Severe vitamin C deficiency in a critically ill adult!

[Shubhankar]

A 79-year-old man was brought to the emergency department because of a progressive onset of confusion associated with marked lethargy. His only complaint consisted of diffuse bone pains. His relatives reported significant weight loss over the past 3 months, associated with anorexia and non-bloody diarrhoea. A treatment of levofloxacine had been started 10 days before admission because of suspected pneumonia. Upon clinical examination, the patient was lethargic. Hemodynamic parameters showed mild hypotension (96/66 mm Hg) associated with tachycardia (97/min), despite a cumulated fluid challenge of 3 l. Oral inspection revealed diffuse and spontaneous bleeding of the gums, which appeared blackened. Many teeth were missing, with the few remaining ones rotten and ready to fall. Subcutaneous edema was noted, involving predominantly the lower limbs, and was associated with purpuric lesions over the legs and forearms. Abdominal auscultation was normal and palpation was painless.

[Samiran]

@shubhankar Vitamin C acts as a unique cofactor for at least eight enzymes involved in the synthesis of collagen, carnitine and norepinephrine. It may also take part in the body anti-oxidant system through its redox potential, buffering harmful oxygen-free radicals produced during pathological conditions such as sustained anaerobic respiration and lasting inflammation. It has critical role in the development of scurvy, through deficient hydroxylation of proline and lysine residues leading to collagen structural instability. Vitamin C supplementation criteria and recommendation for intake have been proposed for the general population.5 For critically ill patients on parenteral nutrition, the recommendation for daily vitamin C supplements ranges from 100 to 3000 mg per day, depending on renal function and the severity of the underlying disease. In severe cases of scurvy associated with multiple organ dysfunction syndrome, high-dose supplementation has been shown to be associated with rapid improvement of the clinical situation without any significant side effects.