History

Patients with vitamin E deficiency may show signs and symptoms of hyporeflexia that progress to ataxia, including limitations in upward gaze.

Patients may present with profound muscle weakness and visual-field constriction.

Patients with severe, prolonged vitamin E deficiency may develop complete blindness, cardiac arrhythmia, and dementia.

Physical Examination

Neurologic findings follow a pattern of progression that can be divided into early and late stages, as follows^{[3, 23]}:

Early findings include hyporeflexia, decreased proprioception, decreased vibratory sense, distal muscle weakness, nyctalopia (night blindness), and normal cognition.
With continued deficiency, neurologic symptoms progress and patients can develop truncal and limb ataxia, as well as diffuse muscle weakness.^[24] Further eye problems may develop, including limited upward-gaze nystagmus and dissociated nystagmus.
Late manifestations include areflexia, loss of proprioception and vibratory sense, dysphagia and dysarthria, cardiac arrhythmias, ophthalmoplegia, and possible blindness. Cognition may be affected in later stages, and dementia can occur.

By contrast, patients with abetalipoproteinemia tend to have a predominance of eye problems, including decline in visual fields and pigmented retinopathy. Children with cholestatic disorders and patients with isolated vitamin E deficiency almost never develop retinopathy. Patients with cholestatic liver disease have a high incidence of behavioral and personality disorders.

Results of certain tests, such as finger-to-nose and rapid, alternating movement tests, are notably affected in vitamin E deficiency. After treatment, patients' ability to perform such tests may remain somewhat impaired but should show some improvement.

Differential Diagnoses

Benomar A, Yahyaoui M, Marzouki N, et al. Vitamin E deficiency ataxia associated with adenoma. J Neurol Sci. 1999 Jan 1. 162(1):97-101. [QxMD MEDLINE Link].
Sokol RJ. Vitamin E and neurologic deficits. Adv Pediatr. 1990. 37:119-48. [QxMD MEDLINE Link].
Sokol RJ, Guggenheim MA, Heubi JE, et al. Frequency and clinical progression of the vitamin E deficiency neurologic disorder in children with prolonged neonatal cholestasis. Am J Dis Child. 1985 Dec. 139(12):1211-5. [QxMD MEDLINE Link].
Tanyel MC, Mancano LD. Neurologic findings in vitamin E deficiency. Am Fam Physician. 1997 Jan. 55(1):197-201. [QxMD MEDLINE Link].
Rino Y, Suzuki Y, Kuroiwa Y, et al. Vitamin E malabsorption and neurological consequences after gastrectomy for gastric cancer. Hepatogastroenterology. 2007 Sep. 54(78):1858-61. [QxMD MEDLINE Link].
Fuller CJ, Huet BA, Jialal I. Effects of increasing doses of alpha-tocopherol in providing protection of low-density lipoprotein from oxidation. Am J Cardiol. 1998 Jan 15. 81(2):231-3. [QxMD MEDLINE Link].
Hathcock JN. Vitamins and minerals: efficacy and safety. Am J Clin Nutr. 1997 Aug. 66(2):427-37. [QxMD MEDLINE Link]. [Full Text].
Traber MG, Frei B, Beckman JS. Vitamin E revisited: do new data validate benefits for chronic disease prevention?. Curr Opin Lipidol. 2008 Feb. 19(1):30-8. [QxMD MEDLINE Link].
West KP Jr, Cole RN, Shrestha S, et al. A plasma α-tocopherome can be identified from proteins associated with vitamin E status in school-aged children of Nepal. J Nutr. 2015 Dec. 145(12):2646-56. [QxMD MEDLINE Link].
Stephens NG, Parsons A, Schofield PM, et al. Randomised controlled trial of vitamin E in patients with coronary disease: Cambridge Heart Antioxidant Study (CHAOS). Lancet. 1996 Mar 23. 347(9004):781-6. [QxMD MEDLINE Link].
Yusuf S, Dagenais G, Pogue J, et al. Vitamin E supplementation and cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000 Jan 20. 342(3):154-60. [QxMD MEDLINE Link]. [Full Text].
Pekmezci D. Vitamin E and immunity. Vitam Horm. 2011. 86:179-215. [QxMD MEDLINE Link].
Traber MG, Stevens JF. Vitamins C and E: beneficial effects from a mechanistic perspective. Free Radic Biol Med. 2011 Sep 1. 51(5):1000-13. [QxMD MEDLINE Link]. [Full Text].
Morley S, Cecchini M, Zhang W, et al. Mechanisms of ligand transfer by the hepatic tocopherol transfer protein. J Biol Chem. 2008 Jun 27. 283(26):17797-804. [QxMD MEDLINE Link].
Jayadev S, Bird TD. Hereditary ataxias: overview. Genet Med. 2013 Sep. 15(9):673-83. [QxMD MEDLINE Link].
Rossato M, Mariotti C. Normal spermatogenesis and sperm function in a subject affected by cerebellar ataxia due to congenital vitamin E deficiency. Andrologia. 2014 Apr. 46(3):322-4. [QxMD MEDLINE Link].
Bromley D, Anderson PC, Daggett V. Structural consequences of mutations to the a-tocopherol transfer protein associated with the neurodegenerative disease ataxia with vitamin E deficiency. Biochemistry. 2013 Jun 18. 52(24):4264-73. [QxMD MEDLINE Link]. [Full Text].
Das SK, Gupta G, Rao DN, et al. Effect of lecithin with vitamin-B complex and tocopheryl acetate on long-term effect of ethanol induced immunomodulatory activities. Indian J Exp Biol. 2007 Aug. 45(8):683-8. [QxMD MEDLINE Link].
Steinraths M, Vallance HD, Davidson AG. Delays in diagnosing cystic fibrosis: can we find ways to diagnose it earlier?. Can Fam Physician. 2008 Jun. 54(6):877-83. [QxMD MEDLINE Link].
Virtamo J, Rapola JM, Ripatti S, et al. Effect of vitamin E and beta carotene on the incidence of primary nonfatal myocardial infarction and fatal coronary heart disease. Arch Intern Med. 1998 Mar 23. 158(6):668-75. [QxMD MEDLINE Link]. [Full Text].
Kono N, Ohto U, Hiramatsu T, et al. Impaired α-TTP-PIPs interaction underlies familial vitamin E deficiency. Science. 2013 May 31. 340(6136):1106-10. [QxMD MEDLINE Link].
Sherf-Dagan S, Buch A, Ben-Porat T, Sakran N, Sinai T. Vitamin E status among bariatric surgery patients: a systematic review. Surg Obes Relat Dis. 2021 Apr. 17 (4):816-30. [QxMD MEDLINE Link].
Ulatowski LM, Manor D. Vitamin E and neurodegeneration. Neurobiol Dis. 2015Dec. 84:78-83. [QxMD MEDLINE Link].
Elkamil A, Johansen KK, Aasly J. Ataxia with vitamin E deficiency in Norway. J Mov Disord. 2015 Jan. 8(1):33-6. [QxMD MEDLINE Link].

Media Gallery

Comparison of the recommended daily allowance (RDA), deficiency replacement dose, and preventive dose in international units (IUs) and milligrams.

of 1

Vitamin E Deficiency Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

What would you like to print?