Chronic Graft Vs. Host Disease Involving Oral Mucous Membranes May Improve with Correction of Vitamin C Deficiency

In the developed world, vitamin C deficiency is typically only seen in patients with diseases that result in significantly impaired oral intake, including cystic fibrosis and anorexia nervosa, or in patients requiring long-term enteral tube feeding.  Patients with chronic graft versus host disease (GVHD) with mucosal involvement should also be assessed for this deficiency, as intake of acidic foods rich in vitamin C is often reduced as a result of pain with ingestion.  We report here a clinical observation of vitamin C deficiency (levels ranging from <0.12 to 0.94 mg/dL, median level 0.6 mg/dL) in 6 pediatric and adolescent patients with a median age of 17.5 years (range 9.8-23.5).  In these patients, mucositis, as evidenced by signs and symptoms such mucoceles, leukoplakia, cheilosis, chelitis, and  bleeding associated with tooth brushing, did not improve with conventional therapies for chronic GVHD.  Mucositis was assessed according to the NIH criteria. When vitamin C deficiency was noted, patients were started on treatment with ascorbic acid 2000mg by mouth daily.  After 4 and 8 weeks of therapy, patients showed an increase in mean serum vitamin C concentrations to 1.25 ± 0.95 mg/dL (median 1.005 mg/dL) and 1.31 ± 0.67 mg/dL (median 1.33mg/dL), respectively.   Subsequently, all patients demonstrated marked visual improvement in their mucositis symptoms and improved oral intake.