P21 Scurvy during home parenteral nutrition
Authors: Iglesias Natalia , Cernat Elena , Trippett Jennifer 
Published: August 2020

Introduction

Degradation of ascorbic acid due to oxygen presence in parenteral nutrition (PN) is well documented.1 Although patients on home parenteral nutrition (HPN) are routinely monitored for some vitamin deficiencies, plasma vitamin C is rarely measured in this population.

We report a case of clinical vitamin C deficiency in a patient with severe dysmotility for whom the only source of nutrition was parenteral nutrition with continuous infusion over 24 hours.

Methods

A 6 years old girl with severe gastrointestinal dysmotility following a fundoplication tolerated no enteral feed and could not have time off PN due to hypoglycaemic episodes. She presented with gingival bleeding and epistaxis and also complaining of pain on her arms and shoulders. A clotting was requested which showed prolonged INR and she was treated with IV vitamin K. An x-ray of her wrist and shoulder showed osteopenia but no other abnormalities. Vitamin C measurement was requested.

Results

Plasma vitamin C was low at 3.5 micromol/L (26.1–84.6) which confirmed the diagnosis of scurvy. She was treated with 3 doses of Pabrinex® over 3 days (providing total of 450 mg vitamin C). 100 mg of ascorbic acid were also added to her PN, providing double the baseline amount. Plasma vitamin C measured after two weeks had risen to normal at 45 micromol/L. Her bleeding and pains resolved over a few days. During the next year plasma vitamin C was measured every three months and remained within reference range. She remained clinically well with no recurrence of bleeding. Due to methodology limitations, the amount of vitamin C in the PN bag could not be tested. Therefore we decided to measure plasma vitamin C in two other patients that had PN as the only source of nutrition and given over 12 hours. In both cases the result was within the reference range at 58.7 and 38 micromol/L respectively. Published literature2 suggests that temperature contributes to vitamin C degradation. The PN fluid would have been at room temperature for around 24 hours for the patient that developed scurvy, compared to half this time in the other two.

Conclusions

This case highlights that there is a significant risk of vitamin C degradation due to the oxygen present within the PN bag. However, the fact that for the other 2 patient’s plasma vitamin C was normal suggests that presence of oxygen alone might not be enough to cause vitamin C insufficiency. Temperature might be a contributing factor to vitamin C degradation, as has been shown with enteral feed.3 From these cases we concluded that measurement of vitamin C during HPN would be indicated not only if there were suggestive symptoms, but should also be added in to routine monitoring in any patient with a 24 hour infusion time and extremely restricted enteral intake.

References

NHS Pharmaceutical Quality Assurance Committee, Standard protocol for derivation and assessment of stability Part 4 – Parenteral Nutrition, May 2016

Turmezei J, Javorszky E, Szabo E, et al. Effect of storage temperature on stability of total parenteral nutrition admixtures prepared for infants. Acta Poloniae Pharmaceutica, Drug Research 2015:72:843–9

Gorman SR, Armstrong G, Allen KR, et al. Scarcity in the midst of plenty: enteral tube feeding complicated by scurvy. Journal of Pediatric Gastroenterology and Nutrition 2002;35:93–95