Scientific letter
Hypovitaminosis C in the context of the COVID-19 pandemic
Hipovitaminosis C en el contexto de la pandemia COVID-19
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Beyond the physical effects of the disease, there are also biopsychosocial impacts, including depression and social isolation resulting from fear of infection.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The purpose of this letter to the editor is to report a case of scurvy that occurred in the context of the COVID-19 pandemic.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 65-year-old male with a past medical history of bilateral retinal detachments leading to blindness, as well as obsessive-compulsive disorder, presented to our hospital with fatigue and ecchymoses in the abdomen, persisting for one month. These areas correlate with the chafing zone of the belt and underpants. He denied any family history of bleeding or hematologic disease. Following the COVID-19 pandemic, the patient experienced social isolation and remained without leaving home for several months. The patient adopted a diet primarily composed of food ordered from the supermarket and consumed at home. This diet consisted of rice, chickpeas, peanuts, chocolate milk, and cheese. The patient reported no intake of fruits and vegetables.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On physical examination, oral cavity examination revealed no abnormalities. Ecchymosis in the inferior abdomen and right groin were evident. Laboratory findings showed hemoglobin of 10.4<span class="elsevierStyleHsp" style=""></span>g/dL, a mean corpuscular volume of 92.4<span class="elsevierStyleHsp" style=""></span>fL, platelets 189<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L, and a white blood cell count of 3.8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L. Coagulation and platelet function assays yielded normal results, and the peripheral smear did not reveal any significant findings.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Considering the clinical presentation with diffuse superficial ecchymoses and the patient's dietary history, a diagnosis of hypovitaminosis C was suspected. Scurvy was confirmed by a reduced serum vitamin C level (0.3<span class="elsevierStyleHsp" style=""></span>mg/dL, normal range: 0.4–2<span class="elsevierStyleHsp" style=""></span>mg/dL). Other nutritional deficiencies were observed, including low levels of zinc, vitamin D, and vitamin A.</p><p id="par0030" class="elsevierStylePara elsevierViewall">To address the condition, oral vitamin C was initiated at a dose of 1<span class="elsevierStyleHsp" style=""></span>g once daily, accompanied by nutritional education and correction of other deficiencies. Subsequently, the ecchymosis resolved within a few days after commencing vitamin C supplementation.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Humans are among the rare vertebrates that 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 increased demand (such as oxidative states, like smoking and alcohol consumption). The total body pool of vitamin C is 1500<span class="elsevierStyleHsp" style=""></span>mg, and clinical manifestations of scurvy occur when this pool is reduced to less than 350<span class="elsevierStyleHsp" style=""></span>mg. Vitamin C must be eliminated from the diet for 60–90 days to reach such a low level. The Food and Drug Administration recently increased the recommended dietary allowance for vitamin C to 75<span class="elsevierStyleHsp" style=""></span>mg daily for women and 90<span class="elsevierStyleHsp" style=""></span>mg daily for men. For example, a single orange contains 50<span class="elsevierStyleHsp" style=""></span>mg of vitamin C. Scurvy is uncommon today, although specific populations remain at risk. At-risk groups include people experiencing poverty (because of reduced access to groceries), psychiatric disorders (e.g., depression, schizophrenia, or anorexia), and individuals with purported allergies to multiple fruits and vegetables. Alcoholic persons represent one of the largest groups at risk for scurvy because they may have poorly balanced diets. Vitamin C contributes to soft tissue maintenance 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. 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. Laboratory investigations may be necessary to confirm less typical cases.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The COVID-19 pandemic can produce psychological disorders that can lead to social isolation. Social isolation, when occurring in people with pre-existing physical and psychiatric comorbidities, can cause changes in diet, bringing back old diseases such as scurvy.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A literature search was performed looking for case reports of scurvy in the context of the COVID-19 pandemic out between 2020 and 2023 in the following database: MEDLINE on PubMed. Study retrieval was performed by using “scurvy”, as free text words combined with “COVID19”, and “pandemic”.</p><p id="par0050" class="elsevierStylePara elsevierViewall">This is the second case of scurvy reported during COVID-19 pandemic. The previous case involved a 28-year-old male patient who developed scurvy due to increased alcohol consumption and a diet primarily consisting of meat (sausage, chicken, burgers) and eggs.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0055" class="elsevierStylePara elsevierViewall">Written informed consent was obtained.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true ] "idiomaDefecto" => "en" "url" => "/23870206/0000016200000001/v2_202401260813/S2387020623005363/v2_202401260813/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016200000001/v2_202401260813/S2387020623005363/v2_202401260813/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623005363?idApp=UINPBA00004N" ]
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