Scurvy Induced Hemodynamic Instability

Aim: Our case report aims to inform practicing clinicians of an unusual presentation of vitamin C deficiency in the setting of a developed nation where this illness is rare and underappreciated.

Case Presentation: We present the case of a noncompliant 16-year-old African American female with vertically transmitted human immunodeficiency virus/acquired immune deficiency syndrome who presented to the emergency department (ED) with a CD4 count of 4 and a hemoglobin level of 5.7 g/dL. In the ED, she was found to have persistent low-grade bleeding initially believed to be of an upper gastrointestinal origin, but which was later found come from the oral mucosa. Her stools were dark in color and guaiac positive. She was hemodynamically unstable, for which she was transfused with packed red blood cells and briefly treated with continuous norepinephrine infusion. Her initial coagulation studies were noncontributory with an international normalized ratio of 1.1, a prothrombin time of 35, and a platelet count that was also within normal limits. Esophagogastroduodenoscopy and a colonoscopy were both unremarkable. Bone marrow biopsy showed normocellular marrow with 80% cellularity and trilinear hematopoiesis. Her vitamin C level was zero. She was diagnosed with scurvy and treated with vitamin C supplementation.

Discussion and Conclusion: Vitamin C deficiency can lead to an often-forgotten medical condition called scurvy. It can cause defective collagen synthesis leading to fragile capillaries, gingival bleeding, and cutaneous changes. Unrecognized, this condition can lead to significant bleeding and can be lethal in select patient populations. Our case is unique in that it shows that vitamin C deficiency can masquerade as upper gastrointestinal bleeding and may present with significant hemodynamic instability requiring blood transfusions and vasopressor support. It is therefore imperative to keep in mind the diagnosis of scurvy as a potential cause of hemodynamic instability even in an industrialized nation such as the United States.

Vitamin C deficiency is a rare and underdiagnosed medical entity in the hospital setting that can lead to hemodynamic instability. Scurvy patients can present with melena and oral bleeding, mimicking hematemesis.