High‐dose vitamin C therapy for symptomatic deficiency in a patient with myasthenia gravis and Crohn's disease

Abstract

Vitamin C (ascorbic acid) is an essential water‐soluble antioxidant, and deficiency (ie, plasma level <11 μmol/L) can result in scurvy. People at the highest risk for vitamin C deficiency (ie, scurvy) are those with inadequate intake, such as patients with alcohol abuse disorder, malnutrition, psychiatric disorders, restrictive eating habits, and food insecurity, as well as those with malabsorptive syndromes. We present a case of a 26‐year‐old woman with Crohn's colitis, myasthenia gravis, and juvenile rheumatoid arthritis who presented with frequent bruising, epistaxis, and excessive bleeding from small cuts and who was found to be deficient in vitamin C. Plasma levels initially normalized with oral vitamin C supplementation, but bleeding symptoms eventually returned despite high‐dose oral supplementation with 2000 mg daily. She ultimately required routine intravenous supplementation in the home setting for the normalization of levels and the resolution of symptoms. Case reports of vitamin C deficiency typically involve patients with an inadequate intake of vitamin C–containing foods or inadequate absorption. In contrast, our patient reported a regular intake of vitamin C–containing foods, in addition to oral supplementation, but continued to have difficulty maintaining normal vitamin C levels. Scurvy should be considered for any patient with symptoms of bleeding, petechiae, or ecchymosis and, although it can typically be treated with oral vitamin C, intravenous repletion may be necessary in some cases.

A Rare Presentation of Scurvy in a Well-Nourished Patient

“…In developed countries where dietary sources of vitamin C are abundant, deficiencies are rarely found. However, studies have found that scurvy is more prevalent in populations with a high prevalence of psychiatric disorders, alcoholism, or ignorance of proper nutrition [ 2 , 6 , 8 , 9 ].…”

“…Humans lack the capacity to synthesize ascorbic acid, but the organic substance is essential to the human diet due to its role as a cofactor to many metabolic processes, the most important being collagen synthesis [ 2 , 7 , 12 ]. Early manifestations of severe vitamin C deficiency include fatigue, decreased exercise tolerance, and depression [ 2 , 4 , 7 , 9 ]. The most distinguishing features of scurvy are cutaneous findings including follicular hyperkeratosis, perifollicular hemorrhages, ecchymoses, leg edema, and poor wound healing [ 2 , 4 , 9 ].…”

“…Early manifestations of severe vitamin C deficiency include fatigue, decreased exercise tolerance, and depression [ 2 , 4 , 7 , 9 ]. The most distinguishing features of scurvy are cutaneous findings including follicular hyperkeratosis, perifollicular hemorrhages, ecchymoses, leg edema, and poor wound healing [ 2 , 4 , 9 ]. Oral findings involve interdental and marginal gingival erythema and swelling, as well as bleeding after minimal trauma [ 2 ].…”

“…Complete resolution of symptoms is usually seen within three months, while permanent findings can be limited to tooth loss [ 2 ]. In cases where gastrointestinal etiology is suspected and absorption of nutrients is compromised, oral supplement may prove ineffective, therefore intravenous administration is required to elevate and stabilize serum levels of ascorbic acid to its normal range [ 7 , 9 ].…”