Purpuric Rash After Starting Hemodialysis: Not the Immediate Suspect
- Hemodialysis: Case Reports, Series, QI Projects
November 04, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
- 801 Dialysis: Hemodialysis and Frequent Dialysis
- Kruzel Davila, Etty, Galilee Medical Center, Nahariya, North, Israel
- Badran, Ashraf, Galilee Medical Center, Nahariya, North, Israel
- Zeitun, Teuta, Galilee Medical Center, Nahariya, North, Israel
Hemodialysis patients are at risk to develop vitamin C deficiency. Several factors can contribute to vitamin C deficiency, including potassium restricted diet, hemodialysis clearance of water soluble vitamins and increased oxidative stress leading to vitamin C utilization. However, clinical manifestation of scurvy is rare or overlooked. Herein, we report a case of scurvy in a hemodialysis patient.
A 74-year-old patient with end stage kidney disease due to diabetic nephropathy has been treated with hemodialysis since 2020. During 2022, she was hospitalized several times due to pulmonary edema. A purpuric rash with perifollicular erythema was noted on her lower legs (Figure A). She also complained of gingival bleeding. Laboratory exam demonstrated undetectable vitamin C level (less than 4 mg/L), hypoalbuminemia and elevated CRP. Based on her dermatologic findings and labs results, a diagnosis of scurvy was made. After 2 months of daily vitamin C supplement, her symptoms and rash resolved, without episodes of pulmonary edema. Echocardiography demonstrated improved LV function (EF 35% improved to 45%), suggesting a therapeutic role for vitamin C repletion.
Recommendation of Clinical Practice Guidelines for Nutrition in CKD about regular vitamin C supplementation is opinion based. The absence of rigorous recommendation stems from lack of double blind randomized controlled clinical trials that explored the potential beneficial effect of vitamin C supplementation and possible deleterious effect of calcium oxalate supersaturation, accumulation and deposition. This case is a reminder that scurvy can occur in hemodialysis patients and may contribute to cardiovascular complications. A high clinical awareness is warranted in order to diagnose this treatable devastating disease.