Sepsis, coma, limb and bowel gangrene and skin ulcers: a case of 21st century scurvy
Author(s):
Hugo Bonatti; Anthony Basel
Background:
Vitamin deficiency together with malnutrition may be encountered in individuals presenting with critical illness including sepsis. In industrialized countries, destitute populations, those in poverty, as well as drug and alcohol abuse and poor dietary choices are common risk factors.
Hypothesis:
Scurvy may still be encountered in the United States.
Methods:
A 77 year-old female with known history of domestic neglect and poor living conditions presented to the emergency department with fever, confusion, abdominal pain with distention, a necrotic left lower leg and a large necrotic area over her sacral/gluteal regions and multiple skin ulcers.
Results:
The large necrotic gluteal area was debrided and laparoscopic exploration for colostomy showed peritonitis originating from scattered areas of bowel necrosis. A segment of necrotic ileum and the sigmoid colon were resected leaving her in discontinuity. On 2nd look surgery the ischemic terminal ileum was resected with ileocoloic anastomosis and end descending colostomy. Despite aggressive source control and medical management, the skin ulcers continued to spread over the coming next days. The patient was found to be profoundly hypothyroid and vitamin C deficient and aggressive supplementation was started. The patient did not recover and the family opted to pursue hospice care.
Conclusions:
Poly vitamin deficiency together with endocrinopathy can complicate a variety of critical illnesses. Providers should remain vigilant to provide early diagnosis and treatment in an effort to improve outcomes in at risk patients. The case led to awareness of Vitamin deficiencies and accordingly the number of patients being tested for Vitamin C and B1 levels significantly increased especially in the surgical department. Approximately 25% of patients were found to be Vitamin C and/or B1 deficient, which is much higher than previsouly reported.