Vitamin C (Ascorbic Acid)
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Vitamin C, also known as ascorbic acid, is a water-soluble vitamin.
The reference range of vitamin C is 0.6-2 mg/dL. [1]
Scurvy is caused by prolonged dietary deficiency of vitamin C (ascorbic acid).
Vitamin C levels generally reflect recent intake amounts more than body stores.
Vitamin C levels of less than 0.3 mg/dL indicate significant deficiency, while levels that exceed 0.6 mg/dL indicate sufficient intake.
There is no known toxic level of vitamin C. [2] However, limited studies have suggested that levels greater than 3 mg/dL may be associated with uricosuria and, in persons with glucose-6-phosphatase deficiency, may induce red blood cell fragility. [1]
Specifics for collection and panels are as follows: [1]
Specimen type: Blood plasma
Container: Vacutainer, green top (heparin)
Collection method: Venipuncture
Specimen volume: 1 mL
Collection conditions: Fasting for 12-14 hours
Vitamin C is sensitive to heat and light, [3] so the specimen should be immediately placed on wet ice and processed within 4 hours. Centrifuge and place plasma in an amber vial to protect it from light. The specimen should be stored frozen. Reject for gross hemolysis but not mild hemolysis or lipemia or icterus.
Vitamin C, also known as ascorbic acid, is a water-soluble vitamin. It is required for the synthesis of collagen, L-carnitine, and neurotransmitters. Vitamin C is also involved in protein metabolism.
Vitamin C is a strong antioxidant and has been shown to regenerate other antioxidants such as vitamin E. Vitamin C also plays an important role in immune function and improves the absorption of nonheme iron. [3, 4, 5]
Vitamin C cannot be produced by humans but is readily available in many types of food. Citrus fruits are the best known sources of vitamin C, but red and green peppers, tomatoes, potatoes, and other vegetables are also excellent sources.
The body tightly regulates tissue and plasma concentrations of vitamin C. [3] With increasing intake of vitamin C, the body absorbs a decreasing fraction of it, making toxicity extremely unlikely. With 30-180 mg/day of vitamin C intake, there is 70%-90% absorption, whereas, with intake greater than 1 g/day, the absorption drops to less than 50%. [4]
Vitamin C is metabolized in the liver and excreted by the kidneys. The renal threshold for excretion of vitamin C is 1.4 mg/100 mL. Excess vitamin C is excreted unchanged in the urine. When plasma concentrations of vitamin C are low, excretion of vitamin C is decreased. [6]
The total body content of vitamin C ranges from 300 mg to 2 g. Vitamin C is stored throughout the body, with highest concentrations in the white blood cells, eyes, adrenal glands, pituitary glands, and the brain.
Increased intake of vitamin C has been reported to be beneficial in several health-related aspects, including cancer prevention, cancer treatment, prevention of cardiovascular disease, prevention of age-related macular degeneration and cataracts, prevention of the common cold, [4] improved wound healing, [7] and improved blood pressure control. [3] These studies have largely been epidemiologic in nature, and whether increased vitamin C or other factors are responsible for any possible effect is controversial. None of these studies have shown any benefit associated with a higher vitamin C plasma level, and laboratory testing of vitamin C is not beneficial.
Vitamin C deficiency leads to scurvy. Humans, unlike other animals, are unable to produce vitamin C and therefore depend on dietary sources. Scurvy has been described since ancient times and is best known for its high incidence in sailors. In the 1700s, addition of citrus fruit to the diet of sailors largely cured scurvy in that group, but there were still incidents of “land scurvy” in populations with abnormal diets. [8]
Today, scurvy is extremely rare because of improved food supplies, vitamin-fortified foods, and vitamin supplements, but can occur in populations with poor diets. [9, 6]
The main function of vitamin C is in the triple-helix formation of collagen; vitamin C deficiency impairs collagen synthesis and results in the typical signs of scurvy. [6] Upon administration of adequate oral vitamin C, the symptoms of scurvy resolve within 1-12 days. [6]
Signs of scurvy (vitamin C deficiency) include the following: [9, 6]
Poor wound healing
Malaise and fatigue
Weight loss
Gingival inflammation with gum bleeding
Loss of teeth
Capillary fragility with petechiae, ecchymosis, and purpura
Joint pain
Dry eyes, dry mouth
Corkscrew hair
Radiographic bone findings (infantile scurvy): Subperiosteal elevation; fractures, dislocations; alveolar bone resorption; ground-glass cortical appearance
The following populations are at risk for vitamin C deficiency: [9, 6]
Infants fed only cow’s milk or evaporated milk for the first year of life
People at risk for malnutrition (including alcoholism, advanced age, anorexia, AIDS)
Individuals with type 1 diabetes mellitus
Persons with small-bowel disease (eg, Crohn disease, celiac disease, Whipple disease)
Pregnant and lactating females
Patients receiving renal dialysis
Persons with thyrotoxicosis
Smokers
Individuals with iron overload disorders
People with poor diets (some elderly persons, drug and alcohol abusers, some with mental disorders)
Because vitamin C (ascorbic acid) levels reflect recent intake and scurvy takes weeks to months to present, levels are generally not obtained to diagnose scurvy. In an at-risk population, such as elderly individuals who live alone, alcoholics, and infants fed with unfortified milk, vitamin C levels may help in assessing adequacy of diet and indicate need for supplementation before clinical disease develops.
Presentation of a patient with the typical clinical picture of scurvy, along with a history of dietary deficiency, is often sufficient for diagnosis. Vitamin supplementation with resolution of symptoms verifies the diagnosis.
The US Food and Drug Administration (FDA) approved Ascor (ascorbic acid injection) for the short-term (<1 wk) treatment of scurvy in adults and children aged 5 months or older for whom oral administration is not possible, is insufficient, or is contraindicated. The exact mechanism of action of ascorbic acid for the treatment of scurvy is unknown. It is believed the administration restores the body pool of ascorbic acid. [10]
Mayo Clinic: Mayo Medical Laboratories. Ascorbic Acid (Vitamin C), Plasma. Available at https://www.mayomedicallaboratories.com/test-catalog/Overview/42362. Accessed: October 6, 2017.
Rosenbloom M. Vitamin Toxicity. Medscape Drugs & Diseases. Available at http://emedicine.medscape.com/article/819426-overview. December 21 2016; Accessed: October 6, 2017.
DSM Food Specialties B.V. Quali®-C (vitamin C). Available at http://www.dsm.com/markets/foodandbeverages/en_US/products/vitamins/vitamin-c.html. Accessed: October 6, 2017.
National Institutes of Health Office of Dietary Supplements. Vitamin C Fact Sheet for Health Professionals. US Department of Health & Human Services. Available at http://ods.od.nih.gov/factsheets/vitaminc/. February 11, 2016; Accessed: October 6, 2017.
Sorice A, Guerriero E, Capone F, Colonna G, Castello G, Costantini S. Ascorbic acid: its role in immune system and chronic inflammation diseases. Mini Rev Med Chem. 2014 May. 14(5):444-52. [Medline].
Goebel L. Scurvy. Medscape Drugs & Diseases. Available at http://emedicine.medscape.com/article/125350-overview. September 18, 2017; Accessed: October 6, 2017.
Moores J. Vitamin C: a wound healing perspective. Br J Community Nurs. 2013 Dec. Suppl:S6, S8-11. [Medline].
Gulko E, Collins LK, Murphy RC, Thornhill BA, Taragin BH. MRI findings in pediatric patients with scurvy. Skeletal Radiol. 2014 Aug 12. [Medline].
Kumar V. Robbins and Cotran Pathologic Basis of Disease. 8th ed. Philadelphia, Pa: Saunders; 2009. 437-38.
Ascor (ascorbic acid injection) [package insert]. Santa Ana, Calif 92704: McGuff Pharmaceuticals, Inc. October 2017. Available at [Full Text].
Carl M Kraemer, MD, FAAEM, FACEP Assistant Director of Clinical Services, Department of Emergency Medicine; Assistant Professor of Surgery, Department of Surgery, Emergency Medicine Division, St Louis University School of Medicine
Carl M Kraemer, MD, FAAEM, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association
Disclosure: Nothing to disclose.
Eric B Staros, MD Associate Professor of Pathology, St Louis University School of Medicine; Director of Clinical Laboratories, Director of Cytopathology, Department of Pathology, St Louis University Hospital
Eric B Staros, MD is a member of the following medical societies: American Medical Association, American Society for Clinical Pathology, College of American Pathologists, Association for Molecular Pathology
Disclosure: Nothing to disclose.
Judy Lin, MD
Disclosure: Nothing to disclose.
Vitamin C (Ascorbic Acid)
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