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Scurvy

Scurvies

Scurvy is a disease resulting from a dietary deficiency of vitamin C. Common symptoms are malaise, lethargy, diarrhea, petechiae, neuropathy, fever, hemorrhage and myalgias.


Presentation

The symptoms of scurvy usually begin three months after a person stops getting enough vitamin C in the diet. The initial symptoms of scurvy include generalized fatigue, malaise, irritability, fever, pain and swelling over long bones, and the appearance of small blue-red spots on the skin.

If left untreated, scurvy can progress to severe problems such as swollen gums, which become soft and vulnerable to bleeding. The teeth may feel loose or fall out. There may be soreness and stiffness of the joints and lower extremities [7]. The petechial hemorrhages and spots develop over the skin at the site of hair follicles, and they often occur on the shins. The hair in the affected area usually twist around like corkscrews and break away easily.

In infants and children, there can be premature stopping of bone growth and complications like pseudoparalysis. Other symptoms include bulging eyes, dry, scaly and brownish skin, poor healing of wounds, pin-point red marks over the bleeding areas, hyperkeratosis and sicca syndrome. In the late stages, jaundice, generalized edema, oliguria, neuropathy, fever, shortness of breath, anemia, convulsions and eventual death are seen.

Easy Bruising
  • The clinical manifestations of follicular hyperkeratosis, perifollicular petechiae, corkscrew hairs, and easy bruising are due to defective collagen synthesis and can be mistaken for small vessel vasculitis.[ncbi.nlm.nih.gov]
  • “While diabetes is not traditionally a risk factor for vitamin C deficiency, the research suggests that clinicians should have a high index of suspicion,” said Professor Gunton, “particularly if their patients present with unhealed ulcers, easy bruising[web.archive.org]
Fatigue
  • A 22-year-old woman with an anxiety disorder and anorexia nervosa, recent pregnancy and ongoing breast feeding, presented with a 10-day history of spontaneous haematomas in the lower limbs, gingivorrhagia and fatigue.[ncbi.nlm.nih.gov]
  • Scurvy can be treated magically or can be overcome with proper nutrition; eating the right foods ends the fatigue and bone pain within 1–2 days and provides a full cure 2d6 days after that. Section 15: Copyright Notice[d20pfsrd.com]
Anemia
  • High-output heart failure due to anemia can be observed.[web.archive.org]
  • Skull-marrow hyperplasia is more likely to result from hemolytic anemia or anemia related to parasitic infestation.[emedicine.com]
  • She had severe anemia and the characteristic gingival and skin lesions, which responded dramatically to ascorbic acid therapy. We report this case to make physicians aware of the possibility of scurvy and of its clinical symptoms.[ncbi.nlm.nih.gov]
  • Other nutritional deficiencies, such as anemia, may also need to be corrected with improved balanced diet and short term use of supplements.[symptoma.com]
Malnutrition
  • The intensivist and dietitian need to consider this diagnosis even in the first world setting, particularly in the presence of sepsis, inflammatory conditions, steroid use and importantly malnutrition.[ncbi.nlm.nih.gov]
  • Infants and children with severe malnutrition or restrictive diets are also at risk for scurvy. There are various factors or lifestyle issues that might increase the risk of scurvy.[symptoma.com]
  • These include: People with chronic malnutrition or those that eat less than 2 servings of fruits/vegetables per day Alcoholics Elderly Men who live alone (bachelor or widower scurvy) Children People on peculiar diets or food fads Psychiatric disease ([dermnetnz.org]
Fever
  • It’s very important to seek treatment if you have typhoid fever or think you might have it. Without treatment, one in five people with typhoid fever may die from complications. You can reduce your risk of getting typhoid fever by getting vaccinated.[healthline.com]
  • In the late stages, jaundice, generalized edema, oliguria, neuropathy, fever, shortness of breath, anemia, convulsions and eventual death are seen.[symptoma.com]
  • The authors report the case of a 50-year-old alcoholic man with chronic hepatitis C virus infection, who presented to the emergency department with fever and exuberant ecchymoses and petechiae on both legs.[ncbi.nlm.nih.gov]
  • The initial symptoms of scurvy are nonspecific and include the following: Malaise Lethargy Loss of appetite Peevishness (ill-tempered) Poor weight gain Diarrhea Tachypnea Fever After 1-3 months of severe or total vitamin C deficiency, patients develop[web.archive.org]
Anorexia
  • A 22-year-old woman with an anxiety disorder and anorexia nervosa, recent pregnancy and ongoing breast feeding, presented with a 10-day history of spontaneous haematomas in the lower limbs, gingivorrhagia and fatigue.[ncbi.nlm.nih.gov]
  • Gum swelling, friability, bleeding, and infection with loose teeth also occur, as do mucosal petechiae Loss of weight secondary to anorexia is common. Upper endoscopy may show submucosal hemorrhage.[web.archive.org]
Loss of Appetite
  • The initial symptoms of scurvy are nonspecific and include the following: Malaise Lethargy Loss of appetite Peevishness (ill-tempered) Poor weight gain Diarrhea Tachypnea Fever After 1-3 months of severe or total vitamin C deficiency, patients develop[web.archive.org]
  • Other symptoms include loss of appetite and weight loss, sore and bleeding gums, skin hemorrhages and bruising, especially on the legs, and a general paleness and weakness.[livestrong.com]
  • These may include: Unusual fatigue A fever Diarrhea Nausea Loss of appetite Pain in your joints and/or muscles A general feeling of being unwell Some people show small "pinpoint" bleeding on their skin, particularly around the area of hair follicles.[wikihow.com]
  • […] of appetite with nausea and vomiting seen with chemotherapy and in AIDS patients Increased utilization or breakdown of vitamin C : – Pregnancy – Breastfeeding – Higher than normal metabolic rate (hyperthyroidism) – Cigarette smoking Decreased absorption[healthhype.com]
Bleeding Gums
  • Physical examination should be done to look for swollen and bleeding gums and rest of the symptoms. Various blood tests can be used to analyze serum ascorbic acid and iron levels.[symptoma.com]
  • Although two of the prisoners escaped, the remaining four developed clinical signs of scurvy; follicular hyperkeratosis of the thighs, buttocks, calves, and the posterior aspects of the arms; swollen bleeding gums; perifollicular hemorrhages and congested[ajcn.org]
  • […] noun A disease caused by a deficiency of vitamin C, characterized by swollen bleeding gums and the opening of previously healed wounds, which particularly affected poorly nourished sailors until the end of the 18th century.[oxforddictionaries.com]
  • […] noun mass noun A disease caused by a deficiency of vitamin C, characterized by swollen bleeding gums and the opening of previously healed wounds, which particularly affected poorly nourished sailors until the end of the 18th century. as modifier ‘the[en.oxforddictionaries.com]
Gingival Swelling
  • Skin examination revealed extensive ecchymoses, hyperkeratosis and follicular purpura with corkscrew hairs, in addition to gingival swelling with bleeding. Clinical diagnosis of scurvy was rendered and confirmed by low serum vitamin C level.[ncbi.nlm.nih.gov]
Scorbutic Rosary
  • Costochondral beading or scorbutic rosary (ie, sternum sinks inward) may occur in children.[web.archive.org]
  • This finding is known as the scorbutic rosary (ie, sternum sinks inward) and may occur in children.[emedicine.medscape.com]
  • Pediatric generalized osteopenia cortical thinning: “pencil-point” cortex periosteal reaction due to subperiosteal hemorrhage scorbutic rosary: expansion of the costochondral junctions may relate to the fracturing of the zone of provisional calcification[radiopaedia.org]
Joint Effusion
  • Three cases of scurvy are being reported presenting uniquely as purpura, right hip joint effusion and right knee joint effusion with haemorrhage in prepatellar and retropatellar bursae, respectively over an 18 month period (2009-2010).[ncbi.nlm.nih.gov]
  • There was no joint effusion and he had no gingival bleeding. FIGURE 1 Growth chart of the patient. The patient was born at term after an uneventful pregnancy (G2P2) and his birth weight was 3100 g.[pediatrics.aappublications.org]
Knee Pain
  • MORE STORIES The Best Outdoor Running Shoes for Handling Whatever Mother Nature Throws at You Sports and Fitness 12 Exercises That Are Safe to Do With Knee Pain Diseases and Conditions What Exactly Is the Keto Ultra Diet Supplement and Should You Take[limestrong.com]
Hip Pain
  • A 30-month-old boy had presented with left hip pain two weeks after falling down on the floor while walking. He developed pain, warmness of the left hip and thigh, and finally was unable to bear weight.[ncbi.nlm.nih.gov]
Ankle Arthritis
  • Case 3 was a man with Down's syndrome who presented with acute ankle arthritis. Scurvy in Cases 1 and 3 were related to abnormal dietary preferences, whereas in Case 2, scurvy was thought to be related to thalassaemia.[ncbi.nlm.nih.gov]
Petechiae
  • Pediatric scurvy is a rare condition characterized by perifollicular petechiae and bruising, hemorrhagic gingivitis and musculoskeletal symptoms, all assumed to be predominantly related to abnormal collagen structure.[ncbi.nlm.nih.gov]
  • Skin changes with roughness, easy bruising and petechiae, gum disease, loosening of teeth, poor wound healing, and emotional changes occur. Dry mouth and dry eyes similar to Sjögren syndrome may occur.[web.archive.org]
  • Gum swelling, friability, bleeding, and infection with loose teeth also occur, as do mucosal petechiae. Periodontal images of the patient taken before periodontal treatment.[emedicine.medscape.com]
Purpura
  • BACKGROUND: Bateman purpura is characterized by diffuse senile skin atrophy, senile purpura and spontaneous stellar pseudocicatrices.[ncbi.nlm.nih.gov]
Alopecia
  • Alopecia may occur secondary to reduced disulfide bonding. Costochondral beading or scorbutic rosary (ie, sternum sinks inward) may occur in children.[web.archive.org]
  • The case of an infant with diffuse, nonscarring alopecia of the scalp and radiologic features of scurvy was reported in India in 2008. [30].[emedicine.medscape.com]
  • Other signs include alopecia, muscle atrophy, poor wound healing, and characteristic corkscrew hairs. Figure 1.[clinicaladvisor.com]
  • Diffuse nonscarring alopecia of scalp: an indicator of early infantile scurvy?. Pediatr Dermatol. 2008 Nov-Dec. 25(6):644-6. [Medline]. Kitcharoensakkul M, Schulz CG, Kassel R, Khanna G, Liang S, Ngwube A, et al.[emedicine.com]
Delayed Wound Healing
  • A lack of vitamin C results in a defective formation of collagen and connective tissues, which can result in easy bruising, bleeding gums, blood spots in the skin, joint pain and delayed wound healing.[theconversation.com]
Exanthema
Irritability
  • Early clinical manifestations consist of pallor, irritability, and poor weight gain. In advanced infantile scurvy, the major clinical manifestation is extreme pain and tenderness of the arms and, particularly, the legs.[web.archive.org]
  • The patient was referred for pathologic fractures of the femur, irritability, and failure to thrive. He had typical radiologic signs of scurvy, such as osteopenia, cortical thinning, Wimberger ring, Frankel line, fracture, and periosteal reaction.[ncbi.nlm.nih.gov]
  • By the time he was 11 months old, he had become tired and irritable and was no longer sitting up. Medical tests revealed widespread bone degeneration, multiple fractures, low calcium and other problems.[abcnews.go.com]
Apathy
  • Scurvy is a thousand-year-old stereotypical disease characterized by apathy, weakness, easy bruising with tiny or large skin hemorrhages, friable bleeding gums, and swollen legs. Untreated patients may die.[ncbi.nlm.nih.gov]
  • But what do we do when sickness isn’t spread by germy fingers, but by apathy? A portion of the research for this series was crowdfunded on Inkshares.[medium.com]
Learning Difficulties
  • CASE REPORT: A 9-year old girl with learning difficulties, developmental delay and refractory epilepsy was placed on the ketogenic diet in 2003.[ncbi.nlm.nih.gov]

Workup

Scurvy can be diagnosed by taking complete medical history with detailed questioning about the patient’s dietary habits. Physical examination should be done to look for swollen and bleeding gums and rest of the symptoms [8].

Various blood tests can be used to analyze serum ascorbic acid and iron levels [9]. Sometimes radiological procedures such as X-rays of the joints (including the knee, wrist and ribs) are ordered for diagnostic purposes.

Normocytic Normochromic Anemia
  • Large hematoma on the inner right thigh After initial supportive treatment, results of primary investigations revealed a normocytic normochromic anemia with a hemoglobin level of 64 g/L. Two units of packed red blood cells were transfused.[ncbi.nlm.nih.gov]
Vitamin C Decreased
  • Gustavo Barja, Mónica López-Torres, Rosa Pérez-Campo, Caridad Rojas, Susana Cadenas, Juan Prat and Reinaldo Pamplona, Dietary vitamin C decreases endogenous protein oxidative damage, malondialdehyde, and lipid peroxidation and maintains fatty acid unsaturation[doi.org]

Treatment

Administration of vitamin C is the specific therapy for scurvy. A dose of 250mg vitamin C 3 times daily by mouth should saturate the tissues quickly. The deficiencies of the patient’s diet should also be corrected and other vitamin supplements given if necessary [10].

Orange juice usually functions as an effective dietary remedy. Other nutritional deficiencies, such as anemia, may also need to be corrected with improved balanced diet and short term use of supplements. Dietary intake of vitamin C more than 1 g/day have been reported to cause diarrhea, abdominal pain, cramps, and the formation of renal oxalate stones.

Prognosis

  • Although the incidence of scurvy has become low in Saudi Arabia, it can still occur and early recognition is important because of the excellent prognosis.[ncbi.nlm.nih.gov]
  • Asparagus Bell pepper (green) Broccoli Cabbage Grapefruit Kiwi Lemon Lime Orange Tomatoes Sweet potato Prognosis The prognosis for scurvy is very good if proper management.[healthhype.com]
  • Prognosis Treatment with vitamin C is usually successful, if the deficiency is recognized early enough. Left untreated, the condition can cause death. Prevention Eating foods rich in vitamin C every day prevents scurvy.[medical-dictionary.thefreedictionary.com]

Etiology

Scurvy is caused by a lack of vitamin C in the diet for a prolonged time. People who eat less than two fruits or vegetables per day are more prone to develop the disease. A number of factors such as bottle feeding in infants with cow’s milk, pregnancy, lactation, smoking, alcohol consumption and pathological conditions (such as Crohn’s disease and malabsorption syndrome) increase the risk of scurvy in these people.

Infants and children with severe malnutrition or restrictive diets are also at risk for scurvy [2] [3]. There are various factors or lifestyle issues that might increase the risk of scurvy. These include crash dieting, allergy diets, fussy eating and eating disorders like anorexia nervosa or bulimia. Certain cancers may also cause vitamin C deficiency [4]. Hemodialysis in the patients with type 1 diabetes mellitus may also cause scurvy [5] [6].

Epidemiology

Scurvy is rare in the United States. The disease is more common in older individuals who are not getting proper nutrition. The condition is particularly common in the under developed regions and third world countries that particularly suffer from the deficiency of vitamin C. The disease is more prevalent in populations that have a low amount of fruits and vegetables in diet.

Sex distribution
Age distribution

Pathophysiology

Ascorbic acid is the most active reducing agent in the aqueous phase of living tissues and is involved in intracellular electron transfer. It takes part in the hydroxylation of proline and lysine in protocollagen to hydroxyproline and hydroxylysine in mature collagen. Hydroxyproline and hydroxylysine are important for stabilizing collagen by cross-linking the propeptides in collagen.

Defective collagen synthesis impairs wound healing. Collagen is an important part of bone, so bone formation is also affected. In the blood vessels, the defective connective tissue leads to fragile capillaries, and causes capillary hemorrhage and reduced platelet adhesiveness. Vitamin C is also important for many other metabolic processes including antioxidant function, iron absorption, and for its role as neurotransmitter in brain.

High-dose vitamin C improves immune function including resistance to common cold. It is very easily destroyed by heat, increased pH and light, and is very easily soluble in water; hence many traditional cooking methods reduce or eliminate it.

Prevention

Scurvy can be prevented by consuming enough vitamin C, either in the diet or as a supplement. Dietary sources of vitamin C include fruits such as oranges, lemon, limes, tomatoes, mangoes, kiwifruits, grapefruits and strawberries. The vegetables rich in vitamin C include particularly green leafy vegetables such as cabbage, capsicum and spinach.

Many animal products such as kidney, whale skin, oysters, brain, spinal cord, adrenal medulla and liver, contain large amounts of vitamin C and can help prevent its deficiency.

Summary

Scurvy is a disease which results from the deficiency of vitamin C in the diet. The condition is characterized by generalized body weakness, bleeding gums, anemia and skin hemorrhages.

Vitamin C is essential for the synthesis of collagen, a major component of connective tissues. It also helps in the proper functioning of immune system, cholesterol metabolism and other biological activities. The human body lacks the ability to synthesize vitamin C, so it has to be taken from exogenous vitamin C sources such as citrus fruits and leafy vegetables in order to meet the body needs.

Scurvy is more common in older adults and alcoholics suffering from malnutrition. Scurvy was commonly associated with sailors of the 16th to 18th centuries who navigated long voyages without enough vitamin C supplements [1]. Modern cases of scurvy are extremely rare.

Patient Information

Scurvy is a disease caused by severe or long term vitamin C deficiency. The patients usually present with body weakness, swollen ad bleeding gums, painful joints and skin rashes.

Good sources of dietary vitamin C include citrus fruits and green vegetables. It is more common in infants and older individuals who do not take proper nutrition. Overdosing of vitamin C can cause problems, so more than recommended dose of vitamin C supplement should not be taken.

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Last updated: 2019-07-11 22:54