A 54-year-old man with a history of alcohol abuse is brought to the emergency department after an episode of tonic-clonic seizures. He has a history of recurrent seizures and has been treated intermittently with phenytoin. Other medical issues include a mood disorder and anxiety. The patient lives in a homeless shelter. He has a 30-pack-year smoking history. He is treated with lorazepam and phenytoin in the emergency department.
Blood pressure is 122/70 mm Hg and pulse is 112/min and regular. BMI is 17 kg/m². Dentition is poor and the gums are swollen with some evidence of bleeding. Small, mobile lymph nodes are palpated in the submandibular region. The lungs are clear to auscultation. The liver is palpated 2 cm below the subcostal margin. No ascites is present. Multiple scattered petechiae are seen on both the upper and lower extremities.
Laboratory results are as follows:
Serum free phenytoin level is markedly low.
Which of the following best explains this patient's findings?

Question

A 54-year-old man with a history of alcohol abuse is brought to the emergency department after an episode of tonic-clonic seizures. He has a history of recurrent seizures and has been treated intermittently with phenytoin. Other medical issues include a mood disorder and anxiety. The patient lives in a homeless shelter. He has a 30-pack-year smoking history. He is treated with lorazepam and phenytoin in the emergency department.
Blood pressure is 122/70 mm Hg and pulse is 112/min and regular. BMI is 17 kg/m². Dentition is poor and the gums are swollen with some evidence of bleeding. Small, mobile lymph nodes are palpated in the submandibular region. The lungs are clear to auscultation. The liver is palpated 2 cm below the subcostal margin. No ascites is present. Multiple scattered petechiae are seen on both the upper and lower extremities.
Laboratory results are as follows:

Serum free phenytoin level is markedly low.
Which of the following best explains this patient's findings?

Quizplus · Accepted Answer

11ec193a_9606_5e11_853d_d5eb7b734163_MD0002_00 This patient with a history of alcohol abuse has gingival bleeding, gingival hypertrophy, and scattered petechiae, raising strong suspicion for scurvy (vitamin C deficiency). His small, submandibular lymphadenopathy is likely due to dental and gum disease; the thrombocytopenia and hepatomegaly are likely the result of chronic alcohol abuse. Vitamin C is a dietary nutrient and deficiency usually arises in the setting of alcoholism/drug abuse, severe malnourishment, and/or a lack of consumption of fruits and vegetables. As vitamin C is crucial for collagen synthesis, deficiency results in the formation of immature connective tissue leading to prominent cutaneous findings (eg, petechiae, perifollicular hemorrhage, bruising), gingivitis, arthralgias, and impaired wound healing. Diagnosis is made by serum ascorbic acid levels. Treatment with oral or injectable vitamin C typically improves constitutional symptoms within 24 hours, but gingival changes may take up to 2 weeks to resolve. Excessive vitamin C supplementation (>2-3 g/day) can lead to toxicity with resultant abdominal pain, diarrhea, nausea, and laboratory abnormalities (eg, elevated alanine aminotransferase, lactate dehydrogenase, uric acid). (Choice A) Leukocytoclastic vasculitis is a skin-isolated vasculitis that usually causes petechiae and/or palpable purpura. However, gum symptoms are not associated with this condition, and most cases occur 7-10 days after a new drug (eg, penicillin) is administered or new infection (eg, hepatitis B, HIV) is acquired. (Choices B and E) Platelet dysfunction and von Willebrand disease can be associated with easy bruising and bleeding, but these conditions are not associated with gingival hypertrophy. This patient's platelet count is not low enough to cause spontaneous gingival bleeding or petechiae. (Choice C) Several drugs can cause gingival hypertrophy, including phenytoin, cyclosporine, and calcium channel antagonists. However, this patient has been using phenytoin only intermittently, and drug-induced gingival hypertrophy is not typically associated with petechiae. Educational objective: Scurvy (vitamin C deficiency) is commonly associated with gingival hypertrophy, bleeding gums, and petechiae. A low ascorbic acid level is diagnostic; treatment with oral or injectable vitamin C rapidly improves symptoms. __________ References: Vitamin C deficiency: more than just a nutritional disorder. (http://www.ncbi.nlm.nih.gov/pubmed/21614623) Scurvy: a disease almost forgotten. (http://www.ncbi.nlm.nih.gov/pubmed/16911372)

A 54-Year-Old Man with a History of Alcohol Abuse Is