Scurvy is a dietary dysfunction attributable to vitamin C deficiency. It was a infamous illness within the historic world, particularly among the many sailors, and is of uncommon prevalence in modern, developed nations on account of elevated entry and development in diet companies. Scurvy primarily impacts the pores and skin and gentle tissue, presenting with a myriad of medical manifestations starting from musculoskeletal to bleeding-related complaints and even sudden loss of life in later levels. On this article, we current the case of an aged feminine with scurvy-related weak spot and gait instability resulting in mechanical falls, straightforward bruising, fatigue, and petechial rash. She had enchancment in her constitutional signs after the initiation of vitamin C dietary supplements. This case reinforces the necessity to think about scurvy as one of many differentials for petechial rash and simple bruising other than bleeding diathesis and vasculitis within the modern world, particularly in at-risk populations.
Introduction
Vitamin C aka ascorbic acid is a water-soluble vitamin that’s the enolic type of alpha-ketolactone. It’s normally absorbed within the distal small gut through adenosine triphosphate (ATP)-dependent energetic transportation and tends to pay attention within the pituitary, adrenal gland, mind, white blood cells, and eyes for storage and utilization [1]. Most animals, apart from apes (together with people), rodents, bats, and monkeys, synthesize ascorbic acid in their very own our bodies. The really useful dietary allowance (RDA) of ascorbic acid is 90 mg/day for males and 75 mg/day for girls, which is able to present for a physique pool of 1500 mg and preserve ascorbate reserves for one to a few months [2]. Pregnant females and aged individuals have elevated necessities of as much as 120 mg/dl complete and people who smoke as much as 35 mg/dl above the RDA. Scurvy can happen on account of decreased dietary consumption or impaired gastrointestinal vitamin C absorption.
Scurvy initially presents with musculoskeletal complaints within the type of weak spot, arthralgias, myalgias, and fatigue, particularly within the higher legs and thighs. That is as a result of faulty osteoid matrix, elevated bone resorption, and secondary edema. The following levels contain melancholy, follicular hyperkeratosis, poor wound therapeutic, corkscrew hair, and swollen gums. Later levels contain hemorrhagic options like ecchymoses, perifollicular hemorrhage, petechiae, hemarthroses, hemopericardium, and so on., to an infection or sudden loss of life [3-4]. Imaging findings embody metaphyseal head lucency, soft-tissue edema, and periosteal response. With applicable therapy, constitutional signs can enhance as early as 24 hours, pores and skin manifestations like ecchymosis or bruising resolve inside a couple of days, whereas musculoskeletal signs may take so long as two weeks for restoration [5]. Herein, we current an attention-grabbing case of an aged feminine with traditional signs and indicators of this historic illness. Early prognosis of scurvy is the important thing for medical enchancment, prevention of problems, and discount of extra well being care prices by avoiding pointless medical assessments.
Case Presentation
A 72-year-old white feminine with a historical past of esophageal stricture and a number of dilatations, delicate cognitive impairment, and left breast adenocarcinoma standing put up lumpectomy and chemoradiation, in remission for 13 years, was admitted with a bilateral ankle harm after a mechanical fall two weeks prior on account of generalized weak spot and problem strolling. Additional historical past revealed decreased urge for food, problem swallowing, fatigue, malaise, straightforward bruising, and 16 kilos weight reduction over the past three months. She had good socio-economic standing, and her weight loss plan primarily consisted of canned meals, ready-to-eat meals, tea, toast, or weight loss plan soda with just a little vegetable or fruit consumption. She denied chills, night time sweats, cough, chest discomfort, haematochezia, melena, hematemesis, alcohol, smoking or illicit drug use, natural dietary supplements, non-steroidal anti-inflammatory medication (NSAIDs), and anticoagulant or antiplatelet drug use. On bodily examination, she had bilateral decrease extremity non-palpable petechial rash, a number of giant blue-red painful ecchymosis of various age over bilateral thighs and each ankles, and gingival irritation (Figures 1–2).
Preliminary laboratory investigations are described in Desk 1. Main differential diagnoses included vasculitis (viral, bacterial, leukocytoclastic, or malignancy-related) or vitamin deficiency. Laboratory workup, together with peripheral blood smear, antinuclear and antineutrophil cytoplasmic antibody, serum, and urine protein electrophoresis, cryoglobulins and enhances, hepatitis, and human immunodeficiency virus panel had been unremarkable. Magnetic resonance imaging of bilateral ankles revealed a number of intraosseous hemorrhages with diffuse intramuscular and subcutaneous edema. A punch biopsy of the left decrease leg confirmed corkscrew hair with perifollicular hemorrhage and perivascular irritation with no proof of microthrombi. Her serum ascorbic acid degree was discovered to be lower than 0.05 mg/dl (ref: 0.2- 2 mg/dl), and a prognosis of scurvy was made. Further dietary workup confirmed decreased serum ranges of vitamin A (0.17, ref: 0.3-1.3 mg/L), vitamin E (4.9, ref: 5.5-18 mg/L), vitamin B1 (54, ref: 70-180 nmol/L ), vitamin B12 (249, ref: 118-914 pg/ml), and vitamin B9 (3.78, ref: 5.9->22.3 ng/ml). She was initially began on 500 mg ascorbic acid every day together with multivitamins with vital enchancment in her constitutional signs inside 24 hours. She was misplaced to follow-up after discharge from the hospital.
Dialogue
Vitamin C is important for wound therapeutic, functioning of the immune system, manufacturing of neurotransmitters like dopamine and prostaglandins, nitric oxide synthesis, and osteoblast and fibroblast development. Latest analysis has related vitamin C with atherosclerotic heart problems by inhibiting low-density lipoprotein oxidation, leading to improved arterial stiffness, lipid profile, and endothelial operate [6]. Vitamin C is important for sustaining the triple helical construction of collagen through the hydroxylation of proline and lysine residues. Collagen is required for the integrity of blood vessels and disruption of collagen leads to weak and leaky vessels with an irregular bruising and petechial rash if poor as in our affected person [7]. As well as, vitamin C, by way of its varied enzymatic and non-enzymatic biochemical reactions, acts as an electron donor (decreasing agent) for vitamin E, folic acid, iron, and copper manufacturing. This will clarify the a number of vitamin deficiencies in our affected person other than malnutrition.
Within the human weight loss plan, 90% of vitamin C comes from citrus fruit and greens like candy peppers, broccoli, cauliflower, and tomatoes. Thermal therapy can lower the vitamin C content material of meals. It takes 40-90 days of sustained hypovitaminosis C for overt scurvy to develop, however medical manifestations can seem inside 30 days of dietary insufficiency of vitamin C. Whereas plasma focus is reflective of latest consumption, leukocyte vitamin C focus is a greater indicator of complete physique shops [8]. Medical scurvy happens when the whole physique pool is lower than 300 mg and the plasma degree is <0.2 mg/dl (11 umol/L) [6]. Our affected person had a plasma ascorbic degree <0.05 mg/dl and repeat ranges weren’t drawn after supplementation as a result of she was misplaced to comply with up.
Whereas the worldwide prevalence varies, the estimated prevalence of vitamin C deficiency in the US (US) is 7.1% [9]. For the reason that Nineteen Seventies, the American weight loss plan has modified lots, with elevated consumption of potatoes, pizzas, and carbonated drinks, and fewer consumption of fruits, greens, and dairy merchandise, which has led to a resurgence of dietary issues like scurvy and elevated prevalence of metabolic issues like weight problems and diabetes [10]. That is attributable to busy work schedules, comfort, insufficient social assist, and a sedentary life-style. Excessive-risk teams for scurvy within the trendy world embody individuals vulnerable to malnutrition – psychiatric sickness, consuming issues, alcoholism; restricted meals entry – aged dwelling alone, homelessness, COVID-19 pandemic; or malabsorptive states – gastric bypass, celiac illness, hemodialysis [11]. A cultural change in direction of higher meals decisions, availability of more healthy ready-to-eat meals, meals fortification, and early initiation of dietary dietary supplements for high-risk populations could also be thought of.
Conclusions
Scurvy is a superb mimic, with manifestations starting from weak spot to sudden cardiac loss of life or loss of life from an infection. The rarity and broad medical options contribute to delay in prognosis. We imagine it is necessary for internists to contemplate this as a differential, particularly in sure high-risk teams. Preserving in thoughts the nice security profile and low value, empiric therapy with vitamin C ought to be accomplished as quickly as doable in suspected sufferers.
