15. Scurvy

Usually presents with swelling, pain and discoloration of the lower extremities where hemorrhages and ecchymoses are commonly found in areas of frequent stress, e.g. lower extremity joints and the soft tissue of the back and buttocks.

Frequently evaluated for suspicion of DVT, cellulitis or rheumatic disease.

May also initially present with gingivitis

  • requires teeth
  • occurs more frequently with pre-existing periodontal disease
  • decay is essentially secondary to loosening of the gums away from the teeth and the loss of alveolar bone
  • there is also the contribution of hemorrhage and poor wound healing, often associated with G.I. bleeding/Fe deficiency.

Early clues may be found in the skin where there is enlargement and hyperkeratosis of the hair follicles with subsequent congestion/proliferation of blood vessels around the follicle leading to a classic lesion of a hyperkeratotic hair follicle with a hemorrhagic halo. Hairs may become fractured, coiled, and bent.

Platelet function and evaluation of laboratory coagulation is usually entirely normal in isolated vitamin C deficiency.

Seventy-five percent of presenting patients have anemia, most often a mild normocytic and normochromic anemia, but megaloblastic or microcytic anemias have been reported. It is unclear as to the exact mechanism of anemia in vitamin C deficiency. In vivo studies of vitamin C deficiency have not been conclusive as to either a direct inhibitory effect on erythropoiesis or inhibition of iron absorption/metabolism.

Terminal stages of scurvy are characterized by generalized edema, fever, hypotension, convulsions, and eventually death.

Modern presentations are rarely an isolated deficiency of vitamin C. Presentations commonly include Fe and/or folate deficiency, vitamin K deficiency, and evidence of malnutrition.

High risk-groups include edentulous, elderly people who live alone (more frequently men), individuals who avoid "acid"-containing foods due to symptoms of dyspepsia or reflux esophagitis, food fadists (often psychiatric patients), and alcoholics.