thiamine-cobaltichlorophyllate (Midoriamin)

Zinc-associated Copper Deficiency Myelopathy: A Case Report.

Goodrich Zachary Z, Schneider Jennifer J

Copper deficiency myelopathy is an uncommon but potentially reversible neurologic disorder characterized by sensory ataxia, gait impairment, and dorsal column dysfunction. Acquired copper deficiency most commonly results from malabsorption, prior gastrointestinal surgery, or excess zinc exposure. Zinc induces intestinal metallothionein, which preferentially binds copper and reduces its systemic absorption, potentially leading to hypocupremia and neurologic dysfunction. Although zinc-containing nutritional supplements are widely used, clinically significant neurologic complications remain rare. A retrospective review of the patient's medical history was performed in addition to a comprehensive literature review. A 70-year-old woman receiving long-term zinc-containing PreserVision AREDS 2 supplementation for age-related macular degeneration presented with 6 months of progressive paresthesia, gait instability, and frequent falls. Neurologic examination demonstrated bilateral sensory deficits and weakness, while magnetic resonance imaging revealed dorsal column T2 hyperintensity. Laboratory evaluation showed undetectable serum copper, mildly elevated serum zinc, normocytic anemia, hypokalemia, and concurrent thiamine deficiency. Zinc-containing supplementation was discontinued, and the patient received copper and thiamine replacement. Over the following two months, serum copper normalized, and she experienced substantial neurologic recovery with restoration of independent ambulation. This report describes a case of copper deficiency myelopathy in a patient receiving long-term high-dose zinc supplementation in the setting of multiple nutritional abnormalities. It highlights the importance of including copper deficiency in the differential diagnosis of patients receiving zinc-containing supplements who present with progressive myelopathy. It is intended to be hypothesis-generating and suggests that individual susceptibility and concurrent nutritional factors may contribute to the development of zinc-associated copper deficiency.

Associations of the gut mycobiome and its cross-kingdom interactions with estrus return in post-weaning sows revealed by metagenomic analysis.

Jiang Pan P, Zhou Mengqing M, Liao Yuhong Y, Du Wenbo W et al.

Post-weaning estrus return is a critical determinant of reproductive efficiency in the swine industry. While the gut microbiome, particularly bacteria, has been significantly associated with estrus return in sows, the role of the gut mycobiome and its cross-kingdom interactions with bacteria in this context remains largely unexplored. Here, we employed fecal metagenomics to characterize the gut mycobiome in 85 sows and investigated its association with post-weaning estrus return. A total of 22 fungal species were significantly associated with estrus return. Normal-return sows were characterized by increased abundance of Arxiozyma slooffiae (formerly Kazachstania slooffiae) and decreased abundances of Malassezia pachydermatis and Alternaria rosae. Moreover, we uncovered cross-kingdom interactions between fungi and bacteria associated with estrus return, where Arxiozyma slooffiae showed a positive correlation with Prevotella spp. enriched in normal-return sows. These interactions were predicted to involve the exchange of metabolites, including Fe2+, thiamine, and nicotinate. Fungal biomarkers demonstrated good discriminatory power for distinguishing normal-return and non-return sows (AUC = 0.906), and the combination with bacterial biomarkers further enhanced the performance (AUC = 0.947). Integrated multi-omics analysis revealed extensive associations between gut fungi and hormones and hormone-related compounds, as well as microbial functional pathways. Notably, Arxiozyma slooffiae was positively correlated with phytoestrogens (including daidzein and genistein) and the steroid hormone biosynthesis pathway but negatively correlated with testosterone. Collectively, these findings provide comprehensive insights into the role of the gut mycobiome and its cross-kingdom interactions in sow reproductive performance.

Letter to the Editor - Regarding Blotske et al: "Evaluating the Utilization and Cost Analysis of High-dose Thiamine when Compounded or Administered via Intravenous Push at an Academic Medical Center".

Hoffman Robert S RS

Wernicke's Encephalopathy in a Young Non-alcoholic Woman Secondary to Prolonged Reduced Oral Intake: A Case Report.

Jabbal Harmanpreet H, Enver Muqeet M, Masood Ahmed Duaa D

Wernicke's encephalopathy (WE) is an acute neurological disorder resulting from thiamine deficiency and is classically associated with chronic alcohol misuse. However, it may also occur in non-alcoholic patients with prolonged malnutrition, persistent vomiting, or impaired nutritional intake, making diagnosis particularly challenging when the classical triad of ophthalmoplegia, ataxia, and altered mental status is incomplete or develops gradually. Delayed recognition can result in irreversible neurological injury, whereas early treatment with thiamine is associated with promising outcomes. We report the case of a 26-year-old woman who presented with persistent vomiting, significant weight loss, and poor oral intake. During her admission, she developed acute binocular diplopia, bilateral ophthalmoplegia, gait ataxia, confusion, and short-term memory impairment. She fulfilled all four Caine criteria for WE, demonstrating dietary deficiency, oculomotor abnormalities, cerebellar dysfunction, and altered mental state/memory impairment. Initial neuroimaging raised concern for pituitary pathology; however, subsequent endocrine investigations and vascular imaging excluded pituitary apoplexy and adrenal insufficiency. Nerve conduction studies and cerebrospinal fluid analysis were unremarkable, excluding peripheral demyelinating disease. Given the characteristic clinical presentation in the setting of prolonged nutritional deficiency, a diagnosis of WE was made, and treatment with intravenous thiamine (Pabrinex) was initiated. The patient demonstrated rapid neurological improvement, with resolution of confusion, marked recovery of ocular signs and ataxia, and improvement in Montreal Cognitive Assessment score from 16/30 to 28/30 before discharge. This case highlights the importance of maintaining a high index of suspicion for WE in non-alcoholic patients presenting with prolonged vomiting and malnutrition. It also emphasises the utility of the Caine criteria in supporting the diagnosis when the classical triad is not initially apparent. Although initial neuroimaging raised concerns regarding pituitary pathology, subsequent investigations excluded alternative diagnoses, reinforcing that imaging findings should not distract from the clinical diagnosis of WE. Prompt empirical thiamine replacement remains essential to prevent permanent neurological damage and achieve excellent clinical recovery.