Vitamin A deficiency:

• Normal levels- 1-3micromol/L
• Deficiency leads to microcytic hypochromic anemia
• Associated with decreased serum ferritin levels
• Iron stores in bone marrow and liver are increased
• Iron supplementation does not correct anemia

Pyridoxine deficiency:

• Normal Plasma level: 20-122 nmol/L
• Acts as coenzyme in the decarboxylation and transamination of aminoacids and in synthesis of ALA
• Causes for deficiency:
  • Drugs: INH
  • Malabsorption syndrome
  • Renal dialysis
• Deficiency causes microcytic hypochromic anemia
• Some patients with sideroblastic anemia respond to large doses of pyridoxine, which is not related to deficiency status

Riboflavin deficiency:

• Normal serum level- 110-640nmol/l
• Reduction in red cell glutathione reductase activity (No hemolysis is observed, but can cause PRCA)
• Deficiency interferes with iron release from ferritin

Niacin deficiency:

• Pallegra may be associated with anemia

Vitamin C deficiency:

• Normal plasma levels- 2585micromol/L
• 80% of patients with scurvy are anemic (due to bleeding or associated folic acid deficiency)
• Vitamin C is required for maintaining dihydrofolate in reduced form (Deficiency causes failure of synthesis of tetrahydrofolate leading to megaloblastic anemia) 
• Iron deficiency can occur in children with vitamin C deficiency (Vitamin C facilitates iron absorption).
• Improvement in hemoglobin is seen only when vitamin C is supplemented with folate/ iron

Vitamin E deficiency:

• Normal serum levels- 12-40micromol/L
• Deficiency occurs when there is chronic fat malabsorption
• Low birth weight babies have vitamin E deficiency if they are fed on diet unusually rich in polyunsaturated fatty acids
• Leads to hemolytic anemia associated with thrombocytosis
• Edema of dorsum of feet and pretibial area
• Treatment: Vitamin E 400-800 units/ day

Protein energy malnutrition:

• Starvation for more than 9 weeks causes marrow hypoplasia
• Hemoglobin may fall to 8gm/dL
• Bone marrow- Normocellular/ slighlyhypocellular
• At 3rd to 4th week after replacement of protein episode of erythroblastichypoplasia can occur and can cause sudden death. This condition has to be treated with riboflavin and prednisolone

Copper deficiency:

• Normal serum level: 11-24micromol/lit
• Copper is part of enzymes- cytochromeoxidase, dopamine beta hydroxylase, urateoxidase, tyrosine and lysyloxidase, ascorbic acid oxidase and superoxide dismutase
• Copper is required for absorption and metabolism of iron
• Causes of deficiency
  • Parenteral nutrition
  • Gastric resection/ bariatric surgeries
  • Excess zinc consuption
  • Wilson's disease, Menke’s disease
• Investigations show
  • Macrocytic anemia
  • Hypoferremia
  • Neutropenia
  • Bone marrow mimics myelodysplastic syndrome. Dysplasia is seen in erythroid and myeloid precursors. Vacuolated erythroid and granulocytic precursors may be seen.
  • X Ray (in children): osteoporosis, flaring of anterior ribs with spontaneous rib fractures, cupping and flaring of long bone metaphysis with spur formation, submetaphyseal fractures and epiphysealseparation
  • S. Ceruloplasmin- <15mg/dL
  • S. Copper- <70mcg/dL
• Treatment- Copper- 2-5mg/day

Zinc deficiency:

• Deficiency is seen in case of hemolytic anemias
• Deficiency is not known to produce anemia

Selenium deficiency:

• Not known to produce anemia, though RBC glutathione levels are markedly decreased