A rare presentation of an ancient disease: scurvy presenting as orthostatic hypotension

Abstract

SUMMARYA 49-year-old man presented to hospital with severe orthostatic hypotension, gingival dysplasia and a purpuric rash involving his extremities. The orthostatic hypotension failed to respond to fluids and, on the basis of physical examination and dietary history, the patient was given a preliminary diagnosis of scurvy (ascorbic acid deficiency). Serum ascorbic acid levels were undetectable and the orthostasis was resolved within 24 h of ascorbic acid replacement. The pathogenesis of orthostatic hypotension in the setting of scurvy appears to involve impaired catecholamine synthesis and attenuated vasomotor response to α-adrenergic stimulation. We believe that this case describes a rare presentation of scurvy and highlights a previously underreported connection between scurvy and vasomotor instability. BACKGROUND

Ascorbate-dependent vasopressor synthesis: a rationale for vitamin C administration in severe sepsis and septic shock?

“…Cases of scurvy, the clinical presentation of severe ascorbate deficiency, have been reported in critically ill patients in intensive care (Table 1 ) [ 34 – 36 ]. One case presented with multiple organ dysfunction and the intravenous administration of ascorbate resulted in improved cardiovascular functioning within 24 h, particularly increased arterial pressure, decreased heart rate, normalised central venous pressure and a decreased need for catecholamines [ 35 ].…”

“…One case presented with multiple organ dysfunction and the intravenous administration of ascorbate resulted in improved cardiovascular functioning within 24 h, particularly increased arterial pressure, decreased heart rate, normalised central venous pressure and a decreased need for catecholamines [ 35 ]. Another case exhibited typical symptoms of scurvy as well as severe orthostatic hypotension that failed to respond to fluids [ 36 ]. The patient’s ascorbate levels were undetectable and the orthostatic hypotension resolved within 24 h of ascorbate replacement.…”

“…The authors suggested that the pathogenesis of orthostatic hypotension in the setting of scurvy could result from impaired catecholamine synthesis. Vasopressin may also play a role in preventing or minimising orthostatic hypotension [ 37 ], indicating a possible link between ascorbate deficiency and vasopressin insufficiency in this case [ 36 ]. High-dose intravenous ascorbate administration to severely burned patients has been shown to decrease the resuscitation volume required [ 38 ] and also to decrease the need for vasopressors in some patients (Table 1 ) [ 39 ].…”

The only way to fill the gap: Combinations of repurposed drugs against antibiotic resistance and lethal sepsis

“…Vitamin C is also a cofactor in two steps in the synthesis of dopamine and adrenaline. Figure 3 from Zipursky et al [34] describes the biochemical pathway. Vitamin C is involved in the rate-limiting step of synthesis of L-DOPA, the precursor of dopamine and it is also required as a cofactor for the enzyme dopamine beta hydroxylase [33] which converts dopamine to adrenaline (epinephrine).…”

A New Player in Circulatory Adaptation to Orthostatism

“…The study also underlines the role of ascorbic acid in the biosynthesis of catecholamines and the consequences of a decrease in its local bioavailability. Circumstantial evidence suggests that severe ascorbate deficiency may present clinically with OH, 11 but bioavailability of ascorbate has not been systematically investigated in OH.…”