Vitamin E Deficiency: Those at risk: premature or low birth weight infants Vegetarians or vegans fat malabsorption or steatorrhea e.g. cystic fibrosis, small bowel overgrowth, pancreatic insufficiency, celiac, Crohns, abetalipoproteinemia genetic defect in hepatic alpha-tocopherol transfer protein > ataxia with vitamin E deficiency (symptoms similar to Friedreichs ataxia) Symptoms: spinocerebellar syndrome w/variable involvement of peripheral nerves: ataxia, dysarthria, hyporeflexia, loss of proprioceptive and vibratory sensation, + Babinski skeletal myopathy pigmented retinopathy hemolytic anemia Heavy Metal Toxicities: Lead: workplace exposure, moonshine, bullets, paint on old houses painless neuropathy often targeting radial nerve > wrist drop in children can produce increased intracranial pressure & cognitive dysfunction anemia w/basophilic stippling, lead line at gum-tooth line abdominal pain, constipation, joint pain/muscle aches fatigue, irritability, insomnia, anorexia, short-term memory impairment Tx: Penicillamine Mercury: Mad Hatter epidemic in 19th century mercury in mirror & felt hat industry, others at risk: dentists, miners, thermometer factory, chloralkali, consumption of polluted fish nausea/metallic taste, gum inflammation, peripheral neuropathy inhibits SAM > excessive salivation, tachycardia, sweating, HTN nephrotic syndrome intention tremor neurasthenia psychiatric symptom: excitability, insomnia, irritation, shyness, depression, etc. in children: acrodynia (Pink disease, common until 1940s Hg in teething powders) characterized by body rash, swelling, irritation of palms and feet, followed by skin desquamation, irritability, photophobia, fever, insomnia, and profuse sweating Tx: decontamination, chelationw/DMSA, penicillamine, dimercaprol Arsenic: metallurgy, treated wood, contaminated water, semiconductor, pesticides, rice acute: painful sensorimotor peripheral neuropathy, garlic breath, torsades de points, acute encephalopathy, hepatitis, pancytopenia, gastroenteritis, Mees lines chronic: symmetric sensorimotor polyneuropathy (sensory first distal to proximal starting w/stocking/glove), calf cramps, diminished vibratory sense, can cause vitamin A deficiency > heart disease and night blindness Tx: chelation w/dimercaprol, give K+ Thallium: hair loss, stupor, GI distress, seizures, headaches, painful symmetric sensory neuropathy; tx: Prussian blue Manganese: Parkinsonism, neuropsychiatric symptoms Mercury: Can produce a sensory neuropathy, but generally associated with paresthesias Copper: hepatic and basal ganglia degeneration, blue vomitus, Wilsons disease Zinc: produces symptoms of copper deficiency like anemia, neurological degeneration, and osteoporosis