Letter to the Editor
Hypovitaminosis C as an unexpected cause of bleeding in a cirrhotic patient
Hipovitaminosis C como causa inesperada de hemorragia en un paciente con cirrosis hepática
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Currently, it is a rare cause of bleeding in developed countries, although it may be underestimated in patients with risk factors such as alcoholism and cirrhosis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> Based on clinical presentation and nutritional assessment, a scurvy diagnosis should be suspected, and low serum levels confirm the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The objective of this letter to the editor is to describe a rare cause of bleeding in a cirrhotic patient with risk factors for scurvy.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 65-year-old male with active alcoholism and Child-Pugh class B9 cirrhosis with a past medical history of heavy smoking habit and mild COPD was referred to our hospital because of a 2-month history of recurrent oropharyngeal bleeding. Bleeding was spontaneous and manifested when coughing or vomiting. The patient had undergone multiple outpatient and inpatient consultations, lab tests, imaging techniques (Angio-CT scans), and endoscopic studies (both ENT (Ear-Nose-Throat) fiberscopes and upper gastrointestinal endoscopies). No active bleeding point was observed. Esophageal varices III/IV were detected, and prophylactic banding was performed. Despite this procedure, recurrent oropharyngeal bleeding persisted, requiring frequent blood transfusions, a total of 15, due to severe anemia. At admission, the patient was conscious and had stable vital signs. Oral cavity examination showed an edentulous patient with hematic residues in the oropharynx without active bleeding. An abdominal exam revealed hepatomegaly without palpable splenomegaly. Mild jaundice and hematomas in the arms and legs were evident. Laboratory findings at admission showed hemoglobin 8.6<span class="elsevierStyleHsp" style=""></span>g/dL, the mean corpuscular volume of 100<span class="elsevierStyleHsp" style=""></span>fL, Platelets 92·10E9/L, and white blood cell count 3.5·10E9/L. Total bilirubin 3.41<span class="elsevierStyleHsp" style=""></span>mg/dL, direct bilirubin 1.6<span class="elsevierStyleHsp" style=""></span>mg/dL, albumin 3.67<span class="elsevierStyleHsp" style=""></span>g/dL, prothrombin time 28<span class="elsevierStyleHsp" style=""></span>s, INR 2.1 and fibrinogen 103<span class="elsevierStyleHsp" style=""></span>mg/dL were also observed. Iron studies, vitamin B12, and folate were within normal ranges. During admission, he presented several episodes of oropharyngeal bleeding (≤100<span class="elsevierStyleHsp" style=""></span>cc) without hemodynamic repercussion or need of blood transfusion. Angio-CT scan and new endoscopic procedures (ENT fibroscopy, upper gastrointestinal endoscopy, and bronchoscopy) were performed without identifying an active bleeding point. In upper GI endoscopy, hematic residues at the hypopharynx and friable mucosa were observed. Given the clinical presentation with diffuse superficial hematomas and easy mucosal bleeding, the diagnosis of hypovitaminosis C was suspected, in addition to other additional factors such as coagulopathy associated with his advanced liver disease. Scurvy was confirmed by a reduced serum vitamin C level (0.27<span class="elsevierStyleHsp" style=""></span>mg/dL, normal range: 0.4–2<span class="elsevierStyleHsp" style=""></span>mg/dL). A detailed review of the patient's dietary habits revealed a low fruit and vegetable intake. Intravenous vitamin C infusion was started (1<span class="elsevierStyleHsp" style=""></span>g/d for 3 days followed by oral intake of 1<span class="elsevierStyleHsp" style=""></span>g once daily). Oropharyngeal bleeding resolved within a few days after vitamin C supplementation. In the follow-up visit after one month, improvement in hemoglobin and vitamin C (0.7<span class="elsevierStyleHsp" style=""></span>mg/dL) values were observed.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Humans are among the rare vertebrates who do not synthesize vitamin C. The only source of vitamin C is diet. Hypovitaminosis C may be secondary to lack of intake, decreased absorption, and/or increased demand (such as oxidative states, like smoking). Alcoholic and cirrhotic patients are at risk for scurvy because of low intake and decreased intestinal vitamin C absorption.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,4</span></a> Vitamin C contributes to the maintenance of the soft tissue through collagen synthesis and elastic fiber stabilization. Hypovitaminosis C produces blood vessel fragility and poor wound healing, classifying scurvy as a disease of soft tissue.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,5</span></a> The diagnosis of scurvy is generally based on dietary history, and clinical features such as gingival bleeding, perifollicular hemorrhage, follicular hyperkeratosis with corkscrew hairs, and blood vessel fragility (which manifests as ecchymoses). A rapid resolution of signs and symptoms is seen after vitamin supplementation.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Laboratory investigations may be necessary to confirm less typical cases.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In addition, serum levels correlate with the risk of developing clinical symptoms.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The classic signs of hypovitaminosis C, such as gingival changes, are not always present (as in our patient, who was edentulous and received a soft-food diet), and the presence of other comorbidities may delay the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This case illustrates the need for a high index of suspicion for scurvy in patients with cirrhosis and coagulopathy who present mucosal bleeding, even when the classic signs of scurvy are missing.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Source of funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Source of funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:2 [ "identificador" => "xack613806" "titulo" => "Acknowledgements" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scurvy: a disease almost forgotten" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.M. 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Raugi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0190-9622(99)70244-6" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1999" "volumen" => "41" "paginaInicial" => "895" "paginaFinal" => "910" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10570371" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack613806" "titulo" => "Acknowledgements" "texto" => "<p id="par0045" class="elsevierStylePara elsevierViewall">None.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015800000012/v1_202206230718/S2387020622002790/v1_202206230718/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015800000012/v1_202206230718/S2387020622002790/v1_202206230718/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622002790?idApp=UINPBA00004N" ]
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