Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 1–4 Contents lists available at ScienceDirect Egyptian Journal of Chest Diseases and Tuberculosis journal homepage: www.sciencedirect.com Serum zinc level in bronchial asthma Aida M. Yousef a,⇑, Ekramy Elmorsy b a b Chest Department Faculty of Medicine, Mansoura University, Egypt Forensic Medicine, Faculty of Medicine, Mansoura University, Egypt a r t i c l e i n f o Article history: Received 11 October 2016 Accepted 19 October 2016 Available online 16 December 2016 Keywords: Bronchial asthma Serum zinc level a b s t r a c t Background: Free radicals has a harmful effects on the cells and tissues. It is responsible for the pathogenesis of many diseases. Antioxidants decrease the harmful effects of free radicals. Trace elements like selenium, zinc and copper are crucial for the activity of these antioxidants. The aim of this study is to determine serum zinc level in asthmatic patients during acute attacks, after inhaled corticosteroid therapy and during asymptomatic periods in order to evaluate the relation of serum zinc level to different clinical phases of asthma. Methods: The study included 46 asthmatic patients (group 1 and group 2) and 30 healthy persons as a control group (group 3) and having no personal or family history of allergy. The first group included patients presenting with acute asthmatic attacks (n = 26). This group was evaluated before the treatment and after three months of inhaled steroid therapy. The second study group included asthmatic patients who were asymptomatic (n = 20). Control group (group 3, n = 30). Serum zinc level was measured in all cases. In addition, pulmonary function tests were performed and forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were determined in all patients. Results: During the acute attacks, serum zinc level was lower than after inhaled corticosteroid therapy in group 1 with a significant difference (p < 0.05). FVC and FEV1 were also statistically different in the pre and posttreatment periods (p < 0.05). Serum zinc level was significantly lower in group 1 (pretreatment) when compared with groups 2 and 3 (p < 0.05). Conclusion: Measurement of zinc level could be recommended in asthmatic adults. proper supplementations of zinc can be useful in the management of asthmatic patients due to increase the effect of antioxidant defense system. However, further multi-centre studies with greater number of patients are needed to warrant the results of this study. Ó 2016 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). Introduction The increased incidence of bronchial asthma and allergic diseases is a matter of concern. injury and inflammation in such cases may be a result of oxidative stress. A potent antioxidant can act against inflammation and prevent the resulting tissue injury. The antioxidant defense need enzymes that act in presence of trace elements like zinc. observational studies have shown that diets low in antioxidants, such as zinc, selenium, magnesium, vitamin C are associated with an increased risk of asthma [1,2]. Zinc is essential for cellular function in the immune response and plays an important role in modulating the immune system [3]. Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis. ⇑ Corresponding author. E-mail address: [email protected] (A.M. Yousef). Oxidative stress occur when an imbalance occurs between oxidants and antioxidants in favor of oxidants. Increased oxidative stress lead to secondary metabolic reactive oxygen species (ROS) that may cause direct lung injury [4]. Our hypothesis is that adult asthmatic patients may have a low serum zinc level that may be a risk factor in this group patients. Our first aim is to evaluate serum level of zinc among asthmatic patients and the second aim is to compare level of zinc between asthmatic patients and healthy controls. Materials and methods This prospective case control study was performed in our institution. The study was conducted between February 2014 to the end of May 2015. The study included 46 asthmatic patients (20 males and 26 females) who were admitted to our department http://dx.doi.org/10.1016/j.ejcdt.2016.10.009 0422-7638/Ó 2016 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 2 A.M. Yousef, E. Elmorsy / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 1–4 and 30 healthy adult (12 males and 18 females) with no history of asthma. Bronchial asthma was diagnosed based on the history, family history, and clinical examination such as episodic breathlessness, cough, wheezing and chest tightness and laboratory results. Measurements of pulmonary function tests provide an assessment of the severity of airflow limitation, its reversibility and provide a confirmation of the diagnosis of bronchial asthma. Detailed history regarding bronchial asthma was taken, including age at the first presentation of asthma, duration of asthma, daytime and night symptoms, frequency of admission per year, types of drug used. Every patient was subjected to epidermal skin tests to detect the atopy with the allergens, PA chest X-ray, complete blood count. Anthropometric measurements which included weight (wt.), height (ht) and body mass index (BMI) was performed in all patients. pulmonary function tests were performed and forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were determined in all patients using spirometer. A local Ethical Committee approved the study. The control group was healthy people of comparable age and sex to the patients, had no disease based on history and physical examination, no history of asthma and zinc deficiency. Inclusion criteria included any patient with confirmed diagnosis of asthma with no zinc supplementation in drug history. Exclusion criteria include every patient take any supplementation of trace elements in both group. Patients with renal or liver disease, diabetes mellitus, infection or thyroid dysfunction were excluded. patients received systemic, inhaled steroids, acetyl salicylic acid or nonsteroidal antiinflammatory drugs for the last 2 weeks. Five cc Blood samples were taken to measure serum zinc level in the three different groups in the study. First group: This group include patients who presented with acute asthma attacks (n = 26). five cc of blood was taken to measure the serum zinc level. After control of the acute asthma attack with the appropriate treatment, patients were discharged on inhaler corticosteroid treatment for three months with follow up. Provided that patient had no another acute attack during this period, another blood sample was taken to estimate the serum zinc level. Thus zinc level has been measured during the attack and after the steroid treatment. Second group: Twenty patients with asymptomatic bronchial asthma who were followed by our department. Third group: Thirty healthy persons based on medical history and clinical examination. Blood samples were collected and prepared following Smith et al. [5]. Briefly, five ml of venous blood sample were obtained from each subject and centrifuged to collect sera. Samples were kept in polyethylene containers and frozen immediately at 20 °C until analysis. All samples were transferred to the laboratory in an ice box using ice chips to preserve them. Before assay, samples were allowed to come to room temperature and mixed gently. Then 0.5 ml of plasma of each sample was added to 2 ml of deionized water in a plastic test tube and mixed for 30 s. Analysis of serum zinc levels (SZnL) was done by Perkin Elmer 2380 Atomic Absorption Spectrophotometer. Assay optimization was carried out following the operating manual. The source of the flame was an air- acetylene mixture and wavelength was adjusted to 213.9 nm. Statistical analysis Statistical analysis was done using Graph PadPRISM 5 (Graph Pad Software Inc., San Diego, CA). As the data showed parametric distribution, student unpaired t-test was used for comparisons. For categoral variable comparisons, Fisher exact and Chi-square test was applied for gender and BMI comparisons, respectively. Pearson test was used for correlation studies. p-values 6 0.05 were considered as significant. Results Mean age of the acute asthmatic patients was 47 ± 3 y (range of 23–63 y) in comparison with 41 ± 3.1 y (range of 22–62 y) in the stable asthmatic patients, and 45 ± 2.3 y (range of 20–65 y) control subjects. There was no significant difference regarding the mean ages of the groups (p > 0.05). There was no significant difference among the groups regarding body mass index (p > 0.05). The parameters of FEV1 and FVC in pulmonary functional tests were significantly decreased during the attacks in comparison to that after the treatment of inhaled steroids with a statistically significant difference (p = 0.0001) (Fig. 1). Hypozincemia was defined when serum Zn level below 60.0 lg/ dL. 44% out of the case group had hypozincemia. Mean serum zinc values of asthmatics was 56.8 ± 6.0, while, it was 82.1 ± 5.9 in the controls. This difference was significant (p < 0.01) (Fig. 2) (Table 1). In the first group, serum zinc levels measured during the attacks were lower than after the treatment with a significant difference (p = 0.008) (Table 1). Discussion Bronchial asthma is a chronic inflammatory lung disease. It is characterized by a production of mucous, airway smooth muscle (ASM)hypertrophy and hyperplasia [6]. Figure 1. Scattered plotgraphs showing differences in respiratory function parameters used in the study between the controlled and uncontrolled asthmatic groups. A.M. Yousef, E. Elmorsy / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 1–4 A B P value 100 *** < 0.0001 100 80 P value *** 0.0008 80 SZnL (µg/dl) SZnL (µg/dl) 3 60 40 20 60 40 20 0 0 Conrol BA UC Asthmatic BA Cont Figure 2. Scattered plots graphs for Serum Zn level (SZnL) in the studied population. (A) shows SZnL in controls and all asthmatic subjects involved in the study, while (B) shows SZnL in controlled and uncontrolled asthmatic cases according to their response to therapy. Table 1 Serum zinc level in asthmatic patients and the control group. Minimum Maximum Mean Std. deviation Control Asthmatic 74.3 93.2 82.1333 5.94573 45.7 70.6 56.8139 6.06325 There is an evidence suggests that bronchial asthma is associated with specific inflammatory abnormalities in the airways of asthmatic patients. This inflammatory state is often associated with increased production of reactive oxygen species [ROS] and free radicals that have a damaging effects on tissues [7]. Antioxidants combat the damaging effects of ROS [8]. Free radicals have a harmful effects on the cells and tissues. It have been proposed to be responsible for the pathogenesis of many diseases. The antioxidant mechanisms that protect the lung against these oxidants include: Glutathione peroxidase (GSH-Px)4 and three superoxide dismutases (SODs). the super oxide dismutases have copper and zinc, while, GSH-Px has selenium in their structure. The most important antioxidant systems are the superoxide dismutase (SOD) which contains zinc and copper in their structures, and hence zinc is essential for the optimal functions of immune system. Changes in the level of serum zinc level has a negative effect on the activity of antioxidant systems leading to hyperreactivity and inflammation in the respiratory tract [9]. Based on the previous data, it was our interest to test the hypothesis that a low serum zinc level may be a risk factor for asthmatic symptoms in patients with bronchial asthma. Our results are in agreement with the results of other researchers [9–13]. There was a significant decrease in SZnL in patients with BA in comparison with the healthy controls. Malo et al. [14] reported that decrease in serum Zn could cause occupational asthma. However, Toro et al. reported no significant differences [15]. Studies using tissues from asthmatic humans and experimental allergic asthmatic mouse models have revealed that antioxidants can be used as promising treatments for people with asthma [16]. Taylor et al. [17] reported that zinc deficiency increases the oxidative stress in mice and that the oxidant damage in the respiratory tract can be prevented when zinc is added to their diet. The mechanism of hypozincemia in enhancing respiratory diseases in adults can be explained by decrease ability of the cell membrane to resist free radicals this lead to impairment of the stability and integrity of the cell membrane due to release of enzymes from lysosome and histamine from mastocytes. During excessive stress, release of leucocyte endogenous mediator from activated phagocytes occur. This lead to redistribution in plasma Zn to the liver [18–20]. 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