Vitamin C deficiency may be a significant risk factor for surgical infections

Author(s):
Hugo Bonatti; Victoria Giffi; Catherine Faege; Maulik Joshi; Aaron George

Background:

Vitamin C deficiency (VCD) is a rare condition in developed countries. Poor dietary choices, socioeconomic barriers, and chronic health conditions may put subsets of the US population at risk for malnutrition including in vitamin deficiencies. Vitamin C may aid in the treatment of severe infections including sepsis.

Hypothesis:

VCD may be underestimated in surgical patients, leading to detrimental complications.

Methods:

After reviewing the course of a patient, who succumbed to Scurvy due to atypical presentation and delay in diagnosis, patients considered at risk to suffer from multi Vitamin deficiency were tested for Vitamin C levels. A data base was created including demographic, clinical and outcome data of VCD patients.

Results:

During a two years period, 44 surgical patients with VCD were identified, fourteen with severe surgical infections. Median age of the ten females and four males was 62.1 (range 45.4 to 77.6) years, median body mass index 33.4 (range 18 to 58.9) kg/m2 (6 morbidly obese); seven suffered from malignancies. The index patient was a 77-year-old female presenting with septic shock, who underwent emergency amputation of her necrotic leg (Figure). After stabilization she underwent debridement of sacral/gluteal necrosis and during laparoscopy for a colostomy the ileocecal region and sigmoid colon were found necrotic causing diffuse peritonitis and were resected. After a protracted course she was made comfort care by her family, and subsequently her Vitamin C levels came back unmeasurable. One cachectic iv drug abuser presented with survey and necrotic leg ulcers. Four patients had leaking staple line/sutured viscus perforation requiring repeat surgery or drainage, three patients had delayed anastomotic leaks and five had poor healing infected soft tissue wounds. Ten patients also had Thiamin deficiency, eleven Zinc deficiency, and twelve had low prealbumin levels. Once diagnosis of VCD was made, patients were started on intravenous ascorbic acid, which was then switched to oral maintenance. Two patients died as a direct result of their VCD, two died from progressive cancer and ten are currently alive.

Conclusions:

VCD is a much more common condition than expected in our rural setting with detrimental consequences in surgical patients. The collected data has prompted us to increase testing for multiple vitamin deficiencies. A prospective study is planned at our hospital to determine the true incidence and prevalence of these deficiency especially in surgical, oncological and bariatric patients as well as various demographics and socioeconomic populations.