenario 1:

A 13-year-old girl presents with tingling and numbness in her right fingers, intermittent muscle cramps, and decaying teeth. On examination, she has carpopedal spasms, positive Chvostek’s and Trousseau’s signs, and dental caries.

  1. Identify the mineral likely to be deficient in this case.
  2. Mention the dietary sources of this mineral.
  3. Describe the functions of this mineral and explain how its plasma level is regulated.

Answers:

  1. Mineral deficient in the above case:
    • The symptoms suggest calcium deficiency.

2. Food sources of calcium:

    • Dairy products: milk, cheese, yogurt
    • Green leafy vegetables: spinach, broccoli
    • Nuts and seeds: almonds, sesame seeds
    • Fish with bones: sardines, salmon

3. Functions of calcium:

    • Provides rigidity and strength to bones and teeth.
    • Essential for neuromuscular excitability and proper nerve conduction.
    • Involved in muscle contraction.
    • Required for blood clotting (coagulation).
    • Acts as a second messenger in hormonal and enzyme signaling.

Regulation of plasma calcium levels:

      • Plasma calcium is tightly regulated by:
        1. Parathyroid hormone (PTH):
          • Increases calcium levels by stimulating bone resorption, increasing renal calcium reabsorption, and activating vitamin D.
        2. Vitamin D (calcitriol):
          • Increases intestinal absorption of calcium.
        3. Calcitonin:
          • Decreases calcium levels by inhibiting bone resorption.

Case Scenario 2:

A 24-year-old woman presents with loss of appetite, inability to concentrate, and fatigue even without exertion. She appears pale and has a history of repeated pregnancies. She also reports brittle nails and occasional pica (craving to eat clay).

Laboratory findings show:

  • Low hemoglobin (Hb)
  • Low serum iron
  • Low ferritin
  • Low mean corpuscular volume (MCV)
  • Increased total iron-binding capacity (TIBC) and transferrin levels.
  1. What is the most probable diagnosis in this case?
  2. Mention the factors affecting the absorption of the deficient mineral in this case.
  3. List the dietary sources, recommended dietary allowance (RDA), and biochemical functions of this mineral.

Answers:

  1. Probable Diagnosis: Suggest iron deficiency anemia (microcytic hypochromic anemia).
  2. Factors affecting iron absorption:

✅ Factors enhancing absorption:

    • Presence of vitamin C (ascorbic acid)
    • Iron in ferrous (Fe²⁺) form (found in heme iron)
    • Increased demand (e.g., pregnancy, growth)
    • Gastric acid (maintains solubility of iron)

🚫 Factors inhibiting absorption:

    • Phytates (found in cereals and legumes)
    • Oxalates (found in spinach, tea)
    • Tannins (tea, coffee)
    • Excess dietary calcium or phosphate
    • Alkaline environment in the stomach (e.g., antacids)

3. Dietary sources, RDA & functions of iron:

📌 Dietary sources:

    • Heme iron: Red meat, liver, poultry, fish
    • Non-heme iron: Green leafy vegetables, legumes, dried fruits, whole grains, jaggery

📌 Recommended Dietary Allowance (RDA):

    • Adult men: 10 mg/day
    • Adult women: 18 mg/day

📌 Biochemical functions of iron:

    • Component of hemoglobin & myoglobin — oxygen transport and storage
    • Present in cytochromes — involved in electron transport chain & ATP production
    • Enzyme cofactor (e.g., catalase, peroxidase)
    • Important for immune function & cognitive performance

Case Scenario 3:

A patient presents with difficulty in speech and writing for the past 4 years, and difficulty in walking for the past 1 year. On examination, he has splenomegaly. Slit-lamp examination of the eye shows bilateral Kayser–Fleischer rings, while his visual acuity remains normal.

  1. Identify the mineral whose metabolism is impaired in this condition.
  2. Mention the dietary sources of this mineral.
  3. Describe the major functions of this mineral.

Answer:

  1. Mineral whose metabolism is impaired:

The findings (neurological symptoms, splenomegaly, Kayser–Fleischer rings) are typical of Wilson’s disease, where copper metabolism is impaired.

2. Dietary sources of copper:

Organ meats: liver, kidney, Shellfish: oysters, crab

Nuts & seeds: cashew, sunflower seeds

Whole grains, Legumes

3. Functions of copper:

    • Component of several enzymes (metalloenzymes), such as:
      • Cytochrome c oxidase → cellular respiration
      • Ceruloplasmin → iron metabolism
      • Superoxide dismutase (SOD) → antioxidant defense
      • Tyrosinase → melanin synthesis
      • Lysyl oxidase → collagen & elastin cross-linking (connective tissue strength)
    • Essential for:
      • Hemoglobin synthesis (via iron metabolism)
      • Maintenance of nervous system & myelination
      • Bone and connective tissue integrity
      • Immune function

Case Scenario 4:

A 10-year-old boy from a rural area presents to the dental clinic with complaints of brownish discoloration and mottling of his teeth. On examination, he has pitted enamel and chalky white patches on several teeth. His parents report that they use groundwater from a deep well for drinking and cooking.

  1. What is the most probable condition and which mineral is involved?
  2. What are the dietary sources of this mineral?
  3. Mention the functions of this mineral and consequences of its deficiency and excess.

Answers:

  1. Probable condition & mineral involved:
  • The boy is suffering from dental fluorosis, caused by excessive intake of fluorine (fluoride).
  • The brown mottling and pitting of enamel are classical signs of fluorosis, seen in areas with high fluoride levels in drinking water (>1.5 ppm).

2. Dietary sources & RDA of fluorine:

📌 Sources:

    • Drinking water (main source)
    • Tea, Seafood
    • Fluoridated salt & toothpaste

3. Functions:

    • Strengthens tooth enamel and prevents dental caries.
    • Helps in the mineralization of bones.

📌 Deficiency:

    • Increased risk of dental caries (tooth decay).

📌 Excess (fluorosis):

    • Dental fluorosis: Mottling, pitting, and discoloration of teeth.
    • Skeletal fluorosis: Increased bone density, joint stiffness, and skeletal deformities in severe cases.

Case Scenario 5:

A 5-year-old boy is brought to the pediatric clinic with complaints of delayed wound healing, frequent infections, poor growth, and loss of appetite. On examination, he has rough, scaly skin with a rash around the mouth and perianal area, and sparse hair.

  1. What is the most probable deficiency and which trace element is involved?
  2. Mention the dietary sources and daily requirement (RDA) of this trace element.
  3. What are the important functions of this element and what are the consequences of its deficiency?

Answer:

  1. Probable deficiency & trace element:

The boy is suffering from acrodermatitis enteropathica, a condition due to zinc deficiency.

2. Dietary sources & RDA of zinc:

    1. Sources:
    • Animal sources: Red meat, liver, eggs, seafood (especially oysters)
    • Plant sources: Whole grains, legumes, nuts
    • Dairy products
    • RDA: Adult men ~12–15 mg/day

3. Functions & consequences of deficiency:

📌 Functions:

    • Cofactor for over 300 enzymes (e.g., DNA & RNA polymerases, carbonic anhydrase, alkaline phosphatase).
    • Essential for:
      • Growth and development.
      • Wound healing & tissue repair.
      • Immune function.
      • Reproduction.
      • Maintenance of skin and hair integrity.
      • Taste perception.

📌 Deficiency manifestations:

    • Growth retardation.
    • Hypogonadism & delayed sexual maturation.
    • Immune deficiency → increased infections.
    • Delayed wound healing.
    • Skin lesions (acrodermatitis, alopecia).
    • Loss of taste (hypogeusia) & appetite (anorexia).

Case Scenario 6:

A 60-year-old man is brought to the emergency department with confusion, lethargy, and seizures. History reveals he has been on diuretics for hypertension and has been vomiting for the past two days. On examination, he shows signs of dehydration. Laboratory findings reveal low serum sodium (hyponatremia).

Questions:

  1. What is the most probable electrolyte imbalance in this patient? Justify your answer.
  2. Mention the dietary sources and daily requirement (RDA) of sodium.
  3. State the major functions of sodium and the consequences of its deficiency and excess.

Answer

a. Probable electrolyte imbalance & justification: The patient has hyponatremia (sodium deficiency).

 b. Dietary sources & RDA of sodium:

📌 Sources:

    • Table salt (sodium chloride)
    • Processed & canned foods
    • Cheese, pickles, salted snacks
    • Naturally present in small amounts in milk, eggs, meat, and vegetables.

📌 RDA:

    • Adults: 2–3 grams/day (about 5–6 grams of salt/day)

c. Functions of sodium & consequences of imbalance:

📌 Functions:

    • Maintains extracellular fluid (ECF) volume & osmotic balance.
    • Important for nerve impulse transmission & muscle contraction.
    • Helps in acid–base balance.
    • Assists in nutrient absorption (e.g., glucose, amino acids in the intestine).

📌 Deficiency (hyponatremia):

    • Causes: Vomiting, diarrhea, diuretics, adrenal insufficiency.
    • Symptoms: Muscle cramps, confusion, seizures, coma (in severe cases).

📌 Excess (hypernatremia):

    • Causes: Excess salt intake, dehydration.
    • Symptoms: Thirst, irritability, muscle twitching, seizures.

Case Scenario 7:

A 55-year-old man with a history of chronic kidney disease presents with muscle weakness and palpitations. On examination, he has decreased reflexes and an irregular pulse. ECG shows tall peaked T-waves and widened QRS complexes. Laboratory findings reveal elevated serum potassium (hyperkalemia).

Questions:

a) What is the most probable electrolyte imbalance in this patient? Justify your answer.
b) Mention the dietary sources and daily requirement (RDA) of potassium.
c) State the major functions of potassium and the consequences of its deficiency and excess.

Answers:

a). Probable electrolyte imbalance & justification:

    • The patient has hyperkalemia (high serum potassium).

b). Dietary sources & RDA of potassium:

📌 Sources:

    • Fruits: Bananas, oranges, avocados
    • Vegetables: Spinach, potatoes, tomatoes
    • Legumes, nuts
    • Dairy products, meat

📌 RDA: Adults: ~3–5 grams/day

c). Functions of potassium & consequences of imbalance:

📌 Functions:

    • Maintains intracellular osmotic pressure & fluid balance.
    • Essential for resting membrane potential in excitable cells (nerve & muscle).
    • Helps in acid–base balance.
    • Aids in carbohydrate metabolism & protein synthesis.

📌 Deficiency (hypokalemia):

    • Causes: Diuretics, diarrhea, vomiting, hyperaldosteronism.
    • Symptoms: Muscle weakness, cramps, fatigue, arrhythmias (flattened T-waves, U-waves on ECG).

📌 Excess (hyperkalemia):

    • Causes: Renal failure, potassium-sparing diuretics, tissue breakdown.
    • Symptoms: Muscle weakness, cardiac arrhythmias, cardiac arrest if severe

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