Lesson of the week: Scurvy in patients with cancer

Case reports

From January 1993 to September 1996 we observed six cases of scurvy in 3723 patients with non-cancerous conditions and six cases in 219 patients with cancer. Tables 1 and 2 give details of the six cases in the patients with cancer. All of the patients were men. Two of them (cases 2 and 4) lived alone and three (cases 1, 2, and 4) drank heavily. All of them had a low serum vitamin C concentration as measured by liquid chromatography, and their condition improved with supplemental vitamin C.

Case 1— A 58 year old man with diabetes mellitus was admitted with a month's history of weakness, weight loss, and anorexia. Clinical examination showed spontaneous ecchymosis, intramuscular haemorrhage on the back, and hepatosplenomegaly. Gingivitis was present. His haemoglobin concentration was 140.5 g/l, packed cell volume 50.3%, leucocyte concentration 3.6 × 10⁹/l, platelet concentration 697 × 10⁹/l, and serum cholesterol concentration 2.2 mmol/l (normal range 4.4-6.4). Folate and serum iron concentrations were normal. No coagulation disorders were found. Polycythaemia vera was diagnosed from a total red cell mass of 53 ml/kg (normal range 26-36), with myelofibrosis evident on bone marrow biopsy. Serum vitamin C concentration was 6 μmol/l (normal range 45-90) (table 2). He received 2 g of vitamin C daily, and the haematoma and gingivitis resolved in 1 week.

Case 2 —A 50 year old man had adenocarcinoma of the colon and hepatic and lung metastases. After a second course of fluorouracil and folinic acid chemotherapy he developed haemorrhagic gingivitis. Fluorouracil toxicity was suspected, but because he had persistent gingivitis and had lost 20 kg in weight in 3 months his serum vitamin C concentration was assayed (<6 μmol/l). His haemoglobin concentration was 83 g/l, mean corpuscular volume 64 fl, serum iron concentration 4 μmol/l (normal range 12-32), and albumin concentration 26 g/l. Serum cholesterol concentration was normal (table 2). No coagulation disorders were found. He received 2 g of vitamin C daily, and the gingivitis resolved within a few days.

Comment

Scurvy should be considered in patients with cancer because of the high incidence of malnutrition caused by the chemotherapy, cachexia caused by the disease, and other factors that might lead to an unbalanced dietary intake—for example, exclusive parenteral nutrition, depression, impaired taste, dysphagia, and abdominal pain. Radiotherapy can also cause mucosal atrophy of the small intestine, leading to malabsorption. Increased energy expenditure and inefficient energy utilisation are often noted in patients with cancer,3 and their requirements for vitamin C may also be increased as in smokers4 and people with diabetes.5 The symptoms of scurvy occur rapidly after 1–3 months of vitamin C deficiency when the body's reserve is <300 mg (normal 1500 mg).

Weakness, anorexia, and depression are common in scurvy but also in patients with cancer. Clinicians should suspect vitamin C deficiency when a patient has haemorrhagic features without a clear explanation and swollen, bleeding gums. 1 2

Scurvy is diagnosed from clinical findings and a low serum vitamin C concentration. Serum vitamin C concentration, however, reflects mainly recent dietary intake. Measuring the concentration of ascorbate in leucocytes is a useful assay because it more closely reflects the body's vitamin C stores. This test, however, is not routinely available. Treatment of scurvy consists of 1 g of vitamin C daily for 2 weeks. Clinical manifestations resolve within 2 weeks. Usually a daily dose of 60–100 mg of vitamin C prevents scurvy (one 100 g orange contains 50 mg of vitamin C).

In patients with cancer, bleeding and gingivitis are not necessarily secondary to the disease or chemotherapy but may be due to scurvy. Deterioration and death may occur if this diagnosis is missed.