A 45-year-old incarcerated man presents to a clinic with painful swollen feet that started several weeks ago. The patient notes feeling nauseous and dizzy mainly when he tries to walk; these symptoms began approximately 2 to 3 months. The patient denies any trauma. He is a performer who dances in his cell to practice his trade.

The patient has practiced intermittent fasting over the past 4 years. He only eats before midnight when he “gorges” himself with ramen-style soups and peanut butter packets purchased from the institution’s commissary. He says that eating at night helps him sleep as he becomes lightheaded and attributes this to a carbohydrate “crash.”  He does not drink water throughout the day and in the evening “drinks like a camel.” He reports drinking approximately 2 to 3 liters of water in the evening.

He complains of dyspnea on exertion and being easily fatigued, particularly when changing positions from sitting to standing and vice versa. He has no contributory medical or surgical history and no allergies. His mental health history shows obsessive symptoms, agoraphobia, and anxiety. He reports drug and alcohol use.

On physical examination, the patient weighs 177 lb, his vital signs are normal (Table 1), and he shows signs of orthostatic hypotension (Table 2). The patient is alert and oriented and not in acute distress. No abnormal effects or behaviors are noted during the examination.

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Table 1. Vital Signs

Measurement Result
Temperature, ºF 97.5
Pulse, beats per minute 81
Blood pressure, mm Hg 123/74
Respiratory rate, breaths per minute 16
Oxygen saturation, % 98

Table 2. Initial Orthostatic Vital Signs

Measurement Lying Sitting Standing
Blood pressure, mm Hg 119/71 98/65 93/66
Pulse, beats per minute 87 104 122
Oxygen saturation, % 100

Bilateral distal extremities are erythematous with flaky skin, petechial-like rashes, and molting. Ecchymosis is noted on the posterior aspect of his thigh consistent with bedsores.  His toes are cool to touch. The patient has a bounding pulse. All other physical examination findings are normal.  

Intravenous access is attempted to correct dehydration but is unsuccessful. He is encouraged to drink water and subsequently consumes more than 1 L. His orthostatic vital signs are reassessed 1.5 hours later and show improvement (Table 3)

Table 3. Orthostatic Vital Signs After Hydration

Measurement Lying Sitting Standing
Blood pressure, mm Hg 119/75 111/74 98/65
Pulse, beats per minute 71 93 99-103
Oxygen saturation, % 100

The patient reports some improvement in symptoms and returns to his cell to eat lunch. After lunch, he is sent to the main institutional infirmary for further evaluation with a physician assistant (PA).

At this visit, the patient reports shortness of breath from his walk over (approximately one-eighth of a mile) and says that he requires 2 to 3 pillows to sleep at night. In addition to the previously described hypotension and lesions, the PA notes extreme pallor.

Laboratory testing shows severe anemia and heart failure (Table 4) and the patient is sent by ambulance to the local hospital.

Table 4. Laboratory Results

Measurement Result
Hemoglobin, g/dL  5.0 (low)
Hematocrit, %  18.1 (low)
Mean corpuscular volume, μm3 81.2 
Platelet count 262 per L
Bilirubin, mg/dL 1.9 (elevated)
D-dimer, μg/mL 0.452 (elevated)
INR 1.4 (elevated)
BNP, pg/mL 296 (elevated)
BNP, brain-type natriuretic peptide; INR, international normalized ratio

At the hospital, the patient receives 4 units of packed red blood cells (PRBC) and undergoes an upper endoscopy and colonoscopy. He is positive for Helicobacter pylori but does not show acute bleeding. Hemolytic anemia is ruled out and anemia is considered to be related to poor diet.

During the next hospital day, a hospitalist notes that the patient’s rash is petechial, and he has classic bleeding gums (gingivitis) seen with scurvy. The patient’s vitamin C level is checked and shows an ascorbic acid level of 0 mg/dL. He is immediately given oral vitamin C 500 mg three times a day until the patient stabilized. 

The patient’s hemoglobin stabilizes at 8.5 g/dL after receiving the PRBC and he is discharged back to the correctional facility on hospital day 4.

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