Scurvy Following Gastric Bypass

This report highlights a unique case of scurvy presentation following gastric bypass surgery. A 39-year-old female presented for outpatient dermatology follow-up for a rash that had been present for several months, affecting the buttocks, extremities, and trunk. Given her clinical presentation paired with histologic findings and a remote history of gastric bypass surgery, concern for vitamin C deficiency (scurvy) was raised. A blood L-ascorbic acid level was drawn showing low vitamin C levels, which confirmed the suspected diagnosis of scurvy. 

Introduction

Scurvy is a disease caused by a deficiency of ascorbic acid, which is more commonly known as vitamin C. Vitamin C deficiency has a predilection for affecting connective tissue.¹ The role of vitamin C in the body is to act as a reducing agent for the amino acids proline and lysine when undergoing hydroxylation. Both of these amino acids are necessary for the synthesis of collagen.¹ When collagen synthesis is defective, vascular integrity is reduced, which results in the clinical presentation of easy bruising, petechiae, gingival bleeding, and impaired wound healing.² A lack of vitamin C is diagnosed in approximately 7% of Americans.³ Several predispositions put patients at a higher risk for developing scurvy, such as primary malabsorptive disorders, secondary bariatric surgery, and food allergies.

The procedure carries multiple inherent risks and possible complications, including chronic malnutrition and subsequent neurological compromise secondary to both water or fat-soluble vitamin deficiencies.⁴ There are several neurologic symptoms associated with gastric bypass surgery, including encephalopathy, optic neuropathy, myelopathy or myeloneuropathy, radiculoplexus neuropathy, polyneuropathy, and mononeuropathy.⁵

The surgeon performing gastric Roux-en-Y bypass divides the stomach into a small top portion, which is referred to as the pouch, using surgical staples.6 The larger portion of the stomach is then bypassed, meaning it no longer stores or digests nutrients.⁶ The small intestine is divided and connected to the new stomach pouch.⁶ Then, the portion of the intestine still attached to the main stomach is reattached farther down, which allows the digestive enzymes to flow to the small intestine.⁶ Because the food now bypasses some of the small intestine, fewer nutrients and calories are absorbed.⁶

There are a variety of vitamin deficiencies that patients may experience after gastric bypass surgery. The most common are Vitamin A, Vitamin B-2, Vitamin B-3, Vitamin B-6, Vitamin B-12 and folate, Vitamin C, and Vitamin D. Vitamin A deficiency can affect vision and may result in a spectrum of ocular changes, particularly xerophthalmia.⁷ Vitamin B-2 deficiency is higher in specific populations such as those who have undergone bariatric surgery, breastfed infants of mothers with B-2 deficiency, patients with alcohol use disorder, patients with hypothyroidism, patients being treated with chlorpromazine and tricyclic antidepressants, or patients with a diet low in red meat or eggs.⁷ Chronic vitamin B-3 deficiency can lead to pellagra presenting classically as a triad of photosensitive dermatitis, diarrhea, and if left untreated, death.⁷ Vitamin B-6 deficiency is rare but presents as seborrheic dermatitis-like eruptions on the face, scalp, neck, shoulders, buttocks, and perineum. Vitamin B-6 is useful in the formation of hemoglobin, which is responsible for the metabolism of proteins, lipids, and carbohydrates for the immune system.⁷ Vitamin B-12 and folate are similar to vitamin B-6 in that they share the features of hematologic abnormalities and oral manifestations, but they lack neurologic symptoms. The most cutaneous common manifestation of Vitamin B-12 and folate deficiency is hyperpigmentation, which is accentuated in the face, palmar creases, and flexures; however, depigmentation may occur on the hair and skin. Lastly, vitamin D deficiency has no primary cutaneous manifestations other than possibly contributing to androgenic alopecia; however, more than 50% of the world population suffers from vitamin D deficiency in the winter months.⁷

Given the nature of the procedure, gastric bypass makes the absorption of vitamins and minerals more difficult. Thus, if the procedure is followed by a vitamin-deficient diet, the patient may be at a higher risk of developing vitamin deficiency, and in this case, vitamin C deficiency.⁸ Patients who have undergone such procedures are encouraged to eat foods high in vitamin C, such as cruciferous vegetables, white potatoes, strawberries, red peppers, and oranges.⁶ However, the diagnosis remains uncommon in adults and was especially unexpected in the following case given the patient’s profession as a nurse and her self-reported healthy, vitamin-rich diet. 

Case Report

The 39-year-old female patient presented to the clinic for a follow-up examination of a rash affecting the buttocks, extremities, and trunk (Figure 1) that had been present for several months. She had undergone a gastric bypass several years earlier.

Figure 1. Crusted grouped erythematous hyperkeratotic papules with follicular accentuation on the buttocks. 

She stated that the rash had never been itchy, but that it did “dry up” and become crusted (Figure 2). She was bothered by her buttocks, upper legs, arms, and slightly on the cheeks. She was given clobetasol 0.05% cream to apply to the affected areas twice daily. She has been on cephalexin 500 mg 3 times a day, and before that a 14-day course of doxycycline 100 mg twice daily. She was also using Hibiclens once weekly, mupirocin 2% ointment 3 times a day for 7 days per month, and clindamycin 1% lotion twice daily (however, she hadn’t needed to use clindamycin 1% lotion).

Figure 2. Crusted grouped erythematous hyperkeratotic papules with follicular accentuation on the buttocks and macular dyspigmentation at the site of previously involved dermatitis.

A 4-mm punch biopsy of the involved area was obtained. Until the results of the biopsy returned, the patient was given a medication modification for the clobetasol 0.05% cream and was directed to apply twice daily for 2 weeks per month, only to raised areas on the trunk or extremities. She was also directed to initiate narrowband UVB phototherapy 2 to 3 times weekly due to clinical concern for pityriasis rubra pilaris. 

It was after this time that the diagnosis of scurvy was made. Normal ascorbic acid levels range from 0.4 mg/dL to 2.0 mg/dL, and the patient’s level was 0.3 mg/dL. The patient didn’t have any abnormal changes in her diet that would yield a vitamin C deficiency. The gastric bypass surgery that she had undergone several year prior to treatment, however, was identified as a potential factor.  

After confirming the diagnosis, the patient was directed to initiate a vitamin C supplementation regime until the resolution of symptoms. She was also directed to follow up with her point of care provider (PCP), as appropriate. Following up 3 months later, the patient concluded that her ascorbic acid levels had only slightly increased. Because of this, she did some of her own research and then started on liquid liposomal vitamin C. She had great improvement in her vitamin C levels, as confirmed by her PCP. Her rash had also improved (Figure 3). The redness and irritation of the spots had decreased, along with the visibility of the symptoms. 

Figure 3. Nine weeks into the patient’s vitamin C supplementation, showing resolving erythematous to violaceous thin folliculocentric hyperkeratotic papules.

The dermatopathology of the sample was unique given the characteristics of vitamin C deficiency. Normal cutaneous findings include follicular hyperkeratosis, perifollicular hemorrhages, and corkscrew hairs.² Additionally, the histopathological features of scurvy can be characterized by the dermal hemorrhage predominantly within the localized area of the hair follicles, but that lacks evidence of vascular damage, coiled hairs, hemosiderin-laden macrophages, and follicular keratosis.⁹

In this case, the punch biopsy report revealed dermatopathology was unique given diagnosis was characterized by follicular plugging with distorted hair shaft and neutrophilic debris and peri-infundibular hemorrhage and fibrosis with sparse lymphohistiocytic inflammation. The characteristic corkscrew hairs, which are associated with collagen fiber inadequacy, weren’t present, which made the diagnosis difficult. Due to the patient’s history of Roux-en-Y gastric bypass, the clinical and histologic findings raised suspicions of scurvy. Differential diagnosis of traumatized keratosis pilaris or folliculitis was also possible, given these histological findings. 

Figure 4.H & E punch biopsy revealed follicular plugging with distorted hair shaft and neutrophilic debris and peri-infundibular hemorrhage and fibrosis with sparse lymphohistiocytic inflammation.

Discussion

Clinical vitamin C deficiency is referred to as “scurvy,” which causes impaired collagen synthesis and results in disordered connective tissue. Frequently, clinicians may not consider scurvy in their initial differential diagnosis. In this case report, the gastric bypass procedure induced the patient to not absorb the adequate abundance of nutrients needed, including vitamin C. There may have been additional facgtors, such as the patient’s intolerance to certain foods based on a diagnosis of Celiac disease in the several years prior to her scurvy diagnosis. 

Patients’ dietary history is not as heavily emphasized in clinical training, nor is it the requirement of clinicians to report nutritional information in their clinical documentation. Nevertheless, it is important for the clinician to be aware of the risk factors posed by poor nutritional intake in adults, which include but are not limited to institutionalization, old age, mental illness, loss of teeth, social isolation, obesity, abdominal surgery, low socioeconomic status, and drug/alcohol abuse. In addition to some of the risk factors listed, the patient also exhibited laboratory parameters consistent with poor vitamin C levels, likely due to her gastric bypass and potentially overlapping with Celiac disease. 

Patients are at an elevated risk for developing nutrient deficiencies following bariatric gastric bypass.⁸ Based on this case report, it is also evident that gastric bypass patients are at an increased risk for developing vitamin C deficiencies if the follow-up to the operation is combined with a poor diet.⁸ Deficiencies as seen in this case report and the literature tend to develop 4 to 6 weeks after the start of vitamin C-depleted nutrition.⁸ This patient had gastric bypass surgery but then had more than a decade’s delay in symptom presentation, which is abnormal after sustained vitamin C deficiency (patients usually present with symptoms at 1 to 3 months).⁷

Improvement of scurvy symptoms can be seen rapidly within days to weeks of starting therapy with vitamin C supplementation. In this case, the patient was prescribed 500 mg of ascorbic acid supplementation for 1 week, and then 100 mg for the following weeks until her ascorbic acid levels became stabilized and normal. After 12 weeks of supplementation, the patient’s vitamin C levels were improved and stable. 

Conclusion

This case suggests that vitamin C deficiency should be considered in at-risk patient groups, including patients who are post bariatric gastric bypass surgery who present with folliculocentric papules, even without classic findings. 

Scurvy can be a debilitating condition, but it is preventable. Its presence is uncommon in the developed world because the clinical presentation may mimic other pathological states, which can obscure the proper diagnosis. The incidence of scurvy is highly influenced by social and nutritional factors, and in paying close attention to such factors, clinicians should be able to promptly diagnose and treat patients with scurvy. 

The authors reported no conflicts of interest with respect to the research, authorship, and/or publication of this article. 

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