Ncmp-24. recurrent bouts of scurvy during glioblastoma remission

Abstract Various nutritional deficiencies are more common in patients with cancer, including thiamine, iron and vitamin B12 deficiences, and can be associated with metabolic stress, treatments given and reduced nutritional intake or absorption. Vitamin C deficiency and scurvy have also been reported as a rare complication in cancer patients, but are not frequently seen in the developed countries. We report a 29 year old woman who underwent partial resection of a bifrontal isocitrate dehydrogenase, methylated glioblastoma followed by radiation and temozolomide four years prior. Her tumor remained stable since that time, but she had ongoing decreased appetite and sensitivity to food smells and tastes, which restricted her diet substantially. She had mild chronic anemia and was underweight, but had remained stable. She presented to us with acutely worsening fatigue, lower limb edema and a new rash that was superficially petechial in appearance. She had gingival hyperplasia and friability, and a jaundiced appearance. No deep venous thrombosis was found and liver tests were normal, giving a picture of scurvy. Her serum vitamin C level was undetectable, B12 was 75, folate 3.4, hemoglobin 6.1, albumin 3.2 and vitamin D 11.5. She was given intravenous and oral ascorbic acid as well as other supplementation and had immediate resolution of limb swelling and greatly improved appetite and energy. One year later, with glioblastoma still stable off treatment, she had recurrent worsening fatigue, appetite and gingivitis, and typical petechia-like rash appeared within minutes of IV placement for MRI contrast in the associated vein. She declined repeat serum testing but symptoms resolved on resuming high dose oral vitamin supplementation. Vitamin C has been studied as a supplement in glioblastomas, but also shown to reduce etoposide toxicity. Vitamin C and other nutritional deficiencies may be more common in brain tumor patients, but under-diagnosed.