A 45-year-old man comes to the clinic for suture removal. Two weeks ago, he was brought to the emergency department due to alcohol intoxication and was found to have a left leg laceration. The laceration was cleaned and sutured, and he received a tetanus toxoid vaccine and a prescription for oral antibiotics, which he completed. The patient has a history of alcohol use disorder and had been hospitalized on several occasions due to alcohol intoxication and acute alcoholic pancreatitis. The patient currently takes no medications, does not use tobacco, and smokes marijuana occasionally. He is experiencing homelessness and has had difficulty staying in homeless shelters regularly due to alcohol use. Temperature is 36.7 C (98.1 F), pulse is 82/min, blood pressure is 124/76 mm Hg, and respirations are 14/min. BMI is 18.8 kg/m². Physical examination shows a disheveled man who appears older than his stated age. Dentition is poor with multiple dental caries. The gingiva is receded and bleeds easily to touch. Cardiopulmonary auscultation reveals clear lungs and normal heart sounds. The abdomen is soft and nontender with no hepatosplenomegaly. Left lower extremity examination shows scant serosanguineous discharge on the wound dressing. The surgical sutures are intact, but the wound margins are poorly approximated. There is mild erythema at the wound borders with no tenderness or warmth. Mild, bilateral, lower-extremity pitting edema is present, and distal pulses are 2+. Skin examination shows scattered ecchymoses. Laboratory results are as follows: Which of the following is the most likely cause of this patient's impaired wound healing?

Question

Quizplus · Accepted Answer

Explanation: 11ec25c8_d90e_1b4a_bc81_ab7b2196c4eb_MD0003_00 This patient's history of alcohol use disorder, gingival bleeding, gingival recession, and ecchymosis suggest his poorly healing wound is due to scurvy (vitamin C deficiency). Vitamin C is an essential dietary nutrient found in citrus fruits and vegetables that acts as a reversible reducing agent and plays a crucial role in fatty acid transport and collagen synthesis. Most cases of vitamin C deficiency arise in the setting of severe malnutrition, which is frequently due to alcohol use disorder, substance use disorder, or psychiatric illness. Manifestations of scurvy usually occur within 3 months of a diet deficient in vitamin C. Common findings include: Cutaneous manifestations - follicular hyperkeratosis, perifollicular hemorrhage, ecchymosis, petechiae, coiled hairs Gingivitis - receded gums that bleed easily and dental caries Impaired wound healing Systemic symptoms - arthralgias, malaise, weakness As the syndrome progresses, hemolytic anemia and edema (eg, capillary leak) also commonly occur. Diagnosis is made by plasma or leukocyte vitamin C levels. Treatment with oral or injectable vitamin C rapidly improves constitutional symptoms, but gingival changes may take up to 2 weeks to resolve. (Choice A) Approximately 80% of patients with alcohol use disorder have thrombocytopenia due to alcohol-induced bone marrow suppression. Anemia and leukopenia can also occur. However, myelosuppression is unlikely to account for this patient's poor wound healing or gingivitis. (Choice B) Although chronic liver disease can cause thrombocytopenia, anemia, ecchymosis, and lower-extremity edema, it is not typically associated with poor wound healing and gingival changes. In addition, there are no other common signs of liver disease (eg, ascites, jaundice, muscle cramps, spider hemangiomas, splenomegaly). (Choice C) Chronic venous insufficiency is marked by edema, pain, skin changes, and ulceration. Although this condition can cause poor wound healing, it is not typically associated with gingivitis or scattered ecchymosis. (Choice E) This patient completed his course of antibiotics and does not currently have local (eg, warmth, pain, purulent discharge) or systemic (eg, fever, leukocytosis) signs of infection. The mild erythema at the border of the wound (without warmth or tenderness) is much more likely to represent healing tissue than infection. Educational objective: Scurvy (vitamin C deficiency) typically occurs in the setting of severe malnutrition due to alcohol use disorder, substance use disorder, or psychiatric illness. Common manifestations include prominent cutaneous findings (eg, follicular hyperkeratosis, perifollicular hemorrhage, ecchymosis, petechiae), gingivitis (eg, recessed gums that bleed easily, dental caries), and impaired wound healing. Diagnosis is made with plasma or leukocyte vitamin C levels. References: Scurvy: reemergence of nutritional deficiencies. (http://www.ncbi.nlm.nih.gov/pubmed/18854467)

A 45-Year-Old Man Comes to the Clinic for Suture Removal