Modern Scurvy and Hematology: A Retrospective Chart Review in Kingston, Ontario

BACKGROUND: Historically known as scurvy, Vitamin C deficiency is a rare disorder in developed countries that can lead to bleeding diathesis. A recognized increase in the number of patients found to have Vitamin C deficiency at Kingston Health Sciences Centre (KHSC) prompted a need to re-evaluate the prevalence, predisposing factors, and management of this nutritional deficiency.

METHODS: We conducted a retrospective chart review of patients evaluated by the Hematology service at KHSC between March 2017 and June 2023 who were found to be Vitamin C deficient, defined as a Vitamin C level <25 μmol/L. Twenty-three patients were identified. Data collected included patient demographics, socioeconomic status, co-morbidities, clinical presentation, concurrent hematologic abnormalities, and treatment strategies.

RESULTS: Twenty-three patients with Vitamin C deficiency were evaluated by Hematology at KHSC between March 2017 and June 2023. Almost half (43.5%, n=10) of patients were first assessed in the General Hematology clinic, while 30.4% (n=7) were seen by the inpatient Hematology consult service and 26.1% (n=6) were first seen in the Bleeding Disorders clinic.

Most patients (65.2%, n=15) were assigned male sex at birth. All adult age ranges were represented: 30.4% (n=7) were younger than 40, 56.5% (n=13) were ages 40 through 65, and 13.0% (n=3) were older than 65.

Four (17.4%) patients had previously undergone weight loss surgery, while five (21.7%) had Type 2 diabetes mellitus. Close to half (43.7%, n=10) of patients were taking a proton pump inhibitor daily, while 78.3% (n=18) were taking nutritional supplements other than Vitamin C.

Over one quarter (26.2%, n=6) of patients reported significant alcohol use, defined as greater than or equal to 10 drinks per week on average. The majority (69.6%, n=16) of individuals used recreational substances daily, including cigarettes, alcohol, or marijuana. The primary source of income for 30.4% (n=7) of individuals was government-funded income support, while 30.4% (n=7) were retired and 26.1% (n=6) were actively employed.

The most common reasons for referral to Hematology was assessment for bleeding disorders (43.5%, n=10) and cytopenia(s) (43.5%, n=10), followed by splenomegaly (n=1), pulmonary embolism (n=1), and macrocytosis (n=1). Seven patients (30.4%) experienced major bleeding, defined as bleeding that required hospitalization or guideline-directed transfusion of red blood cells. Common symptoms at presentation included menorrhagia (42.9% of female patients, n=3), gingival bleeding (34.8%, n=8), hematoma (30.4%, n=7), epistaxis (30.4%, n=7), subjective easy ecchymosis (30.4%, n=7), and subjective delayed wound healing (26.1%, n=6).

A Vitamin C level ($20.50 CAD per test at KHSC) was ordered on the first assessment by Hematology in 73.7% (n=14) of patients. The Vitamin C level was undetectable (<5 μmol/L) in 47.8% (n=11) of patients. The mean Vitamin C level among patients in which it was detectable was 13.5 μmol/L. Vitamin C levels were repeated in four patients and remained low in one. Studies for von Willebrand Disease ($268.76 CAD per patient at KHSC) were obtained in 43.5% (n=10) of patients; one of these patients was diagnosed with acquired von Willebrand disease.

Nearly one third (30.4%, n=7) of patients were also Vitamin B12 deficient, while 39.1% (n=9) were iron deficient and 13.0% (n=3) were Vitamin D deficient. The mean hemoglobin when first assessed by Hematology was 126 g/L among females and 117 g/L among males.

Three patients (13.0%) were treated with intravenous Vitamin C; the remainder were treated with oral Vitamin C supplementation or dietary modifications. Ten patients (43.5%) were referred to a dietician as part of their treatment plan. Three patients (13.0%) were prescribed tranexamic acid for bleeding symptoms.

DISCUSSION: Despite its perceived rarity in modern times, Vitamin C deficiency has contributed to a variety of presentations of bleeding diathesis encountered by Hematologists in Kingston, Ontario in recent years. Thus, detailed dietary and social histories, with consequent consideration of Vitamin C status, should be undertaken in the assessment of undifferentiated bleeding disorders. Increased awareness of the prevalence and presentation of Vitamin C deficiency could facilitate earlier diagnosis and appropriate management, including a decrease in costly testing for other bleeding disorders.