By David Wild

When two of their patients with inflammatory bowel disease presented with some striking signs and symptoms, clinicians at the Mount Sinai Hospital in New York City were forced to consider a condition associated with the Napoleonic Wars, potato famines and long sea voyages: scurvy.

“Many clinicians think of scurvy as a disease of the past, but the prevalence of vitamin C deficiency in the general population is 7%, and IBD patients may be at higher risk of this deficiency due to dietary restrictions or the disease itself,” said Katie Dunleavy, MB BCh, an internal medicine resident at Mount Sinai.

Most of the literature on micronutrient deficiencies in IBD has focused on vitamin D, vitamin B12 and iron, Dr. Dunleavy said. “There’s been almost no mention of vitamin C in the IBD literature since the 1970s.”

The two patients who prompted Dr. Dunleavy and her colleagues to suspect scurvy presented with perifollicular hemorrhage, arthralgia, gingivitis, hair loss and fatigue. Their serum vitamin C levels were less than 0.2 mg/dL, which is considered low. The findings also led them to perform a case series to investigate whether other patients at their hospital had vitamin C deficiency.

They identified 20 patients with IBD treated at their hospital between February 2018 and October 2019 who had laboratory-documented vitamin C deficiency. Of those, 80% had symptoms of scurvy. Specifically, 45% had arthralgia, 30% had dry and brittle hair, 20% had pigmented rash, 15% had gingivitis, 10% bruised easily, and 5% had brittle nails.

Roughly one-third of patients had three or more of these clinical manifestations, Dr. Dunleavy reported at the 2019 meeting of the European Crohn’s and Colitis Organisation (poster 144). Her team also found that 70% of patients with vitamin C deficiency had low levels of vitamin D; 20% had vitamin B12 deficiency; and 40% were deficient in vitamins C and D and iron.

According to the medical record analysis, most patients were younger (median, 27.5 years of age) and had active Crohn’s disease, which Dr. Dunleavy said is not surprising given that vitamin C is absorbed in the small bowel.

She also reported that 30% of the patients had primarily ileal disease, 25% had primarily colonic disease, and the remainder had ileocolonic disease. Half had nonstricturing and nonpenetrating disease, 35% had stricturing disease, and 15% had penetrating disease. About half of the patients had a history of surgery and 70% were receiving biologics.

Dr. Dunleavy said the limited nature of a case series makes it difficult to draw conclusions about the relationship between vitamin C deficiency and disease location and phenotype, but she said her team will be studying possible scurvy risk factors in future prospective studies. In the meantime, a more obvious cause of vitamin C deficiency they found was avoidance of vitamin-rich foods. Specifically, 73% of patients who underwent nutritional counseling said they completely or partially avoided fruits and vegetables, and 22% said they had been advised to do so by a gastroenterologist.

“Our IBD patients need to have appropriate dietary counseling, and physicians need to be educated about nutritional needs, particularly when they advise restrictive diets to patients,” Dr. Dunleavy said.

The new study and previous findings indicate that people with IBD should undergo more frequent evaluation for vitamin C deficiency, said David Suskind, MD, an associate professor of pediatrics in the Division of Gastroenterology, Hepatology and Nutrition at Seattle Children’s Hospital. Laboratory testing is necessary because the signs of deficiency, such as gingivitis, brittle hair and easy bruising, “can be easily overlooked,” said Dr. Suskind, who was not involved with the study.

“These findings remind us that nutrition is central in IBD, and as physicians, we need to be aware of possible deficiencies, since they can impact our patients’ health,” he said. “Knowing whether and what foods patients are leaving out of their diet can help clinicians home in on potential nutritional deficiencies.”