Vitamin E-induced coagulopathy in a young patient: a case report.

BACKGROUND: High-dose vitamin E intake is known to inhibit vitamin K-derived coagulation factor synthesis, which can cause serious bleeding events such as gastrointestinal bleeding and intracranial hemorrhage. We report a case of coagulopathy induced by marginally increased levels of vitamin E. CASE PRESENTATION: A 31-year-old Indian man presented with oral bleeding, black tarry stools, and bruising over his back. He had been taking non-steroidal anti-inflammatory drugs for low backache and vitamin E for hair loss. He had mild anemia with normal platelet count, thrombin time, and prolonged bleeding time, activated partial thromboplastin time, and prothrombin time. Serum fibrinogen was slightly raised. Mixing studies with pooled normal plasma, aged plasma, and adsorbed plasma were suggestive of deficiency of multiple coagulation factors due to acquired vitamin K deficiency. Serum phylloquinone was normal, while prothrombin induced by vitamin K absence-II level was increased. Serum alpha-tocopherol was slightly raised. Upper gastrointestinal endoscopy showed multiple gastroduodenal erosions. A final diagnosis of vitamin E toxicity-related coagulopathy was made. The patient responded well to pantoprazole, vitamin K supplementation, multiple fresh frozen plasma transfusions, and other supportive treatments besides the discontinuation of vitamin E supplementation. The coagulation parameters normalized, and the patient was discharged with complete resolution of symptoms and remained asymptomatic during the follow-up for 6 months. CONCLUSIONS: Vitamin E-related inhibition of vitamin K-dependent factors with coagulopathy may occur even at marginally increased levels of serum vitamin E. This risk becomes significant in patients receiving other drugs that may increase the risk of bleeding.

Effect of Achyranthes aspera, 0.2% Aqueous Chlorhexidine Gluconate and Punica granatum Oral Rinse on the Levels of Salivary Streptococcus mutans in 8 to 12 Years Old Children.

BACKGROUND AND OBJECTIVES: To study the effect Achyranthes aspera, 0.2% aqueous chlorhexidine gluconate and Punica granatum oral rinse on salivary Streptococcus mutans count in children. MATERIALS AND METHODS: A total of 60 children of 8 to 12 years of age were randomly allocated into 3 groups. Group A was given 0.2% chlorhexidine mouthwash, group B was given 10% A. aspera mouthwash and group C was given 15% P. granatum mouthwash. The day 1 saliva samples were collected from the subjects and inoculated onto mitis salivarius bacitracin (MSB) agar. The colony counts were obtained by a clinical microbiologist who was blinded to the subject allocation. Plaque scores were then recorded by the investigator with the help of a volunteer. Following this, they received a thorough scaling and polishing. Subjects in each group were then provided with 140 ml of the respective mouthwash, as a daily supervised rinse after breakfast and before sleeping as per instructions. Following mouth rinsing, the children were instructed not to eat or drink for 15 minutes. At the 7th day, unstimulated saliva was again collected from the subjects of all 3 groups, inoculated onto MSB agar and colony count was obtained. Modified Quigley-Hein plaque index was also evaluated for the refreshed score at this stage. Colony counting was done using loop method and statistical analysis was done using Statistical Package for the Social Science (SPSS) software version 21. RESULTS: All the three mouthwashes showed statistically significant reduction of S. mutans count and plaque index after 7 days, i.e. chlorhexidine (p < 0.001 for reduction in S. mutans count and p < 0.05 for plaque score reduction), A. aspera (p < 0.01 for reduction in S. mutans count and p < 0.05 for plaque score reduction) and P. granatum (p < 0.01 for reduction in S. mutans count and p < 0.05 for plaque score reduction). Chlorhexidine had marginally better results in reducing S. mutans count. CONCLUSION: Efficacy of chlorhexidine, A. aspera and P. granatum was statistically significant with respect to reduction of S. mutans count with chlorhexidine being marginally better than the other two; All the three mouthwashes were found to be at par when plaque index values from baseline and after interception of 7 days was calculated; Punica granatum has better antimicrobial effect than A. aspera.