Case 22-2018: A 64-Year-Old Man with Progressive Leg Weakness, Recurrent Falls, and Anemia

Vitamin C and alcohol: a call to action

“…It manifests primarily as capillary haemorrhages, gingivitis, lassitude and muscle weakness. [11][12][13][14][15][16][17] Apart from scurvy, severe vitamin C deficiency has been shown to increase the relative risk of myocardial infarction, 5 while marginal vitamin C deficiency has also been shown to be significantly associated with all-cause mortality, with weak associations with death from cancer. 4 Despite the significant progress being made in the clinical significance of hypovitaminosis C, little is known about its role or replacement in chronic alcoholics.…”

“…18 This has traditionally been thought to be due to malnutrition with poor living conditions, leading to multiple nutritional deficiencies, especially vitamin B 1 (thiamine) deficiency, associated with Wernicke-Korsakoff syndrome, and vitamin B 3 (niacin) deficiency, associated with pellagra. [11][12][13][14][15][16][17] However, as early as 1978, in a cohort of 35 patients with alcohol-related illness, Baines 21 reported the incidence of vitamin C deficiency to be 91%, compared with that of vitamin B 1 deficiency reported at 31%. Since then, studies from the 1980s have shown that hypovitaminosis C alone is likely to have a significant effect on chronic alcohol use and vice versa.…”

“…The subsequent loss of liver synthetic function also confers difficulty in interpreting whether clinical signs, such as widespread ecchymoses, are a result of a lack of vitamin C or coagulation factors, or both. [11][12][13][14][15][16][17] In addition, progressive muscle weakness and gait unsteadiness in scurvy can mimic ethanol-induced cerebellar toxicity.…”

“…9 Targeting a subpopulation of chronic alcoholics, we suggest stratification of the quantity of alcohol intake and classification of severity of alcoholic liver disease, and adjusting for smoking status, socioeconomic status, dietary intake, quality of life, cognitive assessment, depression scale and acute illness, as vitamin C deficiency has been associated with these parameters. [11][12][13][14][15][16][17] We suggest instituting vitamin C replacement intravenously with a specified regimen. This may be difficult to justify given the current lack of evidence for intravenous replacement, while juggling known risks, such as cannula site infection and hyperoxaluria, one of the side effects of high-dose vitamin C replacement.…”

“…There has been no lack of case reports documenting florid scurvy in chronic alcoholics, [11][12][13][14][15][16][17] yet the mechanistic links between hypovitaminosis C and chronic alcoholism remain postulations based on research from the early 1980s. Furthermore, replacement regimens and routes remain far from standardised, as evidenced by the varied treatment approaches in these reports (table 1).…”