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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]
  • Author information 1 Medical Schools of Mount Sinai, New York, USA and Imperial College, London, United Kingdom. [email protected] Abstract Scurvy is a thousand-year-old stereotypical disease characterized by apathy, weakness, easy bruising with tiny[ncbi.nlm.nih.gov]
  • “Particularly if their patients present with unhealed ulcers, easy bruising or gum bleeding without obvious cause,” she said. AFP[independent.co.uk]
  • Perifollicular hemorrhages and easy bruising are often first seen in the lower extremities, as capillary fragility leads to an inability to withstand hydrostatic pressure.[ncbi.nlm.nih.gov]
  • Vitamin C deficiency leads to muscle and joint pain, tiredness and irritability, blue-red spots on the skin, bleeding and swelling of the gums, slower wound healing and easy bruising, the GP said.[express.co.uk]
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]
  • Three patients presented with symptoms including fatigue, purpuric rash, synovitis with effusion, anemia, and markedly elevated erythrocyte sedimentation rate and C-reactive protein levels. One patient presented with severe pulmonary hypertension.[ncbi.nlm.nih.gov]
  • Because many of the early symptoms of vitamin C deficiency (fatigue, malaise, depression and irritability) are non-specific, the diagnostic possibility of scurvy is usually delayed until haemorrhagic manifestations occur.[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]
Fever
  • 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]
  • Scarlet Fever It sounds like an illness from the “olden days,” but scarlet fever is still around. The infection comes from the group A Streptococcus or "group A strep."[healthline.com]
  • In the late stages, jaundice, generalized edema, oliguria, neuropathy, fever, shortness of breath, anemia, convulsions and eventual death are seen.[symptoma.com]
  • We report two cases of scurvy: a child of 3 years old came to our observation for an important gums' stomatitis, fever, widespread petechiae and ecchymosis on the skin of the lower limbs; in the second moment he had pain in upper and lower limbs with[ncbi.nlm.nih.gov]
  • He also had a high fever gingival hemorrhage, dental caries, petechiae, positive rolling test and limited range of motion of the left hip. The radiographs revealed Wimberger's ring and Frenkel line as scurvy.[ncbi.nlm.nih.gov]
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]
  • It may have contributed to the general ill-health of the members of Scott's polar party in 1912 but their deaths are more likely to have been caused by a combination of frostbite, malnutrition and hypothermia.[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]
Anemia
  • Other nutritional deficiencies, such as anemia, may also need to be corrected with improved balanced diet and short term use of supplements.[symptoma.com]
  • Three patients presented with symptoms including fatigue, purpuric rash, synovitis with effusion, anemia, and markedly elevated erythrocyte sedimentation rate and C-reactive protein levels. One patient presented with severe pulmonary hypertension.[ncbi.nlm.nih.gov]
  • Later symptoms may include anemia, extreme weakness, soreness of upper and lower limbs, tachycardia, and dyspnea.[medical-dictionary.thefreedictionary.com]
  • Identification of scurvy at AUK potentially informs the analysis of other primary burials and scattered bone found there and at other nearby sites, which often reveal evidence of nonspecific lesions that are usually attributed to anemia and infection,[ncbi.nlm.nih.gov]
  • Vitamin C helps the body absorb iron, so anemia is a common symptom of scurvy. Your anemia will become more severe as the disease progresses, internal bleeding being a later symptom.[livestrong.com]
Weight Loss
  • A 45-year-old man presented with follicular exanthema in his lower limbs, alternating bowel habits and significant weight loss. His medical history included seronegative arthritis, bipolar disease and an inconclusive diagnostic laparoscopy.[ncbi.nlm.nih.gov]
  • 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]
  • Generalized symptoms include weakness, fatigue, easily tired, weight loss and irritability. Other system specific symptoms include : Mouth Gums become swollen and spongy, turn red to purple in color and bleed easily (scorbutic gums).[healthhype.com]
  • NHS statistics show that nearly 7,500 people were admitted to hospital with malnutrition – unplanned weight loss caused by insufficient nutrition – in the past 12 months, a rise of more than 50 per cent in just four years.[express.co.uk]
  • During the patient’s admission, a nutritionist was consulted in order to evaluate his anorexia and weight loss.[ncbi.nlm.nih.gov]
Loss of Appetite
  • 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]
  • But the most common ones are – Tender gums Loss of teeth Sunken eyes Poor healing capacity of wounds Gradual weakening Pain in the joints Lethargy, fatigue and loss of appetite Internal bleeding Pale skin and liver spots Nausea Fever Diarrhea Pin point[epainassist.com]
  • Some of the non-specific symptoms of scurvy may include: generally feeling unwell fatigue loss of appetite nausea diarrhoea fever painful joints and muscles small ‘pinpoint’ bleeding around hair follicles visible in the skin.[betterhealth.vic.gov.au]
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]
  • […] 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]
  • […] 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]
  • This eruption occurred in a 46-year-old alcoholic, homeless male, who also had bleeding gums and loose teeth .[medicinenet.com]
  • This eruption occurred in a 46-year-old alcoholic, homeless male, who also had bleeding gums and loose teeth.[webmd.com]
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]
Scorbutic Rosary
  • Paediatric generalised osteopenia cortical thinning: “pencil-point” cortex periosteal reaction due to subperiosteal haemorrhage scorbutic rosary: expansion of the costochondral junctions may relate to the fracturing of the zone of provisional calcification[radiopaedia.org]
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]
Purpura
  • Bateman purpura is characterized by diffuse senile skin atrophy, senile purpura and spontaneous stellar pseudocicatrices. Cutaneous changes in the course of ageing have been related to lower levels of ascorbic acid into the dermis of elderly people.[ncbi.nlm.nih.gov]
  • The patient described in this case presented with sudden oligoarthritis and purpura of the lower extremities.[ncbi.nlm.nih.gov]
  • The classical cutaneous features consist of perifollicular purpura, contorted (corkscrew) hairs and follicular hyperkeratosis, particularly affecting the legs. Large areas of purpura or ecchymosis may occur.[ncbi.nlm.nih.gov]
  • 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]
  • In any patient with spontaneous hematoma and purpura, in the context of nutritional disorder, scurvy should be systematically considered.[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]
  • Gum bleeding, petechiae and pseudoparalysis and suggestive radiograph characterized scurvy. Hyperesthesia improved and child walked with support following administration of vitamin C.[ncbi.nlm.nih.gov]
  • 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 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]
  • We report the occurrence of acute signs and symptoms of scurvy (perifollicular petechiae, erythema, gingivitis and bleeding) in a patient hospitalized for treatment of metastatic renal-cell carcinoma with high-dose interleukin-2.[ncbi.nlm.nih.gov]
Alopecia
  • 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.medscape.com]
Exanthema
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]
Apathy
  • Author information 1 Medical Schools of Mount Sinai, New York, USA and Imperial College, London, United Kingdom. [email protected] Abstract Scurvy is a thousand-year-old stereotypical disease characterized by apathy, weakness, easy bruising with tiny[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]

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]

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

Scurvy has an excellent prognosis if diagnosed and treated appropriately. Consumption of dietary supplements and citrus fruits are healthy means to overcome its deficiency. If left untreated, scurvy is invariably fatal and leads to complications including arthritis, subperiosteal hemorrhages, lameness and dental caries. However, death from scurvy is rare in modern times.

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.

References

Article

  1. Leger D. Scurvy: reemergence of nutritional deficiencies. Canadian family physician Medecin de famille canadien. Oct 2008;54(10):1403-1406.
  2. Mosdol A, Erens B, Brunner EJ. Estimated prevalence and predictors of vitamin C deficiency within UK's low-income population. Journal of public health. Dec 2008;30(4):456-460.
  3. Ratanachu-Ek S, Sukswai P, Jeerathanyasakun Y, Wongtapradit L. Scurvy in pediatric patients: a review of 28 cases. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. Aug 2003;86 Suppl 3:S734-740.
  4. Mayland CR, Bennett MI, Allan K. Vitamin C deficiency in cancer patients. Palliative medicine. Jan 2005;19(1):17-20.
  5. Singer R, Rhodes HC, Chin G, Kulkarni H, Ferrari P. High prevalence of ascorbate deficiency in an Australian peritoneal dialysis population. Nephrology. Feb 2008;13(1):17-22.
  6. Biesalski HK. Parenteral ascorbic acid in haemodialysis patients. Current opinion in clinical nutrition and metabolic care. Nov 2008;11(6):741-746.
  7. Mertens MT, Gertner E. Rheumatic manifestations of scurvy: a report of three recent cases in a major urban center and a review. Seminars in arthritis and rheumatism. Oct 2011;41(2):286-290.
  8. Pimentel L. Scurvy: historical review and current diagnostic approach. The American journal of emergency medicine. Jul 2003;21(4):328-332.
  9. Emadi-Konjin P, Verjee Z, Levin AV, Adeli K. Measurement of intracellular vitamin C levels in human lymphocytes by reverse phase high performance liquid chromatography (HPLC). Clinical biochemistry. May 2005;38(5):450-456.
  10. Smith MS. The diagnosis and treatment of scurvy: an historical perspective. Journal of the Royal Naval Medical Service. Summer 1986;72(2):104-106.

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Last updated: 2017-08-09 18:22