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Scurvy and stroke: is there an association?

TO THE EDITOR: We read with interest the recent letter by He and colleagues. The authors described a case of ischaemic stroke in a patient with scurvy and considered whether there was a connection between the two conditions. They referred to evidence that vitamin C deficiency may be a risk factor for cerebrovascular disease, but acknowledged that a direct causal link is unlikely to be established. We propose adiponectin as the causal link between vitamin C deficiency and stroke. Adiponectin is an adipokine, secreted in multimers by adipose tissue, with insulinsensitising, antiatherogenic and cardioprotective properties. A decrease in adiponectin levels — particularly the more biologically active, high molecular weight (HMW) multimers — is implicated in a number of disease states, such as obesity, type 2 diabetes, heart disease and some cancers. Adiponectin has also been reported to have cerebroprotective properties, and there is some evidence that levels may be reduced in patients with cerebrovascular disease. A recent study demonstrated that vitamin C supplementation increases the proportion of HMW adiponectin secreted from human adipocytes. Vitamin C levels are lower in obese and diabetic patients, and the patient reported by He et al had also been recently diagnosed with type 2 diabetes. While scurvy is admittedly rare, He and colleagues noted that subclinical vitamin C deficiency is not uncommon in the general population (about 10%). We suggest that it would be worthwhile to assay plasma vitamin C levels and total and HMW adiponectin levels in patients presenting with cerebrovascular events, and to undertake prospective studies to determine whether vitamin C supplementation improves patients’ adiponectin levels. Increased HMW adiponectin levels could be explained, at least in part, by the role of vitamin C in the multimerisation of adiponectin. Adiponectin levels are also reduced in other vascular conditions, such as ischaemic heart disease and peripheral vascular disease. As plasma vitamin C levels of patients with these diseases are also reduced, it is tempting to posit that vitamin C supplementation could have a role as a treatment, or even a prophylactic, in populations at risk of a range of adiponectin-related vascular diseases.