Correspondence

Case 39-1995: Scurvy

N Engl J Med 1996; 334:1065April 18, 1996

Article

To the Editor:

In his discussion of Case 39-1995 (Dec. 21 issue),1 involving a nutritional disorder, scurvy, that developed in a 72-year-old man admitted to the hospital because of exertional dyspnea, fatigue, and extensive ecchymoses and purpuric lesions, Dr. Meisel did not mention another equally profound nutritional disorder present in this patient: protein-calorie malnutrition (kwashiorkor). A serum albumin concentration of 2.0 g per deciliter in a patient with severe fatty liver and peripheral edema without weight loss reflects the pathophysiology of kwashiorkor. The absence of evidence of a recent inflammatory condition and the presence of normal white-cell and differential counts on admission suggest that the hypoalbuminemia had principally a nutritional cause. For diet alone to produce a nutritional disorder of this severity, a dietary protein intake of less than 3 percent of calories, or approximately 15 to 20 g per day, is usually required in the presence of an adequate energy intake. This situation is quite uncommon in industrialized societies except in the presence of an excessive intake of calories from alcohol. The function of the fatty liver in protein-calorie malnutrition is often well preserved, as it was in this patient. The prolongation of the QTc interval, as documented in this patient, is also a common finding, as is poor cardiac performance. Protein-calorie malnutrition, although often still unrecognized, is quite prevalent in U.S. hospitals,2 is usually secondary to underlying disease, and contributes greatly to morbidity and mortality.

Bruce R. Bistrian, M.D., Ph.D.
Deaconess Hospital, Boston, MA 02215

2 References

1
Case Records of the Massachusetts General Hospital (Case 39-1995). N Engl J Med 1995;333:1695-1702
Full Text | Web of Science | Medline

2
Bistrian BR, Blackburn GL, Vitale J, Cochran D, Naylor J. Prevalence of malnutrition in general medical patients. JAMA 1976;235:1567-1570
CrossRef | Web of Science | Medline

To the Editor:

With respect to Case 39-1995, was it really 20 days before a dietary history was requested and obtained? A 72-year-old man who was known to be alcoholic and obese should have been a prime candidate for a nutritional evaluation on admission to the hospital. . . . A prompt taking of the dietary history could have averted at least two weeks of hospitalization and numerous diagnostic tests. The resulting cost savings could have been used to pay a good portion of the annual salary of a nutritionist, who could help screen patients at risk for nutritional problems.

Mary E. O'Connor, M.D., M.P.H.
Rainbow Babies and Children's Hospital, Cleveland, OH 44106

Author/Editor Response

Dr. Meisel replies:

To the Editor: Drs. Bistrian and O'Connor make the indisputable point — which I hope was also made in the Case Records — that a detailed nutritional assessment is an integral part of the evaluation of patients,1 particularly those at risk or with an enigmatic illness. This patient was, in fact, screened by a nutritionist. That his specific dietary deficiencies were not identified underscores the need for a core education in nutritional assessment for all members of the health care team. Given the severity of the patient's illness on admission, however, “a prompt taking of the dietary history” would not have obviated the need for the bulk of his diagnostic evaluation. He was given a standard dose of vitamin C beginning on the first hospital day.

Observations suggesting that the patient's cardiac findings were due at least in part to scorbutic intramyocardial hemorrhage include the regional wall-motion abnormalities seen on echocardiography and the absence of myocardial atrophy or decompensation with resumption of feeding.2-4

James L. Meisel, M.D.
Massachusetts General Hospital, Boston, MA 02114

4 References

1
Bistrian BR, Blackburn GL, Vitale J, Cochran D, Naylor J. Prevalence of malnutrition in general medical patients. JAMA 1976;235:1567-1570
CrossRef | Web of Science | Medline

2
Alden PB, Madoff RD, Stahl TJ, Lakatua DJ, Ring WS, Cerra FB. Left ventricular function in malnutrition. Am J Physiol 1987;253:H380-H387
Web of Science | Medline