|Year : 2018 | Volume
| Issue : 1 | Page : 250-253
Assessment of serum iron and zinc levels in rhinoscleroma patients
Abdel-Hai R El-Asi, Ayman A Abdel-Aziz, Heba A Abu El-Naga, Sohair R Abo Shady
Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||09-Oct-2016|
|Date of Acceptance||23-Nov-2016|
|Date of Web Publication||14-Jun-2018|
Sohair R Abo Shady
Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Menoufia
Source of Support: None, Conflict of Interest: None
This study aimed to determine the relation of serum levels of iron and zinc trace elements during the course of rhinoscleroma and stage of disease.
Several risk factors have been associated with rhinoscleroma such as poor hygiene and nutritional deficiencies. Therefore, iron and zinc deficiencies may be predisposing factors to the disease or may be a sequel of the disease as they are essential for cell-mediated immunity, which affects the pathophysiology of the disease.
Patients and methods
Seventy-eight participants (39 cases diagnosed with rhinoscleroma and 39 controls) were enrolled into the study. Patients were subjected to nasal biopsy and a histopathological examination to diagnose rhinoscleroma, and laboratory assessments of serum levels of iron and zinc to determine the changes in serum levels of iron and zinc in patients diagnosed with rhinoscleroma.
There was a significant decrease in the serum level of iron in the case group compared with the control group (P = 0.00) and a significant decrease in the serum level of zinc in the case group compared with the control group (P = 0.00). Also, there was a significant decrease in the serum levels of iron and zinc in the late-stage cases.
Serum levels of iron and zinc were significantly lower in patients diagnosed with rhinoscleroma than controls, reflecting the crucial role of iron and zinc in cell-mediated immunity in such patients.
Keywords: cell-mediated immunity, rhinoscleroma, serum iron, serum zinc, trace element
|How to cite this article:|
El-Asi AHR, Abdel-Aziz AA, Abu El-Naga HA, Abo Shady SR. Assessment of serum iron and zinc levels in rhinoscleroma patients. Menoufia Med J 2018;31:250-3
|How to cite this URL:|
El-Asi AHR, Abdel-Aziz AA, Abu El-Naga HA, Abo Shady SR. Assessment of serum iron and zinc levels in rhinoscleroma patients. Menoufia Med J [serial online] 2018 [cited 2019 Aug 19];31:250-3. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/250/234226
| Introduction|| |
Scleroma is a progressive, granulomatous infectious disease, usually limited to the respiratory tract and caused by Klebsiella rhinoscleromatis. It is transmitted by close long contact with the patient. The term scleroma is preferred over the term rhinoscleroma because this disease affects not only the nose but it initially develops on the nose and may progress to involve the larynx and pharynx. Scleroma primarily affects the nasal cavity (95–100%), but the nasopharynx (18–43%), oropharynx (13–35%), larynx (15–40%), trachea (12%), and bronchi (2–7%) may also be involved .
The characteristic features of scleroma include slow development, long duration, and its resistance to treatment, which may suggest the presence of certain immunological disturbances. Cell-mediated immunity in this disease has scarcely been studied and was found deficient. The stress of recurrent infections is known to affect nutritional well-being, and compromised nutrition contributes toward alterations in immunological functions .
There is currently a widely expanding area of research on the role of trace elements in immune function. Among the essential trace elements in human, zinc and iron are essential for integrity and optimum function of the immune system .
Previous studies have reported on the beneficial effect of zinc supplementation in granulomatous diseases, Mycobacterium tuberculosis; effective clearance of mycobacterial infections requires a Th1-mediated activation of infected macrophages by interferon-γ. Zinc acts by inducing T-cell activation or alterations of lymphokine production, which in turn may activate macrophages to promote bacterial clearance. In humans, zinc deficiency is characterized by reductions of interleukin-2 and interferon-γ, and zinc induces the generation of both interleukin-2 and interferon-γ. Zinc supplementation in patients with M. tuberculosis led to earlier sputum conversion and resolution of radiograph lesions. Zinc supplementation in leprosy led to reductions in the incidence and severity of erythema nodosum leprosum, a gradual decrease in the size of granuloma, and a gradual increase in the number of lymphocytes .
The aim of this work is to determine the possible variations in serum levels of iron and zinc trace elements during the course of rhinoscleroma and its relation to the stage of disease.
| Patients and Methods|| |
Patients were enrolled in this case–control study from March 2015 to April 2016 at the Department of Otolaryngology–Head and Neck Surgery, Menoufia University, after approval of the ethical committee of the hospital was obtained. A written consent was obtained from all patients and they were informed about the results of the study.
Patients diagnosed pathologically with rhinoscleroma who were older than 15 years of age were included in the study as a case group. Patients with a history of previous nasal operation and exposure to previous head and neck radiotherapy were excluded from the study. Patients with primary atrophic rhinitis and those with known debilitating diseases such as hyperthyroidism or malignancy were also excluded from the study. Any patient with known disease that could affect zinc levels such as liver cirrhosis was excluded from the study.
The participants of this study were divided into two groups: group 1 (case group) included 39 patients diagnosed clinically and pathologically with rhinoscleroma. This group was further divided into three subgroups: atrophic stage, granulomatous stage, and fibrotic stage. Group 2 (control group) included 39 patients diagnosed with chronic nonspecific nonatrophic rhinitis.
All patients were evaluated by an assessment of history and a preliminary nasal examination to exclude patients who fulfilled the exclusion criteria and to identify patients fulfilling the inclusion criteria. Tissue samples were taken from areas of active disease under local anesthesia for histopathological examination. Laboratory assessment was performed by collecting blood samples from patients and controls by venipuncture after 12 h of fasting under strict aseptic conditions.
Measurements of trace elements were performed by the atomic absorption spectrophotometric technique using atomic absorption spectrophotometer (Carl Zeiss Jena GmbH Company, Jena, Germany). The liquid sample containing trace elements was atomized and the aerosol generated was supplied to an air/acetylene flame, converting the liquid into a vapor containing the element in its normal state. A light source that emitted radiation characteristics of the elements to be determined was directed through the flame. The atoms absorbed radiation through the flame. The atoms absorbed radiation predominantly of wave lengths corresponding to transition from the normal state. This resulted in a decrease in the radiation measured by a special detector.
We measured the difference in the serum levels of iron and zinc elements between the case and control groups and variations in iron and zinc levels in scleromatous patients with different disease stage.
Data were collected, tabulated, and statistically analyzed using an IBM personal computer with statistical package of social science, version 20 (SPSS Inc., Chicago, Illinois, USA) and Epi Info 2000 programs Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (US). Descriptive statistics were calculated, in which quantitative data were presented in the form of mean, SD, and range, and qualitative data were presented in the form of numbers and percentages. Quantitative variables (serum iron and zinc levels) were analyzed using Student's t-test for parametric variables and the Mann–Whitney test for nonparametric variables. A P value of less than or equal to 0.05 was considered statistically significant.
| Results|| |
The current study included 78 participants: 39 cases and 39 controls. Among the cases, there were 25 women and 14 men; 29 patients were from rural areas and 10 patients were from urban areas. A total of 25 patients were younger than 40 years of age and 14 patients were older than 40 years of age. Among the controls, there were 18 women and 21 men; 27 individuals were from rural areas and 12 individuals were from urban areas. Thirty individuals were younger than 40 years of age and nine individuals were older than 40 years of age. In the case group, there were 19 (48.7%) patients in the atrophic stage, 11 (28.2%) patients in the fibrotic stage, and nine (23.1%) patients in the granulomatous stage.
The current study showed a highly significant decrease in the level of serum iron in the case group compared with the control group (P = 0.00). There was a significant decrease in the level of serum zinc in the case group compared with the control group (P = 0.00) [Table 1].
|Table 1: Comparison of serum iron and zinc levels between case and control groups|
Click here to view
The current study found that serum levels of iron and zinc decreased more in the fibrotic stage than other stages [Table 2], [Table 3], [Table 4].
|Table 2: Comparison of serum iron and zinc levels between atrophic and fibrotic stages|
Click here to view
|Table 3: Comparison of serum iron and zinc levels between atrophic and granulomatous stages|
Click here to view
|Table 4: Comparison of serum iron and zinc levels between granulomatous and fibrotic stages|
Click here to view
| Discussion|| |
The etiopathogenesis of rhinoscleroma is still not fully clear. Infection by K. rhinoscleromatis is fundamental for the onset of the disease, but it is impossible to reproduce rhinoscleroma experimentally only by infection with the bacteria both in humans and in animals. Several risk factors have been associated with rhinoscleroma. This disease is more frequent among individuals in the second or third decades of life, those living in crowded conditions, and individuals living in rural areas, with poor hygienic and nutritional conditions .
The presence of K. rhinoscleromatis is not enough for the development of the disease as contact for many years of a patient with healthy individuals may not necessarily lead to the development of the infection in the latter. This has led to the suggestion that susceptibility of the host is important for the development of the disease including impairment in cellular immunity . Therefore, study of the predisposing factors is important and in view of the declining effectiveness of antibiotics against microbes, we might need a different modality of antimicrobial treatment in the future.
The relationship between iron status and immune function and cellular resistance to infection has been the subject of a number of extensive recent reviews . Studies on leukocytes obtained from iron-deficient patients have shown a number of abnormalities: in iron-deficient neutrophils, bactericidal activity was reduced and the respiratory burst was impaired. In iron-deficient lymphocytes, activation and effector functions were normal, but the proliferative response to mitogens was reduced. Antibody-mediated immunity in iron-deficient individuals appeared to be normal . Bondestam and colleagues , reported that the mean serum concentration of iron was significantly lower in children with undue susceptibility to infection than in healthy controls.
Raulin, in 1869, was the first to describe the role of zinc in biology. It is the second most abundant essential trace element in the human body . Several studies have shown the benefits of zinc supplementation in humans, for example, the beneficial effect of zinc lozenges on the duration and severity of common cold symptoms. Infection with HIV results in AIDS, a disease for which zinc supplementation is used as a supporting therapeutic intervention , and bacterial infections; zinc supplementation in leprosy patients has shown beneficial effects .
Zinc is known to serve as the active center of about 300 enzymes and is an essential trace element in humans . In terms of zinc, we did not find many available studies in the literature showing its relation to scleroma patients, but there are studies that show the effect of zinc on respiratory tract infections, including upper and lower respiratory infections. Two recent meta-analyses carried out by Science and colleagues , concluded that oral zinc administered within 3 days of the onset of illness significantly reduced its duration. In terms of the role of zinc in the lower respiratory tract, in children with stunting and endpoint consolidation (radiographic pneumonia), zinc recipients recovered much faster than those in the placebo group .
We found a significant decrease in serum zinc in scleroma patients compared with the control group. Also, there was a significant progressive decrease in the serum zinc level with progression of the disease stage. These results are in agreement with those of Hammad et al. , who studied 50 rhinoscleroma patients and 15 healthy controls in terms of the serum levels of trace elements. They found that the serum zinc levels in early and late stages of scleroma were statistically significantly low, especially in the late stage.
In the current study, there was a significant decrease in serum iron in scleroma patients compared with the control group. Also, there was a significant progressive decrease in serum iron level with progression of the disease stage. These results are in agreement with those of Hammad et al. , who found that the serum iron levels in early and late stages of scleroma were significantly lower than those in controls, especially in the late stage. Also, previous studies reported that a decrease in iron levels is common in chronic specific infections. Higgs and Wells  noted that of 31 patients with chronic mucocutaneous candidiasis, 23 were iron-deficient and nine of 11 improved with oral and parenteral iron therapy alone. Weijmer et al.  studied 16 patients with recurrent staphylococcal furunculosis who also had nonanemic iron deficiency. Furunculosis resolved after 3–4 weeks of iron therapy in all except one patient.
Further studies are recommended to compare iron and zinc levels between rhinoscleroma and other granulomatous diseases. In addition, parameters for cell-mediated immunity should be assessed in future studies, with assessment of the relationship between the serum iron and zinc levels and cellular changes in each stage.
| Conclusion|| |
Serum levels of iron and zinc were significantly lower in patients diagnosed with rhinoscleroma than controls, reflecting the crucial role of iron and zinc in cell-mediated immunity. Serum levels of iron and zinc were the lowest in the fibrotic stage.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stiernberg CM, Clark WD. Rhinoscleroma – diagnostic challenge. Laryngoscope 1983; 93
Zhong Q, Guo W, Chen X, Ni X, Fang J, Huang Z, Zhang S Rhinoscleroma: a retrospective study of pathologic and clinical features. J Otolaryngol Head Neck Surg 2011; 40
Bondestam M, Foncard T, Medhin MG. Suclinical trace element deficiency in children with undue susceptibility to infections. Acta Paediatr Scand 1985; 74
Karyadi E, West CE, Schultink W, Nelwan RH, Gross R, Amin Z, et al.
double-blind, placebo-controlled study of vitamin A and zinc supplementation in persons with tuberculosis in Indonesia: effects on clinical response and nutritional status. Am J Clin Nutr 2002; 75
Gamea AM, El-Tatawi FA. The effect of rifampicin on rhinoscleroma: an electron microscopic study. J Laryngol Otol 1990; 104
Gaafar HA, Bassiouny M, El-Mofty M, Badour NM, Nour YA. Experimental intravenous inoculation of Klebsiella rhinoscleromatis
bacilli in albino rats: a histopathological and bacteriological study. Acta Otolaryngol 2000; 120
Dhur A, Galan P, Hercberg S. Iron status, immune capacity and resistance to infections. Comparative Biochem Physiol 1989; 94
Hershok C. Iron, infection and immune function. Proc Nutr Soc 1993; 52
Kumar V, Choudhry VP. Iron deficiency and infection. Indian J Pediatr 2010; 77
Zalewski PD, Truong-Tran AQ, Grosser D, Jayaram L, Murgia C, Ruffin RE. Zinc metabolism in airway epithelium and airway inflammation: basic mechanisms and clinical targets. A review. Pharmacol Therap 2005; 105
Coovadia HM, Bobat R. Zinc deficiency and supplementation in HIV/AIDS. Nutr Res 2002; 22
George J, Bhatia VN, Balakrishnan S, Ramu G. Serum zinc/copper ratio in subtypes of leprosy and effect of oral zinc therapy on reactional states. Int J Lepr Other Mycobact Dis 1991; 59
Yanagisawa H. Clinical aspects of zinc deficiency. J Jpn Med Assoc 2002; 127
Science M, Johnstone J, Roth DE, Guyatt G, Loeb M. Zinc for the treatment of the common cold: a systematic review and meta-analysis of randomized controlled trials. CMAJ 2012; 184
Singh M, Das RR. Zinc for the common cold. Cochrane Database Syst Rev 2011; 2
Basnet S, Shrestha PS, Sharma A, Mathisen M, Prasai R, Bhandari N, et al
. A randomized controlled trial of zinc as adjuvant therapy for severe pneumonia in young children. Pediatrics 2012; 129
Hammad MS, Farag BA, Tawifik HM. Trace elements in rhinoscleroma, El-Minia Med Bull 2004; 15
Higgs JM, Wells RS. Chronic mucocutaneous candidiasis: new approaches to treatment. Br J Dermatol 1973; 89
Weijmer MC, Neering H, Welten C. Preliminary report: furunculosis and hyperferraemia. Lancet 1990; 336
[Table 1], [Table 2], [Table 3], [Table 4]