Life-threatening clinical ascorbic acid (vitamin C) deficiency and pyroglutamic acidosis in a patient with Staphylococcus aureus bacteraemia and septic shock

Background Scurvy, a clinical manifestation of severe ascorbic acid (AA) deficiency, is thought to be rare in high-income countries, including New Zealand. At the same time, pyroglutamic acidosis (PGA) is not often considered in patients with high anion gap metabolic acidosis (HAGMA). We report a patient with sepsis and Staphylococcus aureus (S. aureus) bacteraemia who developed both of these presentations, which are often under-recognised in clinical practice. Case presentation A patient in his 60s was admitted to the hospital with septic shock due to disseminated S. aureus infection requiring prolonged critical care admission. He developed HAGMA due to PGA from concurrent use of high dose flucloxacillin and paracetamol. Withdrawal of these offending agents resulted in complete resolution of his acid base disturbance. He also suffered from life-threatening complications of AA deficiency manifesting as scorbutic haemopericardium leading to cardiac tamponade, as well as other clinical signs of scurvy including oromucosal bleeding, skin rash, and wound dehiscence. His initial serum AA level prior to replacement was 1 (reference range 26–85) μmol/L. Replacement with high dose AA intravenously led to resolution of his symptoms and normalisation of his serum AA level. Conclusion This case highlights the importance of considering scurvy in hospitalised patients with sepsis and risk factors for AA deficiency. Furthermore, clinicians should be alert about potential complication from flucloxacillin and paracetamol co-prescription causing PGA.