DIP Episode 517 - B3 and The USMLE

Welcome, my name is Devine. This is episode 517 of the Divine Intervention Podcast. Into these podcasts we're going to be addressing a simple topic that I love to call B3 and the USML. B3 and the USML. For many of you I know this, but I mean B3 is NISN. And when you have a deficiency of NISN there's some pretty classic symptoms you'll have. And again in this era of the USML is where they don't just use buzzwords. It's important to understand descriptions of things. The USML is these days the love descriptions of things. Because I'm sure many of you are familiar with, oh if a person has nice inefficiency they'll have pelagra. And I'm sure many of you know the four D's they'll say diarrhea, dermatitis, dementia and death. But here's the thing. And again by the way I'm going to give like a birth preamble. And then we're going to start making some integrations here. But the USML is again the describe things in many different ways. So like for example the dermatitis, they may describe it as a rush on the neck. And on the hands, to be honest with you, there are some very classic USML pictures for pelagra that you should certainly know. You're going to see like a circular rush around the neck. Some people call that a castles collar. But again they're not going to put castles collar on your exam. They'll just give you a picture or they'll describe it. You see a rush on the hands. Those are very classic USML pictures to know.

Or they may tell you that the person is hyper sensitive to sunlight. Again if you see that they're describing dermatitis. They can give you other symptoms. People that have pelagra for example, they can have like hair loss. Sometimes they can have like a smooth beefy red tongue. And you just see some other brain related symptoms. Like you see them. They have like issues with sleep. They feel weak. They may not tell the person is demented. But they may tell you that the person is confused. The person becomes really aggressive. Aggression is actually a pretty classic symptom found in people that have pelagra. Again they'll also tell you that those people tend to have a lot of diarrhea. They tend to have a lot of diarrhea. Again they will say this person has been having multiple you know stools every day and things of that nature. So again if you see all these things think of pelagra. Think of pelagra. The USML is these days again. They're big on symptom description. Even the answer choices many times are descriptive answers. That's like a testing principle you just want to keep in mind. In a person that as you're taking the USML exams just in general. So again they're very big on descriptions. Please just definitely make sure you keep that in mind. Now you may ask yourself why is it that having myocene deficiencies is a huge problem. Well here's a thing. It's a huge problem because there are two major things in the body that depend on niacin. For example number one is NED.

NEDH. NEDH is extremely useful for so many things. I mean literally if I this may actually be a podcast in the future. But NEDH is used for so many biochemical pathways. Right? Like NEDH is a source of a lot of the high energy molecules that you used to perform oxidative force for relation. You use NEDH to keep your use NEDH to keep the iron in your ribloids cells in the two plus form, the ferrous form. That's the only form that can carry oxygen. There are many things NEDH does. And then another major thing that uses myocene is NEDPH. NEDPH. NEDPH. NEDPH. We make it from the PENTALS-FORCEFILPATHWIN. It's very important for helping us deal with oxidative stress. Remember there is a reason why people that have G6 PD deficiency have so many problems. Why? Because they literally cannot make NEDPH. And also NEDPH is used by your making reactive oxygen species. You've probably heard of NEDPH oxidase deficiency and chronic granulomital stress disease. So, NEDPH is very, very important. Okay? NEDPH is very, very important. Now, one thing our friends at the MBM is LOV is mechanisms. The LOV mechanisms, mechanisms, mechanisms. So today, I'm going to try to use some vignettes to go over the pathophysiology behind NEDPH. So, vignette number one. What if they give you a question about a patient? They tell you that this person is a 31-year-old female. And she has like a three-month-ish short of chronic diarrhea. And we're told that her retro site sedimentation rate is elevated.

And her CRP is also elevated. And we're told that this person has also has like some ulcers, like in their mouth and things like that. If you see chronic diarrhea in a young-ish female, one of the things you want to think about, especially when you see like very elevated inflammatory markers, you want to think about CRP's disease. Remember, niacin isriabs rubbed in the small intestine, especially like in the jajunom and in the ilia. So, if you have jajunal or ilia inflammation for any reason, like in CRP's disease and inflammatory bowel disease, you can certainly get niacin deficiency from that. What's another thing along those bowel lines that can also cause pelagra? If a person is a, if they give you a question about a person, and they tell you that this person has erectile dysfunction, they tell you that this person has megaloblastic anemia, then you're told that this person is GGT. Gamma glutamol transfer is elevated. Well, obviously this person is an alcoholic. Alcoholism also impairs reabsorption of niacin and triptophan in the GI tract. And so if you may be like, why was this triptophan association? Well, here's the thing. Niacin can be made from triptophan. Niacin can be made from triptophan. Niacin can be made from triptophan. So, if you have anything that impairs your ability to reabsorb triptophan in the body, that can certainly cause a person to have pelagra. So, if you're an alcoholic, alcoholism impairs reabsorption of many things.

Like fully, that's why they tend to have megaloblastic anemia. But other things like niacin, triptophan so that can certainly cause them to have issues. Or, what if they give you a question about a patient? And again, they give you the classic pelagra symptoms. And they tell you that this person is noted to have extensive amino aciduria in their urine, extensive amino acid during their urine. If you see this, think of heart-nop disease. Think of what? Heart-nop disease. Heart-nop disease can cause pelagra. Remember, in heart-nop disease, it's a genetic disease is an orosomal recessive. And easy to remember that is if you spell out heart-nop, heart-nop. The second and third letter in the spelling of heart-nop is AR. Think of that as a money for orosomal recessive. It's an orosomal recessive disease where you're unable to reabsorb non-polar amino acids. And amino acids in the proximal tubule. If you can not reabsorb these amino acids, you're going to get in a lot of trouble. Okay? That's why they have a lot of amino acid during. Although remember, another thing, so they won't be able to reabsorb non-polar amino acids like triptophan. If you can not reabsorb triptophan, then you're not going to be able to make niacin. You're going to get in trouble. Another thing along those lines is when people have a global proximal tubule, reabsorption defect, like fancone syndrome, where you have fancone syndrome, that's a global proximal tubule reabsorption defect.

Again, you're not going to be able to reabsorb triptophan. That's going to cause a person to have niacin deficiency. Remember, people that have fancone syndrome, they also will have proximal or type 2 renal tubularcy doses because they also will not be able to reabsorb bicarb in the proximal tubule. So remember, heart-nop disease, the only things you can not reabsorb in the proximal tubule. And also it also affects your GI tract, is a non-polar amino acids like triptophan. But in fancone syndrome, you cannot reabsorb anything in the proximal tubule. You have a global proximal tubule reabsorption defect. So just make sure you keep these things at the back of your mind on exams. What if they give you a question about a person that has pylagristal symptoms? You notice that this person, they tell you that on physical exam, you can hear audible strider. And we were told that this person has chronic diarrhea. And they tell you that this person has this red redness of their face. They have like facial redness. If you see something like this, I really hope you're saying, oh, divine. It sounds like this person has carstenoid syndrome. Carstenoid syndrome can cause pylagra. Because if you think about it, what's the pathophase here? Here's the thing. Here's the thing. In carstenoid syndrome, you have a trimmer, usually in the appendix, that is overproducing serotonin. Where the serotonin come from? Serotonin is made from triptofan.

In fact, another name for serotonin is 5-HT, 5-hydroxy triptofan. So if you're making normally in a normal individual, about 1% of your triptofan is used to make serotonin. But in a person that has carstenoid syndrome, because they have a trimmer, a mast that's making a ton of serotonin, about 70% of their body's triptofan can be used to make serotonin. If you're using an extra 69%, you can already begin to see that, oh, wait, I mean, you don't have enough triptofan to make niacin. And if you don't have enough triptofan to make niacin, you're going to develop pylagra. You're going to develop pylagra. Or what if they give you a question about an immigrant that has been on pharmacotherapy for some infectious disease for a few months, and the Brazilian pylagra style symptoms? Well, think of isonized. Remember, isonized can cause a B6 deficiency. And whenever you have a B6 deficiency, that can cause you to have pylagra. So if you may wonder, how can B6 deficiency cause pylagra? Well, B6 deficiency can cause pylagra because the conversion of triptofan to niacin, it involves an enzyme known as triptofan hydroxylase and a bunch of other enzymes that you don't need to know for your exams. Those enzymes require vitamin B6 as a cofactor. So if you have a B6 deficiency because you're taking a isonized. That can cause you to have pylagra. But another thing as well is that there are other drugs. So please don't just think isonized is the only big one here.

There are actually other drugs that inhibit processes that are associated with conversion of triptofan to niacin. Because again, like I said, I said, ooh, going from triptofan to niacin, you use triptofan hydroxylase. But I said that there are many other enzymes in that process. There are many other enzymes in that process. So what I feel, and again, you don't need to know about these other enzymes. But the critical thing to know is what are some drugs that will inhibit the other enzymes in that process? Well, you want to think about drugs like chloramphenicol. And chloramphenicol can be used to treat many anxieties, especially in developing countries. Although remember, we're doing pretty much using the use because it causes quite a number of problems. The anti-cancer drug, five-floor uersil, can also inhibit the conversion of triptofan to niacin that can certainly cause problems. And then remember, there is this classic immunosuppressant that is used is a phyoprene, or it's close cause in six-megapthopurin. All these things inhibit the conversion of triptofan to niacin. If you give it the conversion of triptofan to niacin that can cause a person to have pelagra. Or what if they give you a question about a person that has pelagra styled symptoms? And you're told that, oh, this person has like a very sweet smell to their secretions like their airwax, their urine, and things like that. That's maple syrup urine disease. Maple syrup urine disease.

Maple syrup urine disease can also cause pelagra. And also, if you may wonder, how can maple syrup urine disease cause pelagra? Well, let's look at the pathophase behind maple syrup urine disease. Maple syrup urine disease is when you have a deficiency. You have a defect in an enzyme known as branch chain ketoacid dehydrogenase. Branch chain ketoacid dehydrogenase. Well, what does branch chain ketoacid dehydrogenase do? Well, what it does is that it breaks down branch chain amino acids. Like what? Like lucine? Isolucine and veilin. Lucine? Isolucine and veilin. Let me ask you this. If you're not able to break down those branch chain amino acids, what's going to happen? What's going to happen? What's going to happen? Well, you're going to have a buildup of what? Of lucine, isolucine and veilin. And if you build up lucine especially, lucine inhibits a very key enzyme that is necessary for niacin synthesis. Whenever you have excess lucine, it's going to inhibit a key enzyme that is necessary for niacin synthesis. Again, you don't need to worry about the enzyme. You can just go QPRT. Again, just don't worry about it. When you're not linoleid, phosphoryboso transferase, QPRT. But again, don't worry about it. Just remember that excess lucine inhibits a critical enzyme that is needed for niacin synthesis. So if you have excess lucine from maple syrup urine disease, that can cause you to have vitamin B3 deficiency and niacin deficiency. And also if you just have a poor diet, right?

Because really, where do we find niacin? Where do we find niacin and triptophan? But we tend to find it in things like meats, like poultry, like fish, right? Meat poultry fish, eggs, peanuts. We tend to find niacin and triptophan in those things. So here's the thing. If you're taking a diet that's pulling those things, like, say for example, you're like a very hard corvegan, that can cause a person to have a niacin deficiency. Although the thing is, especially in the US, there are many foods that are 45 with niacin, so that people do not develop pelagra. Okay, so I'm going to go ahead and stop here. Again, please just make sure you can see all these integrations. This is one of my shorter podcasts, but this is just one of those things that can help you get, like a question or two right on your exam, that you don't have to get wrong. If you're interested, I offer Zoom courses for step one to step three. I've got a separate podcast on that, so you can check that out. I have a bunch of courses coming up in the month of March. And then I offer one on one tutoring for the USML Es. And I have this podcast on Apple, Google, and Spotify. I have a You Tube channel you can check out. And then also don't forget that I also help people with their applications, like mock interviews and things of that nature. And then I have another website called divininterventionlifelessons.com. Divineinterventionlifelessons.com. There's an Apple podcast associated with that.

Every week, I post two podcasts where from a biblical perspective I address a life lesson. So I encourage you to check those out. Many people have listened to those, found those to be incredibly helpful. So thank you for listening to me today. I'll see you in the episode 518. Have a wonderful rest of your day. God bless you. Bye for now. Thank you.

Diarrhea, Dermatitis, and Dementia (or confusion/aggression).

Tryptophan.

Alcoholism or Crohn's disease involving the ileum.

Hartnup disease.

Branched-chain ketoacid dehydrogenase.

Anticonvulsants (e.g., Phenytoin) or anti-TB drugs (Isoniazid).

Defective reabsorption of non-polar amino acids, specifically tryptophan, leading to niacin deficiency.

Carcinoid syndrome (due to a tumor overproducing serotonin).

Excess leucine inhibits an enzyme necessary for niacin synthesis.

Niacin/B3 deficiency (due to loss of precursors like tryptophan).

The conversion involves multiple enzymes; Vitamin B6 is critical.

Isoniazid (anti-TB), Chloramphenicol, or 5-Fluorouracil.

Defective reabsorption of non-polar amino acids, specifically tryptophan, leading to niacin deficiency.

Carcinoid syndrome (due to a tumor overproducing serotonin).

Excess leucine inhibits an enzyme necessary for niacin synthesis.

Niacin/B3 deficiency (due to loss of precursors like tryptophan).

The conversion involves multiple enzymes; Vitamin B6 is critical.

Isoniazid (anti-TB), Chloramphenicol, or 5-Fluorouracil.