Case Presentation: A 49-year-old male with past medical history of anxiety, chronic diarrhea and alcohol dependency presented with blood-tinged emesis.
The patient endorsed a three-week history of non-bilious, blood-streaked emesis after ingestion of both solids and liquids. He also endorsed a cough productive of blood-streaked sputum and easy bruising.

He was a retired librarian. He typically drank 35 alcoholic drinks per week but denied any tobacco or illicit drug use. He was not sexually active. He had never been imprisoned, received any transfusions or tattoos, or traveled out of the country. He ate a variety of foods with no restriction. He drank one glass of orange juice daily with breakfast. His only prescribed medications were as needed diazepam and propranolol, for anxiety. Additionally, he did ingest 1 tablet of activated charcoal per day, which was recommended by his primary care physician to control his diarrhea. He had never undergone any surgical procedures.

Physical exam was notable for mild tenderness with palpation of the epigastrium and for ecchymosis overlying the bilateral upper and lower extremities. Initial work-up revealed hyperbilirubinemia with an indirect predominance, elevated INR and PTT, and normocytic anemia with adequate reticulocyte response. Liver transaminases were within-normal-limits. Imaging of the liver was unremarkable. Subsequent labs revealed an undetectable vitamin C level. A diagnosis of vitamin C deficiency secondary to activated charcoal ingestion was made and the patient was worked up further for sequela.

Discussion: This patient presented with bleeding diathesis, a diagnosis with a broad differential sometimes requiring extensive workup. Workup often begins with evaluation for liver disease and occasionally extends to inspection for factor deficiencies or even rodenticide poisoning. The workup for vitamin C deficiency was performed based on evidence that charcoal binds water soluble vitamins, as the impact of supplemental activated charcoal has not yet been clearly outlined in medical literature. This case highlights the impact of alternative medicine on our patients and reminds us that we must understand alternative medicine if we are to provide optimal care.

Conclusions: Activated charcoal is known in the medical community as a gastrointestinal decontaminant for acute poisoning. To many patients, however, it is known as a safe, natural substance that whitens teeth, decreases abdominal bloating/diarrhea, and reduces hangovers. The fact that patients can acquire over-the-counter supplements without a doctor’s prescription might put them under the false premise that these drugs are harmless. It is our duty as clinicians to be aware of these supplements and their side effects in order to deliver optimal and safe patient care.