1
|
de Boer HC, Sawhney JS. Pediatric scurvy case report: a novel presentation with deep vein thrombosis secondary to large bilateral spontaneous iliac subperiosteal hematomas. BMC Pediatr 2024; 24:126. [PMID: 38365603 PMCID: PMC10870519 DOI: 10.1186/s12887-024-04579-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/20/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Scurvy is an uncommon disease in developed countries caused by deficiency of vitamin C. We present a case of scurvy in a 14-year-old male with autism with both novel presentation and imaging findings. This case had the novel presentation of lower limb deep vein thrombosis (DVT) secondary to compression of the external iliac vein from large bilateral iliac wing subperiosteal hematomas. Subperiosteal hematoma is a well-recognised feature of scurvy but large and bilateral pelvic subperiosteal hematoma causing DVT has not previously been described. CASE PRESENTATION A 14 year old Caucasian male with background of autism and severe dietary restriction presented with lower limb swelling and immobility. He was diagnosed with lower limb DVT. Further investigation revealed an iron deficiency anaemia, and he was found on MRI to have large bilateral subperiosteal iliac hematomata causing compression of the iliac vessels. He improved following treatment with vitamin C replacement and follow-up imaging demonstrated resolution of the DVT and hematoma. CONCLUSION DVT is rare in children and when diagnosed should prompt investigation as to the underlying cause. This case demonstrates an unusual cause of DVT and as an unusual presentation of paediatric scurvy.
Collapse
|
2
|
Al-Subu AM, Long MT, Nelson KL, Amond KL, Lasarev MR, Ferrazzano PA, Lushaj EB, Anagnostopoulos PV. Risk of Hypovitaminosis and Vitamin C Deficiency in Pediatric Patients Undergoing Cardiopulmonary Bypass. Pediatr Cardiol 2023; 44:1487-1494. [PMID: 37498330 DOI: 10.1007/s00246-023-03243-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023]
Abstract
Vitamin C levels are known rapidly decrease in adult critical illness. Vitamin C scavenges free radicals, provides critical protection of the endothelial barrier, and improves endothelial responsiveness to catecholamines. Children with congenital heart disease and undergoing cardiac surgery might be at increased risk for low circulating vitamin C levels. A prospective single-center observational study investigated perioperative changes in vitamin C levels in critically ill Children who underwent congenital heart surgery using CPB. Vitamin C serum levels were collected preoperatively and postoperatively (upon admission to the ICU, 24 and 72 h). Linear mixed-effect model was used to estimate mean circulating concentration of vitamin C and to estimate changes in concentration over time. Primary outcome was change in circulating levels of vitamin C before and after CPB. Secondary outcomes were hospital length of stay (LOS), acute kidney injury (AKI), and illness severity. Forty-one patients with a median age of 4.5 [interquartile range (IQR) 2.6-65.6] months at the time of surgery were consented and enrolled. Median CPB duration was 130 [90-175] minutes, and hospital LOS was 9.1 [5.2-19] days. Mean vitamin C levels (μmol/L) before CPB, at PICU admission, 24 h, and 72 h were 82.0 (95% CI 73.4-90.7), 53.4 (95% CI 44.6,62.0), 55.1 (95% CI 46.3,63.8), and 59.2 (95% CI 50.3,68.1), respectively. Upon postoperative admission to the PICU, vitamin C levels decreased by 28.7 (95% CI 20.6-36.8; p < 0.001) μmol/L, whereas levels at 24 and 72 h recovered and did not differ substantially from concentrations reported upon PICU admission (p > 0.15). Changes in vitamin C concentration were not associated with CPB time, STAT mortality category, age, or PIM3. Three patients had post-CPB hypovitaminosis C or vitamin C deficiency. Reduction in vitamin C levels was not associated with hospital LOS (p = 0.673). A 25 μmol/L decrease in vitamin C levels upon PICU admission was associated with developing AKI (aOR = 3.65; 95% CI 1.01-18.0, p = 0.049). Pediatric patients undergoing cardiac surgery with CPB showed decreased vitamin C levels during the immediate postoperative period. Effects of hypovitaminosis C and vitamin C deficiency in this population remain unclear.
Collapse
Affiliation(s)
- Awni M Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave Rm H6/535, Madison, WI, 53792, USA.
| | - Micah T Long
- Division of Critical Care, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kari L Nelson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kate L Amond
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael R Lasarev
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Peter A Ferrazzano
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave Rm H6/535, Madison, WI, 53792, USA
| | - Entela B Lushaj
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Petros V Anagnostopoulos
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
3
|
Tan MCB, Idrees K, Zhang KS, Ye F, Morton CT, McEvoy MD. Hypovitaminosis C in Surgical Patients: an Under-recognized but Modifiable Risk Factor for Worse Outcomes? A Single-Institution Prospective Study. J Gastrointest Surg 2023; 27:1941-1943. [PMID: 37081222 DOI: 10.1007/s11605-023-05676-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 03/29/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Marcus C B Tan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, USA.
- Vanderbilt-Ingram Cancer Center, Nashville, USA.
| | - Kamran Idrees
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, USA
- Vanderbilt-Ingram Cancer Center, Nashville, USA
| | - Kevin S Zhang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - Colleen T Morton
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, USA
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| |
Collapse
|
4
|
Kurnick A, Zaveri S, Tadayoni A, Chandrakumar HP, John S. Reversible severe pulmonary hypertension and right heart failure with cardiogenic shock due to scurvy: a case report. Eur Heart J Case Rep 2023; 7:ytad404. [PMID: 37650076 PMCID: PMC10464571 DOI: 10.1093/ehjcr/ytad404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/31/2023] [Accepted: 08/15/2023] [Indexed: 09/01/2023]
Abstract
Background The systemic complications of vitamin C deficiency, otherwise known as scurvy, have been well-documented in history. Few case reports have documented severe cardiopulmonary complications such as right heart failure (RHF) and pulmonary hypertension (PH). Case summary A 25-year-old female presented to the hospital with two weeks of progressive fatigue, dyspnoea, myalgias, and arthralgias. She was admitted for symptomatic anaemia requiring transfusion. Her symptoms persisted and she developed severe PH and RHF, complicated by cardiogenic shock and multiple episodes of cardiac arrest. She was found to have severe vitamin C deficiency secondary to a severely self-restricted diet. After repletion of vitamin C, the patient had complete resolution of RHF and PH. Discussion This case adds to the sparse literature documenting severe cardiopulmonary complications of vitamin C deficiency. We believe that this is the first adult case of scurvy causing RHF and PH leading to cardiogenic shock and episodes of cardiac arrest. There are multiple hypotheses on the pathogenesis of scurvy-associated PH and RHF, including overactivation of hypoxia-inducible transcription factors and deficiency of vitamin C's vasodilatory effect that acts through increased nitric oxide production in endothelial cells. When recognized, early vitamin C repletion may prevent severe cardiopulmonary complications of scurvy.
Collapse
Affiliation(s)
- Adam Kurnick
- Department of Internal Medicine, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Sahil Zaveri
- Department of Internal Medicine, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Ashkan Tadayoni
- Department of Internal Medicine, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Harshith P Chandrakumar
- Department of Internal Medicine, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Sabu John
- Department of Internal Medicine, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
- Division of Cardiology, Kings County Hospital, 451 Clarkson Avenue, Brooklyn, NY 11203, USA
| |
Collapse
|
5
|
Parrott JM, Parrott AJ, Rouhi AD, Parrott JS, Dumon KR. What We Are Missing: Using Machine Learning Models to Predict Vitamin C Deficiency in Patients with Metabolic and Bariatric Surgery. Obes Surg 2023:10.1007/s11695-023-06571-w. [PMID: 37060491 DOI: 10.1007/s11695-023-06571-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE Vitamin C (VC) is implicated in many physiological pathways. Vitamin C deficiency (VCD) can compromise the health of patients with metabolic and bariatric surgery (patients). As symptoms of VCD are elusive and data on VCD in patients is scarce, we aim to characterize patients with measured VC levels, investigate the association of VCD with other lab abnormalities, and create predictive models of VCD using machine learning (ML). METHODS A retrospective chart review of patients seen from 2017 to 2021 at a tertiary care center in Northeastern USA was conducted. A 1:4 case mix of patients with VC measured to a random sample of patients without VC measured was created for comparative purposes. ML models (BayesNet and random forest) were used to create predictive models and estimate the prevalence of VCD patients. RESULTS Of 5946 patients reviewed, 187 (3.1%) had VC measures, and 73 (39%) of these patients had VC<23 μmol/L(VCD. When comparing patients with VCD to patients without VCD, the ML algorithms identified a higher risk of VCD in patients deficient in vitamin B1, D, calcium, potassium, iron, and blood indices. ML models reached 70% accuracy. Applied to the testing sample, a "true" VCD prevalence of ~20% was predicted, among whom ~33% had scurvy levels (VC<11 μmol/L). CONCLUSION Our models suggest a much higher level of patients have VCD than is reflected in the literature. This indicates a high proportion of patients remain potentially undiagnosed for VCD and are thus at risk for postoperative morbidity and mortality.
Collapse
Affiliation(s)
- Julie M Parrott
- Temple University Health System, 7600 Centrail Avenue, Philadelphia, PA, 19111, USA.
- Departmet of Clinical and Preventive Nutrition Sciences, Rutgers University, 65 Bergen Street, Suite 120, Newark, NJ, 07107-1709, USA.
- Faculty of Health Sciences and Wellbeing, The University of Sunderland, Edinburg Building, City Campus, Chester Road, Sunderland, SR1 3SD, UK.
| | - Austen J Parrott
- The Child Center of NY, 118-35 Queens Boulevard, 6th Floor, Forest Hills, New York, NY, 11375, USA
| | - Armaun D Rouhi
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - J Scott Parrott
- School of Health Professions, Rutgers Biomedical and Health Sciences, Reserach Tower, 836B, 675 Hoes Lane West, Piscataway, NJ, 08854, USA
| | - Kristoffel R Dumon
- Penn Metabolic and Bariatic Surgery and Gastrointestinal Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| |
Collapse
|
6
|
Kim GC, Davidson AM, Beyda RM, Eissa MA. Scurvy, abnormal MRI, and gelatinous bone marrow in an adolescent with avoidant restrictive food intake disorder. J Eat Disord 2023; 11:41. [PMID: 36941672 PMCID: PMC10029247 DOI: 10.1186/s40337-023-00770-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/12/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Although medical literature describes pediatric scurvy as "rare", a growing number of case reports suggests otherwise. Patients often undergo costly and unnecessary workup due to unfamiliarity with the presentation of scurvy. This case report further supports the small yet growing literature documenting scurvy and its manifestations in patients with eating disorders. CASE PRESENTATION A 15-year-old female presented to the emergency department with bilateral knee and ankle swelling and pain in the setting of chronic lower limb rash and BMI of 16.3. For years, she had restricted her diet to carbohydrates. Exam showed perifollicular petechial hemorrhagic rash with corkscrew hairs, knee edema, ankle edema with restricted range of motion, and antalgic gait. She was admitted for severe malnutrition from avoidant restrictive food intake disorder. Her hospital course was complicated by recurrent normocytic anemia and fever. Hematology workup revealed anemia from iron deficiency, vitamin K deficiency, and anemia of chronic disease. Rheumatology workup was negative. MRI findings showed dark T1 and bright T2 signals and were read as consistent with leukemia/lymphoma, chronic multifocal osteomyelitis, or Langerhans cell histiocytosis. However, bone marrow biopsy showed gelatinous transformation secondary to malnutrition. She was treated with vitamin C and a nutrition plan and her symptoms improved. CONCLUSIONS Although this patient had common manifestations of scurvy, including perifollicular petechial hemorrhagic rash, joint effusions, anemia, and recurrent fevers, she still underwent an extensive workup. Clinicians should be aware that scurvy can present with multiple symptoms that mimic infectious, rheumatic, oncologic and hematological disease. Clinicians should have a high index of suspicion for scurvy in patients with malnutrition and eating disorders.
Collapse
Affiliation(s)
- Ginny Claire Kim
- University of Texas Health Science Center, 6431 Fannin, MSB 3.150, Houston, TX, 77030, USA.
| | - Asha M Davidson
- University of Texas Health Science Center, 6431 Fannin, MSB 3.150, Houston, TX, 77030, USA
| | - Rebecca M Beyda
- University of Texas Health Science Center, 6431 Fannin, MSB 3.150, Houston, TX, 77030, USA
| | - Mona A Eissa
- University of Texas Health Science Center, 6431 Fannin, MSB 3.150, Houston, TX, 77030, USA
| |
Collapse
|
7
|
Lunt H, Carr AC, Heenan HF, Vlasiuk E, Zawari M, Prickett T, Frampton C. People with diabetes and hypovitaminosis C fail to conserve urinary vitamin C. J Clin Transl Endocrinol 2023; 31:100316. [PMID: 36873955 PMCID: PMC9982671 DOI: 10.1016/j.jcte.2023.100316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/27/2022] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Background Hypovitaminosis C has negative health consequences. People with diabetes and hypovitaminosis C may fail to conserve vitamin C in the urine, thereby displaying evidence of inappropriate renal leak of vitamin C. This study describes the relationship between plasma and urinary vitamin C in diabetes, with a focus on the clinical characteristics of participants with renal leak. Methods Retrospective analysis of paired, non-fasting plasma and urine vitamin C, and also clinical characteristics, from participants with either type 1 or type 2 diabetes, recruited from a secondary care diabetes clinic. Plasma vitamin C thresholds for renal leak have been defined previously as 38.1 µmol/L for men and 43.2 µmol/L for women. Results Statistically significant differences in clinical characteristics were seen between those with; i) renal leak (N = 77) and; ii) hypovitaminosis C but no renal leak (N = 13) and; iii) normal plasma vitamin C levels (n = 34). Compared to participants with adequate plasma vitamin C levels, participants with renal leak tended to have type 2 (rather than type 1) diabetes, a lower eGFR and a higher HbA1c. Conclusion In the diabetes population studied, renal leak of vitamin C was common. In some participants, it may have contributed to hypovitaminosis C.
Collapse
Key Words
- BMI, Body mass index, eGFR, estimated glomerular filtration rate
- Diabetes
- Diabetic nephropathy
- HbA1c, glycated haemoglobin, HPLC, high-performance liquid chromatography
- MET, Minimal elimination threshold, SGLT2, sodium glucose cotransporter 2
- Nutritional and metabolic diseases
- Physiopathology
- T1 diabetes, Type 1 diabetes, T2 diabetes, Type 2 diabetes
- Urine
- Vitamin C deficiency
Collapse
Affiliation(s)
- Helen Lunt
- Diabetes Outpatients, Te Whatu Ora Waitaha Canterbury, Christchurch 8011, New Zealand.,Department of Medicine, University of Otago, Christchurch. 2 Riccarton Ave, Christchurch 8011, New Zealand
| | - Anitra C Carr
- Nutrition in Medicine Research Group, Department of Pathology and Biomedical Science, University of Otago, Christchurch. 2 Riccarton Ave, Christchurch 8011, New Zealand
| | - Helen F Heenan
- Diabetes Outpatients, Te Whatu Ora Waitaha Canterbury, Christchurch 8011, New Zealand
| | - Emma Vlasiuk
- Nutrition in Medicine Research Group, Department of Pathology and Biomedical Science, University of Otago, Christchurch. 2 Riccarton Ave, Christchurch 8011, New Zealand
| | - Masuma Zawari
- Nutrition in Medicine Research Group, Department of Pathology and Biomedical Science, University of Otago, Christchurch. 2 Riccarton Ave, Christchurch 8011, New Zealand
| | - Tim Prickett
- Department of Medicine, University of Otago, Christchurch. 2 Riccarton Ave, Christchurch 8011, New Zealand
| | - Chris Frampton
- Department of Medicine, University of Otago, Christchurch. 2 Riccarton Ave, Christchurch 8011, New Zealand
| |
Collapse
|
8
|
Premnath N, Chung SS, Weinberg OK, Ikpefan R, Pandey M, Kaur G, Geethakumari PR, Afrough A, Awan FT, Anderson LD, Vusirikala M, Collins RH, Chen W, Agathocleous M, Madanat YF. Clinical and molecular characteristics associated with Vitamin C deficiency in myeloid malignancies; real world data from a prospective cohort. Leuk Res 2023; 125:107001. [PMID: 36566538 DOI: 10.1016/j.leukres.2022.107001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
Vitamin C is an essential vitamin that acts as a co-factor for many enzymes involved in epigenetic regulation in humans. Low vitamin C levels in hematopoietic stem cells (HSC) promote self-renewal and vitamin C supplementation retards leukaemogenesis in vitamin C-deficient mouse models. Studies on vitamin C levels in patients with myeloid malignancies are limited. We thus conducted a retrospective analysis on a prospective cohort of patients with myeloid malignancies on whom plasma vitamin C levels were measured serially at diagnosis and during treatment. Baseline characteristics including hematological indices, cytogenetics, and molecular mutations are described in this cohort. Among 64 patients included in our study, 11 patients (17%) had low vitamin C levels. We noted a younger age at diagnosis for patients with myeloid malignancies who had low plasma vitamin C levels. Patients with low plasma vitamin C levels were more likely to have acute myeloid leukemia compared to other myeloid malignancies. Low vitamin C levels were associated with ASXL1 mutations. Our study calls for further multi-institutional studies to understand the relevance of low plasma vitamin C level in myeloid neoplasms, the role of vitamin C deficiency in leukemogenesis, and the potential benefit of vitamin C supplementation.
Collapse
Affiliation(s)
- Naveen Premnath
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - Stephen S Chung
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States; Children's Research Institute, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Olga K Weinberg
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ruth Ikpefan
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mohak Pandey
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Gurbakhash Kaur
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | | | - Aimaz Afrough
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Farrukh T Awan
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Larry D Anderson
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Madhuri Vusirikala
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Robert H Collins
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Weina Chen
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Michalis Agathocleous
- Children's Research Institute, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Yazan F Madanat
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| |
Collapse
|
9
|
Gordon BL, Galati JS, Yang S, Longman RS, Lukin D, Scherl EJ, Battat R. Prevalence and factors associated with vitamin C deficiency in inflammatory bowel disease. World J Gastroenterol 2022; 28:4834-4845. [PMID: 36156920 PMCID: PMC9476859 DOI: 10.3748/wjg.v28.i33.4834] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/23/2022] [Accepted: 08/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) are prone to several nutritional deficiencies. However, data are lacking on vitamin C deficiency in Crohn’s disease (CD) and ulcerative colitis (UC) patients, as well as the impact of clinical, biomarker and endoscopic disease severity on the development of vitamin C deficiency.
AIM To determine proportions and factors associated with vitamin C deficiency in CD and UC patients.
METHODS In this retrospective study, we obtained clinical, laboratory and endoscopic data from CD and UC patients presenting to the IBD clinic at a single tertiary care center from 2014 to 2019. All patients had an available plasma vitamin C level. Of 353 subjects who met initial search criteria using a cohort discovery tool, 301 ultimately met criteria for inclusion in the study. The primary aim described vitamin C deficiency (≤ 11.4 μmol/L) rates in IBD. Secondary analyses compared proportions with deficiency between active and inactive IBD. Multivariate logistic regression analysis evaluated factors associated with deficiency.
RESULTS Of 301 IBD patients, 21.6% had deficiency, including 24.4% of CD patients and 16.0% of UC patients. Patients with elevated C-reactive protein (CRP) (39.1% vs 16.9%, P < 0.001) and fecal calprotectin (50.0% vs 20.0%, P = 0.009) had significantly higher proportions of deficiency compared to those without. Penetrating disease (P = 0.03), obesity (P = 0.02) and current biologic use (P = 0.006) were also associated with deficiency on univariate analysis. On multivariate analysis, the objective inflammatory marker utilized for analysis (elevated CRP) was the only factor associated with deficiency (odds ratio = 3.1, 95% confidence interval: 1.5-6.6, P = 0.003). There was no difference in the presence of clinical symptoms of scurvy in those with vitamin C deficiency and those without.
CONCLUSION Vitamin C deficiency was common in IBD. Patients with elevated inflammatory markers and penetrating disease had higher rates of vitamin C deficiency.
Collapse
Affiliation(s)
- Benjamin Langan Gordon
- Department of Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY 10065, United States
| | - Jonathan S Galati
- Department of Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY 10065, United States
| | - Stevie Yang
- Department of Gastroenterology and Hepatology, New York Presbyterian/Weill Cornell Medical Center, New York, NY 10021, United States
| | - Randy S Longman
- Department of Gastroenterology and Hepatology, New York Presbyterian/Weill Cornell Medical Center, New York, NY 10021, United States
| | - Dana Lukin
- Department of Gastroenterology and Hepatology, New York Presbyterian/Weill Cornell Medical Center, New York, NY 10021, United States
| | - Ellen J Scherl
- Department of Gastroenterology and Hepatology, New York Presbyterian/Weill Cornell Medical Center, New York, NY 10021, United States
| | - Robert Battat
- Department of Gastroenterology and Hepatology, New York Presbyterian/Weill Cornell Medical Center, New York, NY 10021, United States
| |
Collapse
|
10
|
Rozemeijer S, Smit B, Elbers PWG, Girbes ARJ, Oudemans-van Straaten HM, de Man AME. Rapid screening of critically ill patients for low plasma vitamin C concentrations using a point-of-care oxidation-reduction potential measurement. Intensive Care Med Exp 2021; 9:40. [PMID: 34368931 PMCID: PMC8349944 DOI: 10.1186/s40635-021-00403-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/07/2021] [Indexed: 11/11/2022] Open
Abstract
Background Hypovitaminosis C and vitamin C deficiency are common in critically ill patients and associated with organ dysfunction. Low vitamin C status often goes unnoticed because determination is challenging. The static oxidation reduction potential (sORP) reflects the amount of oxidative stress in the blood and is a potential suitable surrogate marker for vitamin C. sORP can be measured rapidly using the RedoxSYS system, a point-of-care device. This study aims to validate a model that estimates plasma vitamin C concentration and to determine the diagnostic accuracy of sORP to discriminate between decreased and higher plasma vitamin C concentrations. Methods Plasma vitamin C concentrations and sORP were measured in a mixed intensive care (IC) population. Our model estimating vitamin C from sORP was validated by assessing its accuracy in two datasets. Receiver operating characteristic (ROC) curves with areas under the curve (AUC) were constructed to show the diagnostic accuracy of sORP to identify and rule out hypovitaminosis C and vitamin C deficiency. Different cut-off values are provided. Results Plasma vitamin C concentration and sORP were measured in 117 samples in dataset 1 and 43 samples in dataset 2. Bias and precision (SD) were 1.3 ± 10.0 µmol/L and 3.9 ± 10.1 µmol/L in dataset 1 and 2, respectively. In patients with low plasma vitamin C concentrations, bias and precision were − 2.6 ± 5.1 µmol/L and − 1.1 ± 5.4 µmol in dataset 1 (n = 40) and 2 (n = 20), respectively. Optimal sORP cut-off values to differentiate hypovitaminosis C and vitamin C deficiency from higher plasma concentrations were found at 114.6 mV (AUC 0.91) and 124.7 mV (AUC 0.93), respectively. Conclusion sORP accurately estimates low plasma vitamin C concentrations and can be used to screen for hypovitaminosis C and vitamin C deficiency in critically ill patients. A validated model and multiple sORP cut-off values are presented for subgroup analysis in clinical trials or usage in clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00403-w.
Collapse
Affiliation(s)
- Sander Rozemeijer
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Research VUmc Intensive Care (REVIVE), 1081 HV, Amsterdam, The Netherlands. .,Amsterdam Medical Data Science (AMDS), 1081 HV, Amsterdam, The Netherlands. .,Amsterdam Cardiovascular Science (ACS), 1081 HV, Amsterdam, The Netherlands. .,Amsterdam Infection and Immunity (AII), 1081 HV, Amsterdam, The Netherlands.
| | - Bob Smit
- LabWest, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA, The Hague, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Medical Data Science (AMDS), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Science (ACS), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Infection and Immunity (AII), 1081 HV, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Medical Data Science (AMDS), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Science (ACS), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Infection and Immunity (AII), 1081 HV, Amsterdam, The Netherlands
| | - Heleen M Oudemans-van Straaten
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Medical Data Science (AMDS), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Science (ACS), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Infection and Immunity (AII), 1081 HV, Amsterdam, The Netherlands
| | - Angelique M E de Man
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Medical Data Science (AMDS), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Science (ACS), 1081 HV, Amsterdam, The Netherlands.,Amsterdam Infection and Immunity (AII), 1081 HV, Amsterdam, The Netherlands
| |
Collapse
|
11
|
Hongsawong N, Chawprang N, Kittisakmontri K, Vittayananan P, Srisuwan K, Chartapisak W. Vitamin C deficiency and impact of vitamin C administration among pediatric patients with advanced chronic kidney disease. Pediatr Nephrol 2021; 36:397-408. [PMID: 32683655 DOI: 10.1007/s00467-020-04662-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Vitamin C deficiency is common in chronic kidney disease (CKD) due to losses through dialysis and dietary intake below requirement. We investigated prevalence of vitamin C deficiency and impact of vitamin C treatment in deficient/insufficient patients. METHODS A prospective cohort study in patients aged 1-18 years with CKD stages 4 and 5D collected demographic data including underlying disease, treatment, and anthropometric assessment. Vitamin C intake was assessed using 24-h dietary recall. Hemoglobin, iron status, serum vitamin C, and serum oxalate were measured at baseline and after treatment. Vitamin C (250 mg/day) was given orally for 3 months to deficient/insufficient patients. RESULTS Nineteen patients (mean age 12.00 ± 4.1 years) showed prevalence of 10.6% vitamin C insufficiency and 78.9% deficiency. There were no associations between vitamin C level and daily vitamin C intake (p = 0.64) or nutritional status (p = 0.87). Median serum vitamin C was 1.51 (0.30-1.90) mg/L. In 16 patients receiving treatment, median serum vitamin C increased from 1.30 (0.23-1.78) to 3.22 (1.77-5.96) mg/L (p = 0.008) without increasing serum oxalate (79.92 (56.6-106.84) vs. 80.47 (56.88-102.95) μmol/L, p = 0.82). However, 62.5% failed to achieve normal vitamin C levels. Ordinal regression analysis revealed patients with non-oligoanuric CKD were less likely to achieve normal vitamin C levels (β = - 3.41, p = 0.03). CONCLUSION We describe high prevalence of vitamin C insufficiency/deficiency among pediatric CKD patients. Vitamin C levels could not be solely predicted by nutritional status or daily intake. The treatment regimen raised serum vitamin C without increasing serum oxalate; however, it was largely insufficient to normalize levels, particularly in non-oligoanuric CKD. Graphical abstract .
Collapse
Affiliation(s)
- Nattaphorn Hongsawong
- Department of Pediatrics, Division of Pediatric Nephrology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Notethasoung Chawprang
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kulnipa Kittisakmontri
- Department of Pediatrics, Division of Pediatric Nutrition, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Parach Vittayananan
- Department of Pediatrics, Division of Pediatric Nephrology, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Konggrapun Srisuwan
- Department of Pediatrics, Division of Pediatric Nephrology, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Wattana Chartapisak
- Department of Pediatrics, Division of Pediatric Nephrology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
| |
Collapse
|
12
|
Diab Shehade K, Lamdan R, Aharoni D, Yeshayahu Y. "What can you C in a limping child?" Scurvy in an otherwise healthy "picky eater". Nutrition 2021; 82:111019. [PMID: 33109452 DOI: 10.1016/j.nut.2020.111019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 11/23/2022]
Abstract
We present a case of an otherwise healthy 3-year-old child who presented with limping, bone pain, fatigue, and agitation. Differential diagnosis included an infection of the bone, malignancy, an inflammatory bone disease, and metabolic bone disease. Magnetic resonance imaging of the lower limbs and the spine was consistent with scurvy, and the diagnosis was confirmed by very low levels of vitamin C. Further history taking revealed a diet based entirely on dairy pudding, with no fruits or vegetables, and being a "picky eater" was the sole reason. Intravenous treatment with vitamin C led to full recovery. Previous reports of scurvy were in patients with other medical conditions, such as malabsorption, or behavioral conditions as in autism. This case demonstrates that scurvy, an almost forgotten condition from past centuries, can occur in otherwise healthy children and should raise awareness regarding the importance of a balanced diet and proper nutritional history taking. Following growth charts as the only screening tool for balanced and inclusive nutrition may not be sufficient.
Collapse
|
13
|
Abstract
BACKGROUND Vitamin C deficiency may be more common than is generally assumed, and the association between vitamin C deficiency and adverse psychiatric effects has been known for centuries. This paper aims to systematically review the evidence base for the neuropsychiatric effects of vitamin C deficiency. METHODS Relevant studies were identified via systematic literature review. RESULTS Nine studies of vitamin C deficiency, including subjects both with and without the associated physical manifestations of scurvy, were included in this review. Vitamin C deficiency, including scurvy, has been linked to depression and cognitive impairment. No effect on affective or non-affective psychosis was identified. CONCLUSIONS Disparate measurement techniques for vitamin C, and differing definitions of vitamin C deficiency were apparent, complicating comparisons between studies. However, there is evidence suggesting that vitamin C deficiency is related to adverse mood and cognitive effects. The vitamin C blood levels associated with depression and cognitive impairment are higher than those implicated in clinical manifestations of scurvy. While laboratory testing for ascorbic acid can be practically difficult, these findings nonetheless suggest that mental health clinicians should be alerted to the possibility of vitamin C deficiency in patients with depression or cognitive impairment. Vitamin C replacement is inexpensive and easy to deliver, although as of yet there are no outcome studies investigating the neuropsychiatric impact of vitamin C replacement in those who are deficient.
Collapse
Affiliation(s)
- David Plevin
- Central Adelaide Local Health Network, Adelaide, SA, Australia. .,Discipline of Psychiatry, The University of Adelaide, Adelaide, SA, Australia. .,Ramsay Health Care Mental Health, Gilberton, SA, Australia.
| | - Cherrie Galletly
- grid.1010.00000 0004 1936 7304Discipline of Psychiatry, The University of Adelaide, Adelaide, SA Australia ,Northern Adelaide Local Health Network, Adelaide, SA Australia
| |
Collapse
|
14
|
Abstract
BACKGROUND Severe vitamin C deficiency, or scurvy, encompasses a syndrome of multisystem abnormalities due to defective collagen synthesis and antioxidative functions. Among the more common presentations is a combination of oral or subcutaneous hemorrhage with lower extremity pain, the latter often exhibiting inflammatory bone changes on magnetic resonance imaging (MRI). CASE PRESENTATION A 12-year-old male with anorexia nervosa presented with asymmetric painful swelling of multiple fingers of both hands. Imaging demonstrated soft tissue and bone marrow edema of several phalanges, without arthritis, concerning for an inflammatory process. Extensive imaging and laboratory evaluations were largely unrevealing, with the exception of a severely low vitamin C level and a moderately low vitamin D level. A diagnosis of scurvy was made and supplementation was initiated. Within 3 weeks of treatment, serum levels of both vitamins normalized and the digital abnormalities resolved on physical exam. CONCLUSIONS This represents the first description of scurvy manifesting with bone and soft tissue changes limited to the hands. There must be a high index of suspicion for scurvy in children with restricted dietary intake or malabsorption who have bone pain, irrespective of location of the lesions.
Collapse
Affiliation(s)
- Emily J. Liebling
- grid.239552.a0000 0001 0680 8770Division of Rheumatology, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Raymond W. Sze
- grid.239552.a0000 0001 0680 8770Department of Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA USA ,grid.25879.310000 0004 1936 8972Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA USA
| | - Edward M. Behrens
- grid.239552.a0000 0001 0680 8770Division of Rheumatology, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA ,grid.25879.310000 0004 1936 8972Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA USA
| |
Collapse
|
15
|
Alten ED, Chaturvedi A, Cullimore M, Fallon AA, Habben L, Hughes I, O'Malley NT, Rahimi H, Renodin-Mead D, Schmidt BL, Weinberg GA, Weber DR. No longer a historical ailment: two cases of childhood scurvy with recommendations for bone health providers. Osteoporos Int 2020; 31:1001-1005. [PMID: 31901946 PMCID: PMC7383933 DOI: 10.1007/s00198-019-05264-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/15/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Scurvy, due to vitamin C deficiency, is commonly referenced as a "forgotten" or "historical" disease. A growing number of case reports challenge this notion. Bone health providers are often consulted early in the presentation of scurvy to evaluate musculoskeletal complaints resulting from impaired collagen production and disrupted endochondral bone formation. In this report, we describe two cases of childhood scurvy. Our objective is to summarize the key features of scurvy for bone health providers, with the goal of raising awareness and facilitating diagnosis in future cases. CASE DESCRIPTIONS Case one occurred in a 12-year-old non-verbal, non-ambulatory female on a ketogenic diet for refractory epilepsy. Clinical findings included hemarthrosis, transfusion dependent anemia, elevated inflammatory markers, and epiphysiolysis. Magnetic resonance imaging (MRI) revealed multi-focal bone marrow signal abnormalities and physeal irregularities. Case two occurred in a typically developing 5-year-old male presenting with limp and knee pain. Symptoms progressed despite casting and immobilization. Mild anemia, elevated inflammatory markers, and multi-focal marrow and physeal MRI abnormalities were identified. Subsequent dietary history revealed total absence of fruit or vegetable consumption. The diagnosis of scurvy was confirmed in both cases by undetectable plasma vitamin C concentrations. Treatment with vitamin C led to rapid clinical improvement. CONCLUSION Scurvy can no longer be considered a historical diagnosis and should not be forgotten when evaluating children with musculoskeletal ailments. Early recognition of the signs, symptoms, and imaging findings of scurvy can reduce the clinical burden of this disease with the timely initiation of vitamin C therapy.
Collapse
Affiliation(s)
- E D Alten
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - A Chaturvedi
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - M Cullimore
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - A A Fallon
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - L Habben
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - I Hughes
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - N T O'Malley
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - H Rahimi
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - D Renodin-Mead
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
- Oak Orchard Community Health Center Inc., Brockport, NY, USA
| | - B L Schmidt
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - G A Weinberg
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - D R Weber
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA.
| |
Collapse
|
16
|
Irvine I, Walshe T, Capra M, Hayes R. Scurvy: an unusual complication of paediatric cancer treatment. Skeletal Radiol 2019; 48:995-998. [PMID: 30374635 DOI: 10.1007/s00256-018-3103-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/13/2018] [Accepted: 10/16/2018] [Indexed: 02/02/2023]
Abstract
Scurvy is a disease that is rarely encountered in modern medicine. A condition that was classically associated with sailors, its incidence has decreased dramatically since the discovery of its association with vitamin C deficiency. We present the case of a 2-year-old boy, whose treatment for neuroblastoma was complicated by gastrointestinal disease, which necessitated enteral feeding. While still undergoing treatment, he started to complain about increasing pain in his lower limbs, which appeared to be markedly tender on palpation. Radiographic findings suggested a diagnosis of scurvy, which was subsequently confirmed on serum biochemistry. This was an unexpected finding, as the child had been receiving adequate vitamin C in his enteral feeds. However, his absorption had become severely impaired due to pseudomembranous gastritis and enteritis, leading to his deficient state. He significantly improved after intravenous ascorbic acid replacement and demonstrated a full recovery, both clinically and radiologically. This case highlights the importance of considering scurvy in the differential diagnosis for at-risk patients. Early recognition can facilitate the simple treatment of this potentially serious condition.
Collapse
Affiliation(s)
- Iain Irvine
- Department of Radiology, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland.
| | - Triona Walshe
- Department of Radiology, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Michael Capra
- Department of Oncology, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Roisin Hayes
- Department of Radiology, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| |
Collapse
|
17
|
Abstract
Background Numerous cases of scurvy secondary to diet limitations have been reported in the literature with most being boys with special needs. To date, the focus of the literature describing vitamin C deficiency has been the medical sequelae of the deficiency. There has been little attention given underlying diet limitations causing the vitamin C deficiency. Case presentation A five-year-old female with typical development initially presented with rash, then later for pain in both lower extremities. After evaluation revealed vitamin C deficiency, she was admitted into an intensive day treatment feeding program. A feeding assessment found she had life-long problems with eating and had a diet that never exceeded ten foods. Across the course of treatment, she learned to eat 29 new foods. At six-month follow-up her body mass index had increased from the 1st to the 61st percentile. At one-year follow-up her body mass index was at the 85th percentile. All sequalae of her deficiency resolved. Conclusions This case is unusual as most reported studies describe males with special needs. The severity of her eating issues suggest providers may consider referral to allied health professionals to address diet limitations for both children identified with nutrient deficiencies as well as children whose selective eating places them at risk for nutritional deficiencies or problems with growth. The child we described was anemic, like 42% of children described in the case literature on scurvy and like 32% of the children in this literature, our patient was underweight. In the literature, comorbid nutrient deficiencies were reported in 22% of the scurvy case studies. We suggest vitamin C supplementation is a necessary component for addressing vitamin C deficiency, but insufficient for addressing the diet limitations causing the nutrient deficiency. Electronic supplementary material The online version of this article (10.1186/s12887-019-1437-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Timothy Hahn
- Feeding Program, Penn State Hershey Medical Center, 905 W. Governor Road, Hershey, PA, 17033, USA
| | - Whitney Adams
- Feeding Program, Penn State Hershey Medical Center, 905 W. Governor Road, Hershey, PA, 17033, USA
| | - Keith Williams
- Feeding Program, Penn State Hershey Medical Center, 905 W. Governor Road, Hershey, PA, 17033, USA.
| |
Collapse
|
18
|
Shaikh H, Faisal MS, Mewawalla P. Vitamin C deficiency: rare cause of severe anemia with hemolysis. Int J Hematol. 2019;109:618-621. [PMID: 30666502 DOI: 10.1007/s12185-018-02575-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 12/11/2018] [Accepted: 12/25/2018] [Indexed: 12/12/2022]
Abstract
Historically known to be a disease of sailors and soldiers in the seventeenth and eighteenth century, scurvy is a rare nutritional deficiency in the developed world, but it can still be seen among the alcoholics and the malnourished. We present a case of a 39-year-old alcoholic male who presented with progressive fatigue and diffuse purpuric rash with scattered ecchymosis for 2 months. Blood work was remarkable for hemoglobin of 9.1 g/dl, which further dropped to 7 g/dl over the next few days. He was then found to have hemolysis on lab work. After an extensive workup, the common causes of hemolytic anemia were ruled out, vitamin C level was checked, which interestingly resulted as 0 mg/dl. Supplementation with oral vitamin C resulted in the gradual resolution of hemolytic anemia and rash. Hemoglobin improved to 15 g/dl in 4 weeks, with normalization of vitamin C level. The clinical features of scurvy can easily be confused with conditions such as vasculitis, deep venous thrombosis, and systemic bleeding disorders. Therefore, comprehensive workup up is required prior to the diagnosis. Although rare, being a reversible condition, early diagnosis and treatment of scurvy in high-risk populations cannot be stressed enough.
Collapse
|
19
|
Golding PH. Experimental folate deficiency in human subjects: what is the influence of vitamin C status on time taken to develop megaloblastic anaemia? BMC Hematol 2018; 18:13. [PMID: 29946471 PMCID: PMC6007024 DOI: 10.1186/s12878-018-0107-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 05/30/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND In 1962 Victor Herbert developed megaloblastic anaemia four months after commencing a severely folate-deficient diet whereas, in his self-experiment 50 years later, this author took 19 months to fully deplete his liver folate store. This author proposed that his own larger initial liver folate store, due to his vegetarian diet and consumption of fortified foods, was the cause of the time difference. MAIN TEXT This author now proposes that Herbert was also likely to have been deficient in vitamin C, thus shortening the time taken to develop folate deficiency. Several human experiments have confirmed the role of vitamin C in protecting reduced forms of folate from oxidation. Although there has historically been no consensus on the required intake of vitamin C, and official recommendations set a level below that required to ensure plasma saturation, recent research supports an intake that would ensure saturation. There have been no longitudinal experiments on human subjects since the introduction of voluntary or mandatory folic acid fortification of food, and the few published models differ significantly in their estimates of human liver folate storage capacity. CONCLUSION Because of the importance of folate in one-carbon metabolism, the potential influence of vitamin C intake on the time taken to deplete the liver folate store should be experimentally investigated.
Collapse
|
20
|
Klimant E, Wright H, Rubin D, Seely D, Markman M. Intravenous vitamin C in the supportive care of cancer patients: a review and rational approach. ACTA ACUST UNITED AC 2018; 25:139-148. [PMID: 29719430 DOI: 10.3747/co.25.3790] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This article reviews intravenous vitamin C (IV C) in cancer care and offers a rational approach to enable medical oncologists and integrative practitioners to safely provide IV C combined with oral vitamin C to patients. The use of IV C is a safe supportive intervention to decrease inflammation in the patient and to improve symptoms related to antioxidant deficiency, disease processes, and side effects of standard cancer treatments. A proposed rationale, together with relevant clinical safety considerations for the application of IV C in oncologic supportive care, is provided.
Collapse
Affiliation(s)
- E Klimant
- Salish Cancer Center, Fife, WA, U.S.A
| | - H Wright
- Naturopathic Specialists, Scottsdale, AZ, U.S.A
| | - D Rubin
- Naturopathic Specialists, Scottsdale, AZ, U.S.A
| | - D Seely
- Department of Research and Clinical Epidemiology, Ottawa Integrative Cancer Centre, Ottawa, ON
| | - M Markman
- Department of Medical Oncology, Cancer Treatment Centers of America, Philadelphia, PA, U.S.A
| |
Collapse
|
21
|
Golriz F, Donnelly LF, Devaraj S, Krishnamurthy R. Modern American scurvy - experience with vitamin C deficiency at a large children's hospital. Pediatr Radiol 2017; 47:214-220. [PMID: 27778040 DOI: 10.1007/s00247-016-3726-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/08/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Until recently scurvy has been viewed in developed countries as a disease of the past. More recently there have been reports of case series of children with scurvy who have had a delayed diagnosis after an extensive diagnostic workup that included imaging. Most of these children have had underlying neurologic conditions such as autism. OBJECTIVE To review the medical records of children diagnosed with vitamin C (ascorbic acid) deficiency based on serum ascorbic acid levels at a large pediatric health care system, to determine imaging findings and utility of imaging in management, and to identify at-risk pediatric populations. MATERIALS AND METHODS We retrospectively identified cases of vitamin C deficiency in children tested for serum ascorbic acid levels during the last 5 years. We used the criteria of normal ascorbic acid >23 μmol/L and included children with ascorbic acid levels <23 μmol/L. We evaluated their clinical history, underlying medical condition, imaging studies obtained and imaging findings. RESULTS We identified 32 children with vitamin C deficiency. All of these children had underlying medical conditions, most commonly iron overload from multiple transfusions related to sickle cell anemia or thalassemia (20), neurologic disorders (4) and bone marrow transplant/chemotherapy (3). No cases of scurvy from dietary deficiency in otherwise normal children were identified. All except two children had multiple imaging studies, primarily related to their underlying conditions. Three of these children had extensive imaging workups related to diffuse musculoskeletal pain. Imaging findings included ill-defined sclerotic and lucent metaphyseal bands (mainly at the knee) on radiography and MRI studies that showed diffuse increased T2-weighted signal in the bilateral lower-extremity long-bone metaphyses, periosteal reaction and adjacent soft-tissue edema. CONCLUSION Vitamin C deficiency is not uncommon in large pediatric health care facilities, and it is frequently missed on clinical evaluation and diagnostic imaging. At-risk populations include those with iron overload, neurologic conditions and history of chemotherapy. Scurvy related to dietary deficiency in otherwise normal children was not encountered. When characteristic MRI findings are seen, particularly in children with a predisposing condition for vitamin C deficiency, scurvy should be considered and a serum ascorbic acid level checked to potentially confirm a diagnosis prior to further invasive tests.
Collapse
Affiliation(s)
- Farahnaz Golriz
- Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA
| | - Lane F Donnelly
- Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.
| | - Sridevi Devaraj
- Department of Pathology and Laboratory Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Raj Krishnamurthy
- Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA
| |
Collapse
|