3.16.16 – VA Ambulatory Report Pearls – The Power of Vitamin C

The History of Scurvy

LT enlightened us this morning on the history of scurvy. To recap, James Lind (1716-1794) was born in Edinburgh,Scotland and became a surgeon in the British Royal Navy. He served in the Mediterranean on the HMS Salisbury and it was there that he conducted the first ever clinical trial and developed the theory that citrus fruits were a treatment for scurvy. He documented this in a book titled, “A Treatise of the Scurvy,” which “contains an inquiry in the nature, causes and cure, of that disease.”

You can read Lind’s ground-breaking clinical trial here: http://www.jameslindlibrary.org/lind-j-1753/

A Brief Word on Scurvy

Sources:

Main sources of vitamin C include citrus fruits, tomatoes, potatoes, brussel sprouts, cauliflower, broccoli, strawberries, cabbage, and spinach.

Function of vitamin C:

Ascorbic acid is crucial for collagen synthesis and deficiency results in impaired wound healing, defective tooth formation, and deficient osteoblast and fibroblast function.

Diagnosis:

Onset of symptoms is usually 3 months after deficient intake. Diagnosis of vitamin C deficiency (or scurvy) is made clinically based on the following symptoms:

  1. Perifollicular hemorrhage with petechiae and coiled hairs
    1. Note: the skin lesions are typically in dependent areas (e.g, lower extremities) and can coalesce and become palpable; they can mimic systemic vasculitis findings
  2. Ecchymoses
  3. Gingivitis with bleeding and receding gums and dental caries
  4. Impaired wound healing
  5. Arthralgias secondary to hemorrhage into the muscles or periosteium
  6. Edema
  7. Anemia
  8. Generalized systemic symptoms include weakness, malaise, anorexia, depression, neuropathy, and vasomotor instability

Scurvy occurs mostly in severely malnourished individuals, patients with h/o illicit drug use or heavy alcohol use, or those with food insecurity and in the elderly can be due to simply poor dietary intake.

Should I check a vitamin C level?

Yes and no. Be wary that recent vitamin C bolus can normalize plasma ascorbic acid concentrations even when the tissue levels are still deficient. You can measure ascorbic acid levels in leukocytes, which is a better measurement of body stores, but the test is not widely available.

Treatment:

A wide range of replacement doses have been used successfully. Adults are usually treated with 300-1000mg daily for one month.

Many of the constitutional symptoms improve within 24 hours of treatment! Bruising and gingival bleeding resolve within a few weeks!

Vitamin C Deficiency in Patients on Warfarin

We discussed the importance of recognizing vitamin deficiencies in patients taking warfarin. The rationale behind this is that many of the vitamin K rich foods that patients are advised to avoid can also be critical sources of vitamin C. There is a great clinical vignette on this in JGIM and is attached here.

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