Spontaneous ecchymoses

Diagnosis: Scurvy

Based on the patient’s appearance and her dietary history, we suspected scurvy, so a serum vitamin C level was ordered. The results took several days to return. In the meantime, additional lab work revealed hyponatremia (sodium, 129 mmol/L; normal range, 135-145 mmol/L), hypokalemia (potassium, 3 mmol/L; normal range, 3.5-5.2 mmol/L), hypophosphatemia (phosphorus, 2.3 mg/dL; normal range, 2.8-4.5 mg/dL); low serum vitamin D (6 ng/mL; normal range, 20-40 ng/mL); and macrocytic anemia (hemoglobin, 7.4 g/dL; normal range, 11-18 g/dL) with a mean corpuscular volume of 101.1 fL (normal range, 80-100 fL). Her iron panel showed normal serum iron and total iron binding capacity with a normal ferritin level (294 ng/mL; normal range, 30-300 ng/mL). A peripheral blood smear test uncovered mild anisocytosis and polychromasia, with no schistocytes. A fecal immunochemical test was negative.

Several days after admission, the results of the patient’s vitamin C test came back. Her levels were undetectable (< 5 µmol/L; normal range, 11-23 µmol/L), confirming that the patient had scurvy.

A health hazard to marinersthat is still around today

Scurvy is a condition that arises from a deficiency of vitamin C, or ascorbic acid. The first known case of scurvy was in 1550 BC.¹ Hippocrates termed the condition “ileos ematitis” and stated that “the mouth feels bad; the gums are detached from the teeth; blood runs from the nostrils … ulcerations on the legs … skin is thin.”¹ Scurvy was a major health hazard of mariners between the 15thand 18th centuries.² Today, the deficiency is uncommon in industrialized countries because there are many sources of vitamin C available through diet and vitamin supplements.³ In the United States, the prevalence of vitamin C deficiency is approximately 7%.⁴

Patients with scurvy may initially experience malaise and irritability. Dermatologic findings include hyperkeratotic lesions, gingival swelling, petechiae, and corkscrew hairs.

An essential nutrient in humans, vitamin C is required as a cofactor in the synthesis of mature collagen.³ Collagen is found in skin, bone, and endothelium. Inadequate collagen levels can result in poor dermal support of vessels and tissue fragility, leading to hemorrhage, which can occur in nearly any organ system.

Vitamin C deficiency occurs when serum concentration falls below 11.4 µmol/L, at which point noticeable manifestations of scurvy can begin.^1,4 Alcohol use, tobacco use, poverty, male sex, and poor nutrition are risk factors.^1,4

Continue to: Scurvy manifests after 8 to 12 weeks