Reversible Right Heart Failure in Scurvy Rediscovery of an Old Observation

Abstract

A previously healthy 50-year-old woman presented with 3 months of progressively worsening shortness of breath associated with extreme fatigue, anorexia, a 5 to 10 pound weight loss, yellowing of her eyes, heavy menstrual bleeding, and a lower extremity rash. She denied recent trauma.She had never been admitted to the hospital before and had no history of surgical procedures. She took no medications. There was no significant family history. She was a housewife who had worked in the past as a secretary and had never smoked, drank alcohol, or used recreational drugs.Physical examination revealed blood pressure 91/56 mm Hg, heart rate 92/min, respiratory rate 20/min, and temperature 37°C. Oxygen saturation was 85% on room air. Her skin and conjunctiva were pale, and scleral icterus was present. Her neck veins were distended to her earlobes when sitting, and there was massive hepatomegaly. A nonconfluent, nonblanching petechial rash was noted on her anterior legs ( Figure 1A and 1B), and there was a large ecchymosis on her thighs and buttocks (Figure 2).Laboratory data showed severe normocytic anemia with hemoglobin 3.4 g/dL, hematocrit 12%, mean corpuscular volume 90 fL, reticulocyte count 9.7%, serum iron 9 µg/dL, total iron binding capacity 271 µg/dL, and ferritin 147 ng/mL. lactate dehydrogenase was 1117 U/L, haptoglobin (109 g/L) was normal, and direct Coombs was negative. Liver function tests were abnormal with aspartate transaminase 726 U/L, alanine transaminase 670 U/L, alkaline phosphatase 154 U/L, direct bilirubin 1 mg/dL, indirect bilirubin 4.2 mg/dL, and international normalized ratio 2.2. The viral hepatitis panel was nonrevealing. Serum acetaminophen and salicylate levels were undetectable and urine drug screen was negative. anti-neutrophil cytoplasmic antibody and anti smooth muscle antibody tests were negative, and complement levels were normal. Tissue transglutaminase and immunoglobulin A were negative. Serum lactate was 4.2 mmol/L, and B-type natriuretic peptide was elevated (347 pg/mL).An ECG revealed normal sinus rhythm with low voltage in the anterioinferior leads. A computerized tomography scan of her abdomen-pelvis showed periportal edema with hepatosplenomegaly, an enlarged inferior vena cava, portal vein, and splenic vein (Figure 3).Echocardiogram showed enlarged right atrium and right ventricle, septal flattening, right ventricular moderate hypokinesis, and mild-to-moderate tricuspid valve regurgitation without systolic reversal in the hepatic vein ( Figure 4A through 4D). There was no evidence of left ventricular dysfunction.The clue to the underlying pathogenesis of her complicated clinical picture was obtained from a dietary history, which evolved during her hospital stay. The patient refused to drink water from the hospital because she believed it to be contaminated. She rejected hospital food because she only ate organic food at home. Her diet at home was strictly limited to cereal, eggs, and milk. Vitamin deficiency was suspected, and vitamin C level was found to be 0.1 mg/dL (normal ...

Vitamin C Can Shorten the Length of Stay in the ICU: A Meta-Analysis

“…According to case reports of scurvy, in addition to fatigue, anemia, bruising, hematomas, and different types of pain, vitamin C deficiency has been associated with various cardiovascular symptoms [67,68,69,70,71,72,73,74,75,76], dyspnea [64,70,71,72,73,74,75,76,77,78,79,80,81], lower limb edema [13,64,66,70,72,80,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175], infection-type symptoms [66,67,68,73,160,161,165,167,174,175,176,177], bleeding in the gastrointestinal and other regions [76,164,172,175,177,178,…”

“…While scurvy is relatively rare nowadays, it has not disappeared altogether. A number of case reports have described patients with overt scurvy in diverse hospital settings, including ICUs [13,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81]. Furthermore, even though clinical scurvy is rare, very low vitamin C plasma levels, such as those found in scurvy patients, are not uncommon in hospitals.…”

A Very Uncommon Case of Pulmonary Arterial Hypertension

“…Abbas et al [5], described a case of a 50-year-old female presenting with dyspnea, ecchymosis, heavy menses, and jaundice. After detailed evaluation she was diagnosed with pulmonary HT.…”

“…While clinical scurvy is rare in the United states, vitamin C deficiency is not uncommon, and can affect up to 13% of the population, especially malnourished patients and those that suffer from alcohol abuse [5]. Vitamin C deficiency related PAH is thought to occur as a result of the loss of the vasodilatory effect of vitamin C, whereby vitamin C increases synthesis of endothelial NO in the pulmonary circulation [6].…”

Pulmonary Hypertension Secondary to Scurvy in a Developmentally Typical Child

“…Consistent with prior reports, PH rapidly improved after vitamin C supplementation. [3][4][5][6] The mechanism by which scurvy causes PH is unknown, but severe vitamin C deficiency can affect nitric oxide signaling, potentially leading to PH. 7-9 n We thank the pediatric dermatology team, specifically Dr Meena Julapalli and Dr Megan Craddock, for their role in recognizing key physical exam findings, documenting relevant images, and playing a significant role in the clinical decision-making of this case.…”