Nutritional deficiencies of the opioid epidemic: a story of scurvy masquerading as systemic lupus erythematosus

Introduction

Scurvy, although one of the oldest diseases in human history, is uncommon in developed countries. Nevertheless, rare cases still occur, especially in the elderly, persons with extreme dietary restrictions, malabsorption and drug dependence. We describe a case of scurvy in the context of autoimmune disorder, irritable bowel syndrome (IBS) with diarrhea and opioid abuse. Early recognition of scurvy can be difficult because symptoms may appear nonspecific and can mimic more common conditions. In any patient with spontaneous hematoma and purpura, scurvy should be considered in the context of nutritional disorder.

Case description

We describe a 49-year-old female with a history of systemic lupus erythematosus on methotrexate therapy, IBS-D and opioid dependence. She was seen by her primary care doctor for complaints of painless ecchymosis on the left hip with gradual increase in size over the past five days as well as ongoing bleeding in her gums for six weeks. The patient denied any trauma or use of anticoagulant medications. Laboratory investigations were remarkable for a vitamin C level of less than 5 µmol/l, without anaemia. A coagulation panel was unremarkable. The patient was treated with oral vitamin C replacement resulting in the resolution of her symptoms.

Commentary

Scurvy is a nutritional disease manifesting with sequelae of collagen defects caused by a deficiency of vitamin C. Because vitamin C cannot be synthesised endogenously, dietary consumption is crucial [1]. There are no reliable determinants of functional vitamin C status. However, plasma and leukocyte vitamin C levels are the mainstay for assessment and correlate reasonably well with vitamin C intake. In the United States, most vitamin C deficiencies are seen in severely malnourished individuals, patients who abuse drugs and alcohol, or those living in poverty with diet devoid of foods rich in vitamin C. Studies on substance use disorders have found extreme nutritional deficiencies in drug abusers like weight loss and changes in dietary patterns [2, 3]. These deficiencies have also been linked to developing barriers to successful withdrawal from opiate use. Factors contributing to unhealthy eating behaviours in this group include lack of nutritional knowledge, food preparation skills and social environments [4-6]. A study from 2011, assessing nutritional and socio-demographic characteristics of patients who abuse opioids during detoxification programme found that these patients consume less than the minimum amount of vegetables, fruits, and grains recommended by the food pyramid and are more eager to consume sweets [7].
Interestingly, this patient was previously diagnosed with SLE. Scurvy has been found to mimic symptoms of connective tissue disease and leukocytoclastic vasculitis [8]. This brings the validity of the patient’s previously diagnosed SLE into question and demonstrates the intricate interplay amongst the patient’s various comorbidities – opioid dependence and rheumatologic disease – on vitamin C metabolism and absorption. Symptoms of scurvy generally occur at plasma concentrations below 0.2 mg/dl (or 11 µmol/l). For adults, daily vitamin C supplementation for one month is recommended. Constitutional symptoms may resolve within 24 hours of treatment initiation but other symptoms (such as bleeding gums) take weeks to resolve. Unfortunately, the burden of nutritional deficiencies in dependence and the potential scope of nutrition services in drug detoxification programmes has not yet been well established. The recent opioid epidemic in the United States has led to an increased awareness of nutritional deficiencies in these patients. Future directions include more widespread study to determine the scope of various nutritional deficiencies found in patients with opioid dependence.

Conflict of interest/Konflikt interesów

None declared./Nie występuje.

Financial support/Finansowanie

None declared./Nie zadeklarowano.

Ethics/Etyka

The work described in this article has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) on medical research involving human subjects, Uniform Requirements for manuscripts submitted to biomedical journals and the ethical principles defined in the Farmington Consensus of 1997.
Treści przedstawione w pracy są zgodne z zasadami Deklaracji Helsińskiej odnoszącymi się do badań z udziałem ludzi, ujednoliconymi wymaganiami dla czasopism biomedycznych oraz z zasadami etycznymi określonymi w Porozumieniu z Farmington w 1997 roku.

References/Piśmiennictwo