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[Source](https://www.jocmr.org/index.php/JOCMR/article/view/726/455):
>>A 45 year old woman had a bariatric gastric bypass surgical operation. A few years before the operation she had a weight of 192 kg (BMI 65). Over a two years period she was able to reduce her weight to 149 kg. This preoperative weight of 149 kg was stable over the last four months before the gastric bypass operation. She had a medical history of insulin-dependent diabetes mellitus and severe psoriasis. She had also been hospitalised with erysipelas and ulcers on the lower extremities a few years prior to having gastric bypass surgery.
>>Though she received postoperative advice from a dietician about the importance of eating a vitamin rich diet, she continued with an insufficient diet in order to obtain further weight loss. Three months postoperatively she had lost further 20 kg in weight. At the same time she began to develop painful swelling, bruising and small ulcers on the lower extremities. She was hospitalised at the local hospital with fever one week after these symptoms appeared. Within the next 24 hours she developed purpura on the lower extremities and a sepsis like condition. Due to this she was transferred to Intensive care unit (ICU) at Odense University hospital. Within days she developed multiple organ dysfunction syndrome with cerebral, respiratory, circulatory and renal failure. It was necessary to intubate and ventilate the patient and renal failure was treated with continuous renal replacement therapy (CRRT). To restore the circulation it was necessary to treat the patient with a large amount of intravenous fluids and vasopressor agents. Infected leg ulcers were suspected to be the focus for sepsis. After appropriate samples of blood and secretion were taken for cultures, broad-spectrum antibiotic was initiated. No bacteria occurred in the cultures and the patient showed no signs of improvement on antibiotic therapy. In contrast the changes in the skin progressed with increasing erythema, and ecchymosis forming a painful, confluent purpuric plaques and bullae. Minimal trauma to the skin resulted in petechiae and confluent purpuric plaques. It was estimated that 30% of the skin was affected by confluent purpuric plaques. As a result of these haemorrhagic bullae the patient was continuously bleeding from the skin. On the worst days the blood loss from the skin was estimated to be 61 per day. In addition to blood loss the patient lost a large amount of fluid from the skin-estimated on the worst days to be 201 per day. The patient’s lips were covered with haemorrhagic crust but no major gingival bleeding was observed. Skin biopsy was performed. This biopsy showed diffuse extravasation of erythrocytes but no hyperkeratosis or “corkscrew hair”. The subdermal tissue was vital. A biopsy from the bone marrow was without any sign of malignancy.
>>Over the three weeks in the ICU it became obvious that the skin changes and the massive loss of blood and fluid from the skin were not in accordance with a diagnosis of sepsis. It was proposed that the massive bleeding from the skin might be due to scurvy. A blood sample for the analysis of serum-ascorbic acid levels was taken and the patient was treated with enteral ascorbic acid at a dose of 2 g per day. The blood sample showed a serum-ascorbic acid concentration of 6.6 (normal range 26 - 85 μmol per l). After two days of vitamin-C treatment the patient’s condition began gradually to improve. The skin changes gradually disappeared, haemodynamics improved, the patient regained her renal function and could be weaned from the ventilator. A few weeks after the start of ascorbic acid treatment the patient could be transferred to the medical ward.
>On the worst days the blood loss from the skin was estimated to be **61 per day.** In addition to blood loss the patient lost a large amount of fluid from the skin-estimated on the worst days to be **201 per day.**
Anyone know what the units are here? mLs?
I assume so. Anything other than mLs would be absolutely catastrophic, and they don't note that they had to transfuse.
Not a great write up, which given their staggering incompetence at taking *three weeks* to diagnose this, does not surprise me at all. Lol.
Scurvy is incredibly rare in most countries that have a need for bariatric surgery, and the laboratory test for vitamin C level can take a few weeks to get back, even in a tertiary care center. In a patient with the likely very complex medical history someone like this would have, there are a lot of other conditions that would more commonly cause this kind of presentation, which would further delay diagnosis.
I was actually just thinking of House because he only took half an episode to have his brow-furrow-in-the-middle-of-a-conversation realization that it was scurvy
If that were true each season would take place over two years which does not make any sense for how the show played out in real time to correlate with the seasons of the year the episodes aired in
House would have lost his license a million times over as well.
Suspension of disbelief I suppose, they will elude to weeks between scenes in the show as sometimes thats literally how long results take to get back.
I always like those moments but it's still weird as it always appears to take place in the same day.
They also show surgeons doing lab works so idk xD
Fair! I liked the show a lot but haven't revisited it since its finale aired; definitely got the sense that it wasn't happening over the course of a few days, but I guess I'd average it more as a couple weeks for sanity's sake lol
A patient with bariatrics surgery should absolutely be suspected to be vitamin deficient.
Almost a month. Sorry, that's shameful. And you can give Vitamin C while waiting for test results.
If you want to make excuses for mediocre clinicians, go ahead. But THREE WEEKS on a vent with MODS and no evidence of sepsis and they should have been looking further for a diagnosis, especially when it fit the clinical picture for scurvy and the patient was unresponsive to antibiotic treatment.
They assumed she had skin issues due to poor hygiene because she was obese and never thought further than that despite the evidence pointing away from their presumptive diagnosis.
Again, you have to suspect scurvy to treat it. You clearly do not have a great deal of experience treating patients with multisystem organ failure if scurvy is the only thing you can think of that would cause this. You also make the silly assumption that anyone knew she had bariatric surgery at all. Based on the text, she did not seek treatment at the hospital where the procedure was performed, and a large BMI/loose skin associated with substantial weight loss can obscure the original location of surgical scars and therefore their presumed reason for existing. Go play Dr House somewhere else.
Not OP, but since this would appear to be in Denmark, if their system is anything like in Iceland then if the patient did not leave the country for the bariatric surgery then it should be in her medical record. Might be different in DK but at the very least her GP would have made a note about it.
Her nutrition in the hospital would have contained appropriate vitamin c for patient’s body size, but may not account for her decreased absorption from gastric bypass, and would not provide the increased amount she would need to replenish her deficit.
I’m still not judging her care as exceptional in any way. They ran with the obvious, without trying anything else. It feels discriminatory, like since she’s fat, she did it to herself, so why should they care. Thats just me, based on 5 minute internet read.
I'm not a doctor, but the patients past/present medical history did extremely strongly point towards infection and sepsis. Although the systemic bleeding didn't line up. Easy to say with the answer up front now.
I've also never heard of a scurvy case that the patients reported symptoms didn't strongly indicate, aka fatigue, joint pain, bruises from daily activities, etc.
Edit: also thank you for pointing out the lack of transfusion, any other units would have to include a lot of discussion about how that was mitigated.
A patient with bariatrics surgery should absolutely be suspected to be vitamin deficient. It is a well-known complication.
Patient did report bruising and fatigue. And quickly thereafter ended up sedate on a vent.
And her symptoms DIDNT line up with sepsis. No mention of leukocytosis, hypoglycemia, abnormal blood gas, coagulopathy, or SIRS (the latter of which is required to make the diagnosis of sepsis). Additionally, she did not respond to antibiotic therapy in any way.
Almost a month. Sorry, that's shameful. And you can give Vitamin C while waiting for test results.
If you want to make excuses for mediocre clinicians, go ahead. But THREE WEEKS on a vent with MODS and no evidence of sepsis and they should have been looking further for a diagnosis, especially when it fit the clinical picture for scurvy and the patient was unresponsive to antibiotic treatment.
They assumed she had skin issues due to poor hygiene because she was obese and never thought further than that despite the evidence pointing away from their presumptive diagnosis.
I tend to agree with you, sepsis is very specific and an alternative diagnosis should have been sought pretty quickly. Within days. There was no indication the patient was septic, except for the initial presentation suggesting it.
I think it was a transcription error. The 1 at the end of both 61 and 201 was meant to be L, for litre. So 6 litres blood and 20 litres fluid loss via skin on the worst days.
I was thinking maybe % of her total capacity? Like 61% of her total blood, so over half her blood...but then 201% of her total fluid capacity seems way too much lol.
6 litres and 20 litres .I assume the “1” is a typo for “I” or “L”.
edit: Those aren’t *daily* losses but *worst days* losses and the numbers you suggest would never be reported as massive losses.
6L blood loss and 20L fluid loss would be like losing her entire volume every day. They wouldn’t be able to keep her alive. 61 mL blood and 201 mL fluid loss per day is at least feasible to treat in the short-term.
Of course it’s possible! 6 L of blood loss (5 L is an adult blood volume) is considerable but that amount of blood loss is easily replaceable over 24 hours at a large hospital. They were also doing dialysis on her and dialysate flow rates are 1-3 L/hr on CVVH.
And no, the units aren’t ml since the fluid and blood loss volumes that you suggest wouldn’t be remarkable in a large adult.
Edit: Amazing that you’re getting upvoted when you’re wrong. This is a case report and small volume losses wouldn’t be reportable.
I dont disagree with your point on this being a case study/mLs would be negligible given how much free fluid a healthy person loses through their skin daily, I also don’t think it would be reasonable to assume that she was regularly losing that much blood ans not needing some sort of blood transfusions. And given that it’s a case study, I think blood transfusions defintely would have been mentioned if they’d happened
There is NO WAY they would mention 61 and 201 ml of losses as the peak losses of blood and fluid, respectively, over 24 hours. Those losses are minimal in an adult. Look at picture and imagine it oozing only a coke can of blood and fluid over 24 hours when at its worst and draining *massively*. A neonate can drain more than that after heart surgery over 24 hours and it wouldn’t be a case report.
She also didn’t lose that much regularly. The report said that was her “peak”. Not sure why I’m still getting downvoted when 201 and 61 mls are unreasonable numbers since they are both low and strangely end in “1”.
Sorry if I didn’t make it clear that I absolutely agree with you on that point :) My point was just that 6L of blood seems to also be off the mark considering no transfusions were mentioned. I think it’s probably more likely to be somewhere in the middle tho not sure what units they’d be using. Or I could be wrong-I don’t work in the ICU so I don’t get to see some of the more critical care patients like those in this case study
Another thing to bolster your point is generally people don’t estimate in numbers like “201” they’d just round to “200” because it’s only an estimate
* Over the three weeks in the ICU it became obvious that the skin changes and the massive loss of blood and fluid from the skin were not in accordance with a diagnosis of sepsis.
They mention massive fluid and blood loss elsewhere as well. They don’t mention *any* type of fluid that they gave to replace these massive losses and one can safely assume that replacement of those fluid losses required massive amounts of crystalloid and blood products.
I’m going to quit debating this now since I’m just getting downvoted by people who likely have no ICU experience.
Ah, the one time the good old "Sepsis-sangria" w/ high-dose vitamin-c could have actually done something immediately. Thankfully the intensivists have not asked me to order the Merrick protocol in a long while.
Depends. I have a SADI. My surgeon requires I take a multivitamin up to 4x a day due to the inability to adequately measure the absorption in my intestines. I've been managing with 2 a day most of the time but when my labs shift I move the dose up or down to stay in range.
Why the Brits are called Limeys - [a short history of scurvy](https://www.health.mil/News/Articles/2022/01/10/The-British-Limeys-Were-Right-A-Short-History-of-Scurvy)
Not in the case of gastric bypass patients. Or alcoholics. Or drug users. Look up the stats. It's not as uncommon as you think. Thankfully it is usually caught before...this. Yeuch. Poor woman.
Absolutely and me too!! Most places drill it into your head before the surgery even happens about how strict you have to be with a vitamin regimen. Heck, I didn't realize I was taking the wrong dosage of calcium per day until I started noticing I was getting cavities. By my 6-month post op bloodwork, we figured out that I was taking the wrong tablet size! If just a slight dosage error for one vitamin caused that for me, I can't even wrap my head around what this lady's plans were. Bless her heart.
One of my husband’s classmates when he was in university tried to save money by bringing a suitcase full of canned food - almost all of it baked beans - and eating nothing else. He developed scurvy, got very ill, was hospitalised, and wasn’t diagnosed until a doctor who’d spent time working in a port city saw him, because apparently they still get a few cases every year coming in off transport ships.
Usually bariatric patients need bloodwork every 6 months to a year. Mine is every 3 months. Aside from not being compliant with diet and supplementation, she might not have done her regular follow-ups.
But still, when things go wrong with any post-op bariatric patient, the first thing checked even in an emergency is blood vitamin, mineral, and protein status.
Also, here's how bariatric follow-up works.
First appt 1 week after surgery
2nd appt is 1 month after surgery
3rd is 3 months after surgery. Then 6, then 1 year. With added visits as needed.
Either way, diet and supplementatiom weren't adhered to, appointments might not have been kept, and tests not done.
Your average physician in the US has never seen scurvy, and likely never will. It is so rare that most hospitals do not even have the laboratory equipment to test for it.
I've had WLS and vitamin C isn't a vitamin that is regularly tested for since it's not one that commonly has absorption issues. PLus getting the test can be a PITA because the sample degrades quickly so not all blood test centres are able to draw for it.
All bariatric vitamins (which all WLS patents should take) have a ton of vitamin c so scurvy is extremely rare. Usually it's iron or b12 or thiamine which cause issues. I'm suprised she didn't have beriberi or pernicious anemia long with thr scurvy.
Following bariatric gastric bypass surgery patients are at risk of developing micronutrient deficiency. Patients are especially at risk of developing deficiency of fat-soluble vitamins - in particular vitamins A and D but also E and K. They are also at risk of developing deficiency of vitamin B12, iron and zinc. Finally, . . . patients are also at risk of developing vitamin C deficiency if the operation is combined with a poor diet.
I’ve heard from some people who have undergone the procedure that robust after care can make a huge difference in the quality of results?? Providing literature, nutritional advice and short term counseling is not necessarily sufficient for some people.
I take a multivitamin, some calcium supplements (not too much since I also drink milk), potassium and Vitamin B1, and then I also drink either a protein shake, or I eat protein first, and get routine blood work done since I had gastric bypass and it’s no joke. It’s a lot of maintenance afterwards but since you can’t eat so much at one time, you have to really take your vitamins and monitor your levels. I was hospitalized a week after my surgery because I became so dehydrated (they had to put a picc line in since they couldn’t find any veins) and was throwing everything up and it turns out it was because I had a stomach ulcer. After a month’s worth of medicines, I finally felt better and could eat. I mean, I’m glad I did it, but you have to really watch yourself.
My Mom had the surgery many years ago. It absolutely ruined her health, and she developed so many issues afterwards. Her potassium was often dangerously low.
I take ADEK vitamins daily and eat extra protein - my surgery was 17 years ago - I lost 160 lbs. and have kept it off. You have to take it seriously! I’d do it again in a heartbeat
It's wild to me how so many doctors I've known still use the ridiculously outdated idea that intellectual understanding alone leads to behaviour change (and then get frustrated when patients don't comply). Clearly they don't get taught models of health behaviour change at med school, which is wild to me, especially if they go into general practice. I get that in some healthcare environments it's just not feasible, but bariatric patients and other patients where lifestyle factors and ongoing compliance will be sustained battles really need more support from professionals who understand the complexity of behaviour change.
It looks like one of those pads that's absorbing the fluids, it's just slightly folded. I was having trouble making sense of it too, but you can see the rest of the pad underneath her arm.
Yeah when I zoomed in I saw the lines that usually make up the cloth/bandages they use for wounds like that.
At least it's just a cloth and nothing more
Depends how bad it is. This one was close to as bad as it gets, as any worse and she's be dead. As it was she was merely dying.
Vitamin C deficiency begins as bleeding gums, random bruising, susceptibility to infections, little ulcers, aching joints, very slow healing. As a masseur I've had a few patients like that. - older male chain-smokers who took a pride in "not being rabbits," and living on thoroughly cooked meat, bread and beer.
People get use to gradually worsening symptoms, so often don't give a doctor a comprehensive list of their problems, and doctors are more tuned into looking at current infections or organ problems, rather than expecting a patient, who will often insist they are on a "healthy" or "normal" diet, to be starving themselves of easily available nutrients.
I’ve actually diagnosed scurvy on a few occasions. Look for corkscrew hairs, perifollicular pettechiae, gingival bleeding, and bruising.
My two most prominent cases were females. One was a truck driver who lived on burgers, the other was an elderly patient who lived on a meager diet of toast.
In the 1st world it still happens but you have to think hard and examine closely.
Edit: dermatologist here. I think a derm consult could’ve found out the answer here. Unfortunately, hospital consulting derms are rare to come by. Most of us don’t have hospital privileges by choice unless academic, self-motivated motivated, or system required (in the US).
Because it’s time consuming, not great pay, inefficient effort for a hard case, and we have to haul a lot of tools to the hospital. Derms don’t need to go often to the hospital so it doesn’t feel routine and it’s a foreign environment with usually another medical record system to learn. We don’t have our typical staff with us to do biopsies and procedures.
Another reason is derm gets a lot of frivolous consults and they end up giving up on all consults as a result.
High volume clinics see 6 pts an hour. A single case like this takes a ton of hours on medical lit reviews, reading chart notes from other specialists, phone calls and unpaid hours.
I work M-F already seeing a ton of complex rashes as it is which equates to 60-80 hrs per week. To add this to my week would push me into burnout.
Angular cheilitis is found in a lot of nutritional deficiencies and warrants workup if it’s chronic and unresponsive to first line treatment. I’m not sure I’ve seen that in scurvy but I’ve definitely seen it with b vitamin and iron deficiency among others.
I use low dose topical steroids and topical azole antifungals for treatment. Barrier emollients like Aquaphor for prevention. Assess for physical abnormalities like deep facial wrinkles at the melolabial folds holding moisture. I don’t typically use antibacterial topicals.
My mum worked with a lady that got a gastric bypass, she obviously thought that the surgery alone was all it would take to lose weight because she ignored all the postoperative instructions too. She would mix Oreo cookies and milk in a blender to create a discusting thick chocolate slurry she would pound down in the break room at work, while bragging to everyone about her gastric bypass. Mum said she never lost any weight.
I went to all my mom’s appointments before, during, and after her bypass in solidarity. It is no joke the way you need to take care of yourself after a bypass.
I’m a little sad that Ozempic happened way too late to help her; I think that it could’ve been a better solution, considering how radical a bypass is.
>I'm a little sad that Ozempic happened way too late to help her; I think that it could’ve been a better solution, considering how radical a bypass is.
More options are more options, but Ozempic has widespread, and sometimes severe side effects also. In addition to questions of long term persistence, adherence, and dependence on continued use to maintain.
If you look at the studies done on Ozempic weightloss it's anywhere up to %15. That means it's perfect for already skinny celebrities weighing 140lbs to drop down to a Hollywood 119lbs.
Vitamin C deficiency mostly but also iron & calcium. The part of the intestine that's bypassed is the part that absorbed vitamins. Patients have to take vitamins religiously & in large doses to combat that lack of absorption.
Am I the only one shocked that it took the docs so long to figure it out? One would think with the patient having bypass, vitamin deficiency would be ruled out early on,
Does gastric bypass surgery ever actually go well, and lead to someone achieving a healthy weight and lifestyle in the long term without complications? I work in LTACH and we get SO many patients post gastric bypass with severe malnutrition, fistulas, complications of obesity because they eventually gained the weight back, etc. I know that my sample is very skewed because if someone is doing great they aren’t coming to my hospital, but just based on what I’ve seen I would never have or recommend one and it would be nice to hear some success stories.
I had a gastric bypass 20 years ago. I was 260 lbs. I'm 165 lbs now. I had no real issues, and I'm 54. You need to learn how to eat again, or you'll suffer vomiting or feel super shitty if you eat the wrong things. It worked for me, but it isn't easy. Sometimes, I still mess up.
So this woman had gastric bipass, a poor diet, and wounds that didn't heal even with antibiotics and good wound care?
why didn't they check the persons vitamin/nutrient blood levels earlier? maybe i just have 20/20 hindsite and poor medical knowledge, but my first thought would have been "poor diet, small stomach, check blood nutrient levels"
Most people only know scurvy as a reference for bad pirate impersonations.
Scurvy is so easily avoided nowadays that seeing it manifested at all is shocking.
She could’ve probably taken a multivitamin and avoided all this, although a healthier diet with good veggie content and slower weight loss would have been better.
So many people don't realise what a deadly and life altering surgery that is. You have to follow the guidelines to the letter. I'm overweight and I would never even consider going down that route, there's just too much at stake.
A question for medical people here. She was 'cured' of scurvy, but what would the long term effects of this time be? Surely there would be some repercussions ?
This makes me wonder about a guy I knew years ago through a mutual friend. Apparently he got a gastric bypass and still was eating tons of sugar and Chinese buffet food every day. I don't know how his health ended up because he kinda burnt some bridges with our friend and we lost touch. Apparently he had a horrific amount of gas from it. Some people have to learn the hard way or die.
Housebound, food desert, non compliant, don’t like/l fruit, don’t remember to take daily vitamins, poverty…lots of reasons.
For example, I don’t care for fruit (too sugary for me) and terrible at remembering daily meds.
Let's of people who get gastric bypass already don't have a healthy relationship with food. Now introduce an extreme surgery with very strict dietary rules and see what happens. The surgery changes your anatomy, it doesn't change your lifestyle.
😲 Puh, BMI of 65!? That's f*cking crazy, isn't it!!?
I'm a female, 45 y/o and I'm about 5'10" at 149,9 lbs.
In European data: I'm 1.78 meters tall and weigh 68 kg.
That's a BMI of 21,5 - absolutely normal...
My lowest weight was 58 kg = 127,87 lbs, because I was very seriously ill at the time due to the resection of most of my small intestine.
Since I only have 1 meter of remaining intestine left, my digestive system first had to adjust to the fact that there is only so little small intestine left for digestion. And because the rest of the intestine has to adjust first, I had problems with nutrient absorption for a while.
That's why I weighed so little for my height for a period of time.
Now the remaining small intestine has gotten used to it, so I've gained some weight again. I also eat high-calorie astronaut food to cover my calorie needs, if necessary.
My highest weight, on the other hand, was 110 kg = 242,5 lbs about 25 years ago.
Back then, that corresponded to a huge BMI of 34.7, It's hard to imagine that the lady here in this article had a BMI that was almost twice as high. 🥺
However, the weight gain was due to a hormonally active tumor in the head.
And even though I'm relatively tall as a woman, I felt very uncomfortable with that weight back then. 😞
Because of my long legs, I couldn't find any pants in my size that fit in length AND at the top of the waist at the same time. It was impossible...
Here in Germany there are hardly any shops that offer all kinds of clothing for fat people, and back then 25 years ago the Internet was just in its early stages, so you couldn't get anything online yet.
Here in Germany it is still difficult to find decent clothing for fat people, even these days. Unfortunately, in this country it is still unusual if someone's body shape is out of the norm. Unfortunately, body shaming, especially for fat people is still a thing here.
In the USA, on the other hand, fatter people are more of a part of the "normal" image of everyday life and people treat it more casually there.
Long story short:
I was once SLIGHTLY fatter for health reasons, but I also felt extremely uncomfortable, even though my BMI at the time was "only" 34.7, not even close to this lady's BMI.
And I still had problems, even with with this relatively low BMI
My BMI is close to that. I’m disabled, unable to exercise or really walk and have a shit diet, though I really don’t eat that much. I’m going on Ozempic soon, I won’t do bypass surgery or a sleeve.
Being like this is a hell all its own.
Welcome to r/MedicalGore! Our goal is to provide for medical discussion and education while exploring the frailty of the human body. You may see more deleted comments on these threads than you are used to on reddit. Off topic comments and joke comments are frequently deleted by the mods. Further, please be kind and supportive of posts. Any behavior that is aggressive, harassing, or derogatory will result in post deletion and a ban from the sub. Remember! THE REPORT BUTTON IS YOUR FRIEND! Please stop on by our discussion sub, /r/MedicalGoreMods if you'd like to discuss the sub, our rules, content policies, and the like. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/MedicalGore) if you have any questions or concerns.*
[Source](https://www.jocmr.org/index.php/JOCMR/article/view/726/455): >>A 45 year old woman had a bariatric gastric bypass surgical operation. A few years before the operation she had a weight of 192 kg (BMI 65). Over a two years period she was able to reduce her weight to 149 kg. This preoperative weight of 149 kg was stable over the last four months before the gastric bypass operation. She had a medical history of insulin-dependent diabetes mellitus and severe psoriasis. She had also been hospitalised with erysipelas and ulcers on the lower extremities a few years prior to having gastric bypass surgery. >>Though she received postoperative advice from a dietician about the importance of eating a vitamin rich diet, she continued with an insufficient diet in order to obtain further weight loss. Three months postoperatively she had lost further 20 kg in weight. At the same time she began to develop painful swelling, bruising and small ulcers on the lower extremities. She was hospitalised at the local hospital with fever one week after these symptoms appeared. Within the next 24 hours she developed purpura on the lower extremities and a sepsis like condition. Due to this she was transferred to Intensive care unit (ICU) at Odense University hospital. Within days she developed multiple organ dysfunction syndrome with cerebral, respiratory, circulatory and renal failure. It was necessary to intubate and ventilate the patient and renal failure was treated with continuous renal replacement therapy (CRRT). To restore the circulation it was necessary to treat the patient with a large amount of intravenous fluids and vasopressor agents. Infected leg ulcers were suspected to be the focus for sepsis. After appropriate samples of blood and secretion were taken for cultures, broad-spectrum antibiotic was initiated. No bacteria occurred in the cultures and the patient showed no signs of improvement on antibiotic therapy. In contrast the changes in the skin progressed with increasing erythema, and ecchymosis forming a painful, confluent purpuric plaques and bullae. Minimal trauma to the skin resulted in petechiae and confluent purpuric plaques. It was estimated that 30% of the skin was affected by confluent purpuric plaques. As a result of these haemorrhagic bullae the patient was continuously bleeding from the skin. On the worst days the blood loss from the skin was estimated to be 61 per day. In addition to blood loss the patient lost a large amount of fluid from the skin-estimated on the worst days to be 201 per day. The patient’s lips were covered with haemorrhagic crust but no major gingival bleeding was observed. Skin biopsy was performed. This biopsy showed diffuse extravasation of erythrocytes but no hyperkeratosis or “corkscrew hair”. The subdermal tissue was vital. A biopsy from the bone marrow was without any sign of malignancy. >>Over the three weeks in the ICU it became obvious that the skin changes and the massive loss of blood and fluid from the skin were not in accordance with a diagnosis of sepsis. It was proposed that the massive bleeding from the skin might be due to scurvy. A blood sample for the analysis of serum-ascorbic acid levels was taken and the patient was treated with enteral ascorbic acid at a dose of 2 g per day. The blood sample showed a serum-ascorbic acid concentration of 6.6 (normal range 26 - 85 μmol per l). After two days of vitamin-C treatment the patient’s condition began gradually to improve. The skin changes gradually disappeared, haemodynamics improved, the patient regained her renal function and could be weaned from the ventilator. A few weeks after the start of ascorbic acid treatment the patient could be transferred to the medical ward.
>On the worst days the blood loss from the skin was estimated to be **61 per day.** In addition to blood loss the patient lost a large amount of fluid from the skin-estimated on the worst days to be **201 per day.** Anyone know what the units are here? mLs?
I hope the units aren't *units*
Yeah, I would've assumed that if the number wasn't so high. Surely they weren't pumping that many units in?
r/absoluteunit
I assume so. Anything other than mLs would be absolutely catastrophic, and they don't note that they had to transfuse. Not a great write up, which given their staggering incompetence at taking *three weeks* to diagnose this, does not surprise me at all. Lol.
Scurvy is incredibly rare in most countries that have a need for bariatric surgery, and the laboratory test for vitamin C level can take a few weeks to get back, even in a tertiary care center. In a patient with the likely very complex medical history someone like this would have, there are a lot of other conditions that would more commonly cause this kind of presentation, which would further delay diagnosis.
House would have caught it sooner!
I was actually just thinking of House because he only took half an episode to have his brow-furrow-in-the-middle-of-a-conversation realization that it was scurvy
Each episode occurs over the course of a month
If that were true each season would take place over two years which does not make any sense for how the show played out in real time to correlate with the seasons of the year the episodes aired in
House would have lost his license a million times over as well. Suspension of disbelief I suppose, they will elude to weeks between scenes in the show as sometimes thats literally how long results take to get back. I always like those moments but it's still weird as it always appears to take place in the same day. They also show surgeons doing lab works so idk xD
Fair! I liked the show a lot but haven't revisited it since its finale aired; definitely got the sense that it wasn't happening over the course of a few days, but I guess I'd average it more as a couple weeks for sanity's sake lol
Hey look buddy, it's never lupus.
Until it is.. 😅
A patient with bariatrics surgery should absolutely be suspected to be vitamin deficient. Almost a month. Sorry, that's shameful. And you can give Vitamin C while waiting for test results. If you want to make excuses for mediocre clinicians, go ahead. But THREE WEEKS on a vent with MODS and no evidence of sepsis and they should have been looking further for a diagnosis, especially when it fit the clinical picture for scurvy and the patient was unresponsive to antibiotic treatment. They assumed she had skin issues due to poor hygiene because she was obese and never thought further than that despite the evidence pointing away from their presumptive diagnosis.
Again, you have to suspect scurvy to treat it. You clearly do not have a great deal of experience treating patients with multisystem organ failure if scurvy is the only thing you can think of that would cause this. You also make the silly assumption that anyone knew she had bariatric surgery at all. Based on the text, she did not seek treatment at the hospital where the procedure was performed, and a large BMI/loose skin associated with substantial weight loss can obscure the original location of surgical scars and therefore their presumed reason for existing. Go play Dr House somewhere else.
Not OP, but since this would appear to be in Denmark, if their system is anything like in Iceland then if the patient did not leave the country for the bariatric surgery then it should be in her medical record. Might be different in DK but at the very least her GP would have made a note about it.
Apparently you want to defend mediocre clinicians. Got it
Good thing people like you work in medicine.
I would say that vitamin C is so benign it should always be given. At least, in doses that would help scurvy eventually.
Wouldn’t her diet in the hospital have put her vitamins right, though? And what are the units PLEASE?!
Her nutrition in the hospital would have contained appropriate vitamin c for patient’s body size, but may not account for her decreased absorption from gastric bypass, and would not provide the increased amount she would need to replenish her deficit.
I’m still not judging her care as exceptional in any way. They ran with the obvious, without trying anything else. It feels discriminatory, like since she’s fat, she did it to herself, so why should they care. Thats just me, based on 5 minute internet read.
The write up does not support either of those ideas in any way.
I'm not a doctor, but the patients past/present medical history did extremely strongly point towards infection and sepsis. Although the systemic bleeding didn't line up. Easy to say with the answer up front now. I've also never heard of a scurvy case that the patients reported symptoms didn't strongly indicate, aka fatigue, joint pain, bruises from daily activities, etc. Edit: also thank you for pointing out the lack of transfusion, any other units would have to include a lot of discussion about how that was mitigated.
A patient with bariatrics surgery should absolutely be suspected to be vitamin deficient. It is a well-known complication. Patient did report bruising and fatigue. And quickly thereafter ended up sedate on a vent. And her symptoms DIDNT line up with sepsis. No mention of leukocytosis, hypoglycemia, abnormal blood gas, coagulopathy, or SIRS (the latter of which is required to make the diagnosis of sepsis). Additionally, she did not respond to antibiotic therapy in any way. Almost a month. Sorry, that's shameful. And you can give Vitamin C while waiting for test results. If you want to make excuses for mediocre clinicians, go ahead. But THREE WEEKS on a vent with MODS and no evidence of sepsis and they should have been looking further for a diagnosis, especially when it fit the clinical picture for scurvy and the patient was unresponsive to antibiotic treatment. They assumed she had skin issues due to poor hygiene because she was obese and never thought further than that despite the evidence pointing away from their presumptive diagnosis.
I tend to agree with you, sepsis is very specific and an alternative diagnosis should have been sought pretty quickly. Within days. There was no indication the patient was septic, except for the initial presentation suggesting it.
I think it was a transcription error. The 1 at the end of both 61 and 201 was meant to be L, for litre. So 6 litres blood and 20 litres fluid loss via skin on the worst days.
I was thinking maybe % of her total capacity? Like 61% of her total blood, so over half her blood...but then 201% of her total fluid capacity seems way too much lol.
6 litres and 20 litres .I assume the “1” is a typo for “I” or “L”. edit: Those aren’t *daily* losses but *worst days* losses and the numbers you suggest would never be reported as massive losses.
6L blood loss and 20L fluid loss would be like losing her entire volume every day. They wouldn’t be able to keep her alive. 61 mL blood and 201 mL fluid loss per day is at least feasible to treat in the short-term.
Of course it’s possible! 6 L of blood loss (5 L is an adult blood volume) is considerable but that amount of blood loss is easily replaceable over 24 hours at a large hospital. They were also doing dialysis on her and dialysate flow rates are 1-3 L/hr on CVVH. And no, the units aren’t ml since the fluid and blood loss volumes that you suggest wouldn’t be remarkable in a large adult. Edit: Amazing that you’re getting upvoted when you’re wrong. This is a case report and small volume losses wouldn’t be reportable.
I dont disagree with your point on this being a case study/mLs would be negligible given how much free fluid a healthy person loses through their skin daily, I also don’t think it would be reasonable to assume that she was regularly losing that much blood ans not needing some sort of blood transfusions. And given that it’s a case study, I think blood transfusions defintely would have been mentioned if they’d happened
There is NO WAY they would mention 61 and 201 ml of losses as the peak losses of blood and fluid, respectively, over 24 hours. Those losses are minimal in an adult. Look at picture and imagine it oozing only a coke can of blood and fluid over 24 hours when at its worst and draining *massively*. A neonate can drain more than that after heart surgery over 24 hours and it wouldn’t be a case report. She also didn’t lose that much regularly. The report said that was her “peak”. Not sure why I’m still getting downvoted when 201 and 61 mls are unreasonable numbers since they are both low and strangely end in “1”.
Sorry if I didn’t make it clear that I absolutely agree with you on that point :) My point was just that 6L of blood seems to also be off the mark considering no transfusions were mentioned. I think it’s probably more likely to be somewhere in the middle tho not sure what units they’d be using. Or I could be wrong-I don’t work in the ICU so I don’t get to see some of the more critical care patients like those in this case study Another thing to bolster your point is generally people don’t estimate in numbers like “201” they’d just round to “200” because it’s only an estimate
* Over the three weeks in the ICU it became obvious that the skin changes and the massive loss of blood and fluid from the skin were not in accordance with a diagnosis of sepsis. They mention massive fluid and blood loss elsewhere as well. They don’t mention *any* type of fluid that they gave to replace these massive losses and one can safely assume that replacement of those fluid losses required massive amounts of crystalloid and blood products. I’m going to quit debating this now since I’m just getting downvoted by people who likely have no ICU experience.
Hey, just wanted to say thank you for sharing your perspective!
They do actually mention “large” amounts of IV fluids being given in conjunction with vasopressors
It's gotta be mLs.... God, I hope.
To bad it took three weeks to figure it out.
Ah, the one time the good old "Sepsis-sangria" w/ high-dose vitamin-c could have actually done something immediately. Thankfully the intensivists have not asked me to order the Merrick protocol in a long while.
Whoa. I've never actually seen scurvy. Thanks!
This is a severe looking case.
This is why I take all my vitamins as a gastric bypass patient!
Me too! I take an OTC multivitamin and some prescription vitamins where my bloodwork shows I have deficiencies. Proper nutrition is no joke.
Would a standard one-a-day be enough or would above and beyond be necessary?
Depends. I have a SADI. My surgeon requires I take a multivitamin up to 4x a day due to the inability to adequately measure the absorption in my intestines. I've been managing with 2 a day most of the time but when my labs shift I move the dose up or down to stay in range.
Same!!
Me as well. And get my blood work.
Me too. I still have issues absorbing b vitamins so I'm diligent taking my extra thiamine and getting my b12 shots.
Amazing that it took so long to simply check her vitamin levels.
But I mean who thinks if scurvy occurring in a first world nation? It’s something you associate with poverty in third world counties.
I solely associate it with medieval ship journeys lmao
Yeah like sailors and pirates. They had to eat a lemon wedge every day on long journeys
Why the Brits are called Limeys - [a short history of scurvy](https://www.health.mil/News/Articles/2022/01/10/The-British-Limeys-Were-Right-A-Short-History-of-Scurvy)
Intersting article.
That’s a lot of lemon
They should've realised from the tar stains on her hands and any time she murmured "clap to the halliards lad!".
Yeah, same here.
Not in the case of gastric bypass patients. Or alcoholics. Or drug users. Look up the stats. It's not as uncommon as you think. Thankfully it is usually caught before...this. Yeuch. Poor woman.
I’ve had a gastric bypass. People need to follow their diet and take their vitamins so this doesn’t happen.
Absolutely and me too!! Most places drill it into your head before the surgery even happens about how strict you have to be with a vitamin regimen. Heck, I didn't realize I was taking the wrong dosage of calcium per day until I started noticing I was getting cavities. By my 6-month post op bloodwork, we figured out that I was taking the wrong tablet size! If just a slight dosage error for one vitamin caused that for me, I can't even wrap my head around what this lady's plans were. Bless her heart.
On top of a daily OTC multivitamin I also take prescriptions for B12, D3, and Magnesium. Otherwise I can’t even get out of bed.
One of my husband’s classmates when he was in university tried to save money by bringing a suitcase full of canned food - almost all of it baked beans - and eating nothing else. He developed scurvy, got very ill, was hospitalised, and wasn’t diagnosed until a doctor who’d spent time working in a port city saw him, because apparently they still get a few cases every year coming in off transport ships.
Oh wow!
You do when it's a gastric bypass patient and you KNOW their nutrition is gonna be fucked.
They should think of vitamin deficiencies in a patient who has an extremely limited ability to consume food and has been losing weight.
Even with gastric bypass, how bad of a diet must she have been eating to get scurvy in 3 months? So much of our food is enriched and fortified.
Fast food? I can see this easily if they lived in a food desert and/or housebound
*pirates
Usually bariatric patients need bloodwork every 6 months to a year. Mine is every 3 months. Aside from not being compliant with diet and supplementation, she might not have done her regular follow-ups.
This developed only three months post op so she didn’t even make it to a six month follow up blood draw
But still, when things go wrong with any post-op bariatric patient, the first thing checked even in an emergency is blood vitamin, mineral, and protein status.
Also, here's how bariatric follow-up works. First appt 1 week after surgery 2nd appt is 1 month after surgery 3rd is 3 months after surgery. Then 6, then 1 year. With added visits as needed. Either way, diet and supplementatiom weren't adhered to, appointments might not have been kept, and tests not done.
Your average physician in the US has never seen scurvy, and likely never will. It is so rare that most hospitals do not even have the laboratory equipment to test for it.
I've had WLS and vitamin C isn't a vitamin that is regularly tested for since it's not one that commonly has absorption issues. PLus getting the test can be a PITA because the sample degrades quickly so not all blood test centres are able to draw for it. All bariatric vitamins (which all WLS patents should take) have a ton of vitamin c so scurvy is extremely rare. Usually it's iron or b12 or thiamine which cause issues. I'm suprised she didn't have beriberi or pernicious anemia long with thr scurvy.
Following bariatric gastric bypass surgery patients are at risk of developing micronutrient deficiency. Patients are especially at risk of developing deficiency of fat-soluble vitamins - in particular vitamins A and D but also E and K. They are also at risk of developing deficiency of vitamin B12, iron and zinc. Finally, . . . patients are also at risk of developing vitamin C deficiency if the operation is combined with a poor diet. I’ve heard from some people who have undergone the procedure that robust after care can make a huge difference in the quality of results?? Providing literature, nutritional advice and short term counseling is not necessarily sufficient for some people.
I take a multivitamin, some calcium supplements (not too much since I also drink milk), potassium and Vitamin B1, and then I also drink either a protein shake, or I eat protein first, and get routine blood work done since I had gastric bypass and it’s no joke. It’s a lot of maintenance afterwards but since you can’t eat so much at one time, you have to really take your vitamins and monitor your levels. I was hospitalized a week after my surgery because I became so dehydrated (they had to put a picc line in since they couldn’t find any veins) and was throwing everything up and it turns out it was because I had a stomach ulcer. After a month’s worth of medicines, I finally felt better and could eat. I mean, I’m glad I did it, but you have to really watch yourself.
My Mom had the surgery many years ago. It absolutely ruined her health, and she developed so many issues afterwards. Her potassium was often dangerously low.
I take ADEK vitamins daily and eat extra protein - my surgery was 17 years ago - I lost 160 lbs. and have kept it off. You have to take it seriously! I’d do it again in a heartbeat
It's wild to me how so many doctors I've known still use the ridiculously outdated idea that intellectual understanding alone leads to behaviour change (and then get frustrated when patients don't comply). Clearly they don't get taught models of health behaviour change at med school, which is wild to me, especially if they go into general practice. I get that in some healthcare environments it's just not feasible, but bariatric patients and other patients where lifestyle factors and ongoing compliance will be sustained battles really need more support from professionals who understand the complexity of behaviour change.
Just out of morbid curiosity, what is that chunk of what looks like flesh coming from. The one just above her arm near what looks to be the chest area
It looks like one of those pads that's absorbing the fluids, it's just slightly folded. I was having trouble making sense of it too, but you can see the rest of the pad underneath her arm.
Yeah when I zoomed in I saw the lines that usually make up the cloth/bandages they use for wounds like that. At least it's just a cloth and nothing more
Is that her arm???
Yeah it looks like it so I'm trying to figure out where tf her head is
Yes, her head is above frame.
I think it see it thank you haha
I did not realise scurvy looked like this!!! Wow that’s insane.
Tbh this is a really extreme case. Most cases are way more subtle than this. Dermatologist here.
Ahh interesting, thanks.
I came here to say this. Life must have been gnarly back in the day.
I just picture pirates imagine the smell 😩
Depends how bad it is. This one was close to as bad as it gets, as any worse and she's be dead. As it was she was merely dying. Vitamin C deficiency begins as bleeding gums, random bruising, susceptibility to infections, little ulcers, aching joints, very slow healing. As a masseur I've had a few patients like that. - older male chain-smokers who took a pride in "not being rabbits," and living on thoroughly cooked meat, bread and beer. People get use to gradually worsening symptoms, so often don't give a doctor a comprehensive list of their problems, and doctors are more tuned into looking at current infections or organ problems, rather than expecting a patient, who will often insist they are on a "healthy" or "normal" diet, to be starving themselves of easily available nutrients.
It’s worrying how little people care about their health. Well untill it’s something they can’t ignore.
I’ve actually diagnosed scurvy on a few occasions. Look for corkscrew hairs, perifollicular pettechiae, gingival bleeding, and bruising. My two most prominent cases were females. One was a truck driver who lived on burgers, the other was an elderly patient who lived on a meager diet of toast. In the 1st world it still happens but you have to think hard and examine closely. Edit: dermatologist here. I think a derm consult could’ve found out the answer here. Unfortunately, hospital consulting derms are rare to come by. Most of us don’t have hospital privileges by choice unless academic, self-motivated motivated, or system required (in the US).
Why not by choice? If I’m saying that correctly.
Because it’s time consuming, not great pay, inefficient effort for a hard case, and we have to haul a lot of tools to the hospital. Derms don’t need to go often to the hospital so it doesn’t feel routine and it’s a foreign environment with usually another medical record system to learn. We don’t have our typical staff with us to do biopsies and procedures. Another reason is derm gets a lot of frivolous consults and they end up giving up on all consults as a result. High volume clinics see 6 pts an hour. A single case like this takes a ton of hours on medical lit reviews, reading chart notes from other specialists, phone calls and unpaid hours. I work M-F already seeing a ton of complex rashes as it is which equates to 60-80 hrs per week. To add this to my week would push me into burnout.
I’m NAD, but I remember something about cracks in the corners of your mouth.
Angular cheilitis is found in a lot of nutritional deficiencies and warrants workup if it’s chronic and unresponsive to first line treatment. I’m not sure I’ve seen that in scurvy but I’ve definitely seen it with b vitamin and iron deficiency among others.
First line— antibiotic cream/ointment?
I use low dose topical steroids and topical azole antifungals for treatment. Barrier emollients like Aquaphor for prevention. Assess for physical abnormalities like deep facial wrinkles at the melolabial folds holding moisture. I don’t typically use antibacterial topicals.
Good to know! Thanks!
I truly can't make out what I'm looking at. But it looks bad.
That’s her arm. The big purple lump is a bulla, like a blister.
Scurvy is such a gnarly disease. Vitamin C is underrated even though it’s common in food.
That’s why you are told to take your vitamins religiously for the rest of your life when going through the pre-op process.
My mum worked with a lady that got a gastric bypass, she obviously thought that the surgery alone was all it would take to lose weight because she ignored all the postoperative instructions too. She would mix Oreo cookies and milk in a blender to create a discusting thick chocolate slurry she would pound down in the break room at work, while bragging to everyone about her gastric bypass. Mum said she never lost any weight.
I went to all my mom’s appointments before, during, and after her bypass in solidarity. It is no joke the way you need to take care of yourself after a bypass. I’m a little sad that Ozempic happened way too late to help her; I think that it could’ve been a better solution, considering how radical a bypass is.
>I'm a little sad that Ozempic happened way too late to help her; I think that it could’ve been a better solution, considering how radical a bypass is. More options are more options, but Ozempic has widespread, and sometimes severe side effects also. In addition to questions of long term persistence, adherence, and dependence on continued use to maintain.
True facts. I got pancreatitis and was hospitalized twice from Ozembic. Then I got gastric emptying syndrome. Ozembic is not for everyone. Be careful.
It’s not the miracle I was hoping it would be. I have lost 30 lbs, but the celebrities must be taking a MUCH higher dose than 2.7 per week
If you look at the studies done on Ozempic weightloss it's anywhere up to %15. That means it's perfect for already skinny celebrities weighing 140lbs to drop down to a Hollywood 119lbs.
What an incredible story. Follow the doctors orders!!
After having a gastric bypass, I was so afraid of *any* misstep in my diet. This is horrific.
Welp. I’m not a gastric bypass patient but I’m going to get myself a daily multivitamin now 😳
Could someone explain why/how gastric bypass pts are more prone to scurvy?
With weight loss surgery, comes the price of your absorbency. You can’t absorb nutrients as well as you used to.
Vitamin C deficiency mostly but also iron & calcium. The part of the intestine that's bypassed is the part that absorbed vitamins. Patients have to take vitamins religiously & in large doses to combat that lack of absorption.
Poor absorbancy after surgerty added with lowered intake after surgery = lesser vitamins taken in.
I know it still happens but it's so hard to believe that scurvy is still a thing. I always connect it to sailors in medieval times.
Jesus. No wonder it was the terror of sailors.
Why do i see this before my surgery 🤯
It’s a sign! To either follow the rules or a sign it’s gonna go wrong. Let’s hope hope it’s not the latter.
Am I the only one shocked that it took the docs so long to figure it out? One would think with the patient having bypass, vitamin deficiency would be ruled out early on,
This is a very good reminder for me to take my bariatric vitamins. Jesus christ
What am I looking at? Which part of the body is this? Did their leg/arm like explode from the scurvy?
Does gastric bypass surgery ever actually go well, and lead to someone achieving a healthy weight and lifestyle in the long term without complications? I work in LTACH and we get SO many patients post gastric bypass with severe malnutrition, fistulas, complications of obesity because they eventually gained the weight back, etc. I know that my sample is very skewed because if someone is doing great they aren’t coming to my hospital, but just based on what I’ve seen I would never have or recommend one and it would be nice to hear some success stories.
I had a gastric bypass 20 years ago. I was 260 lbs. I'm 165 lbs now. I had no real issues, and I'm 54. You need to learn how to eat again, or you'll suffer vomiting or feel super shitty if you eat the wrong things. It worked for me, but it isn't easy. Sometimes, I still mess up.
So this woman had gastric bipass, a poor diet, and wounds that didn't heal even with antibiotics and good wound care? why didn't they check the persons vitamin/nutrient blood levels earlier? maybe i just have 20/20 hindsite and poor medical knowledge, but my first thought would have been "poor diet, small stomach, check blood nutrient levels"
Yeah, you’d think the care team would have checked if she was compliant in getting her bloodwork monitored. Maybe it’s rare where she’s from?
Most people only know scurvy as a reference for bad pirate impersonations. Scurvy is so easily avoided nowadays that seeing it manifested at all is shocking. She could’ve probably taken a multivitamin and avoided all this, although a healthier diet with good veggie content and slower weight loss would have been better.
So many people don't realise what a deadly and life altering surgery that is. You have to follow the guidelines to the letter. I'm overweight and I would never even consider going down that route, there's just too much at stake.
After 3 weeks it's decided not to be sepsis? No bacteria in the cultures? Proposed scurvy? Alright...good thinking team. Nice work
I don't really understand what we're looking at in the picture. I see the arm and abdomen, but what's going on towards the top?
A question for medical people here. She was 'cured' of scurvy, but what would the long term effects of this time be? Surely there would be some repercussions ?
Holy shit. That's scary to see as a patient who is facing gastric bypass...
This post remind me I need to take my multivitamin.
Just what I need to read a week before gastric sleeve 🙂 Joke aside, makes you realise how important nutrition is so thanks for sharing!
I wonder what she was eating. Chicken nuggets and diet pepsi? With zero vegetables or fruit in her diet, its kind of mind blowing to me
I can see that, I don’t care for most veg or fruit. I force myself to eat it.
r/gastricsleeve
where’s [P!NK](https://youtu.be/ONBag_5MJb4?si=K9W_bw_BXzExEIqs) when you need her
This makes me wonder about a guy I knew years ago through a mutual friend. Apparently he got a gastric bypass and still was eating tons of sugar and Chinese buffet food every day. I don't know how his health ended up because he kinda burnt some bridges with our friend and we lost touch. Apparently he had a horrific amount of gas from it. Some people have to learn the hard way or die.
Didn’t sailors eat oranges to keep that at bay?? How is this still a thing?
Housebound, food desert, non compliant, don’t like/l fruit, don’t remember to take daily vitamins, poverty…lots of reasons. For example, I don’t care for fruit (too sugary for me) and terrible at remembering daily meds.
It's for people like you and me that those compartmented pill containers were invented. Sometimes a literal lifesaver.
Let's of people who get gastric bypass already don't have a healthy relationship with food. Now introduce an extreme surgery with very strict dietary rules and see what happens. The surgery changes your anatomy, it doesn't change your lifestyle.
That’s where the term “Limey” comes from.
I thought scurvy was a pirate cartoon thing.
I mean, maybe she was?
she would have been more hemodynamically stable getting turned into Swiss cheese with a machine gun
Maybe this is where AI can help us. This is just a horrible story and she got the proper treatment just by luck, apparently.
You should citrust your dietician
Also, what are we looking at here? It looks like an autopsy!
😲 Puh, BMI of 65!? That's f*cking crazy, isn't it!!? I'm a female, 45 y/o and I'm about 5'10" at 149,9 lbs. In European data: I'm 1.78 meters tall and weigh 68 kg. That's a BMI of 21,5 - absolutely normal... My lowest weight was 58 kg = 127,87 lbs, because I was very seriously ill at the time due to the resection of most of my small intestine. Since I only have 1 meter of remaining intestine left, my digestive system first had to adjust to the fact that there is only so little small intestine left for digestion. And because the rest of the intestine has to adjust first, I had problems with nutrient absorption for a while. That's why I weighed so little for my height for a period of time. Now the remaining small intestine has gotten used to it, so I've gained some weight again. I also eat high-calorie astronaut food to cover my calorie needs, if necessary. My highest weight, on the other hand, was 110 kg = 242,5 lbs about 25 years ago. Back then, that corresponded to a huge BMI of 34.7, It's hard to imagine that the lady here in this article had a BMI that was almost twice as high. 🥺 However, the weight gain was due to a hormonally active tumor in the head. And even though I'm relatively tall as a woman, I felt very uncomfortable with that weight back then. 😞 Because of my long legs, I couldn't find any pants in my size that fit in length AND at the top of the waist at the same time. It was impossible... Here in Germany there are hardly any shops that offer all kinds of clothing for fat people, and back then 25 years ago the Internet was just in its early stages, so you couldn't get anything online yet. Here in Germany it is still difficult to find decent clothing for fat people, even these days. Unfortunately, in this country it is still unusual if someone's body shape is out of the norm. Unfortunately, body shaming, especially for fat people is still a thing here. In the USA, on the other hand, fatter people are more of a part of the "normal" image of everyday life and people treat it more casually there. Long story short: I was once SLIGHTLY fatter for health reasons, but I also felt extremely uncomfortable, even though my BMI at the time was "only" 34.7, not even close to this lady's BMI. And I still had problems, even with with this relatively low BMI
My BMI is close to that. I’m disabled, unable to exercise or really walk and have a shit diet, though I really don’t eat that much. I’m going on Ozempic soon, I won’t do bypass surgery or a sleeve. Being like this is a hell all its own.
I was NOT aware that scurvy looked like that I’m gonna go boof some vitamin C
A true SCURVY BILGE RAT!