Scurvy in a housewife manifesting as anemia and ecchymoses

ARTICLE

Auteur(s) : Emek Kocatürk, Selin Aktas, Mukaddes Kavala, Feride Kocak, Merve Sürücü, Aytekin Oguz

Göztepe Training and Research Hospital Department of Dermatology, Nadiraga Sok. 25/9 Goztepe, 34073 Istanbul, Turkey

Scurvy is considered by many a historical disease associated with sailors traveling to distant countries. Today, with many food products available, it is hard to believe it still exists in urban areas. We report a housewife diagnosed with scurvy.

A 32-year-old woman was admitted to the internal medicine department because of fatigue, myalgias, arthralgias and ecchymoses on the legs, present for one month. Her medical history was unremarkable except for weight loss (10 kilos in three months) and painful chronic gingivitis, which resulted in a very limited diet, consisting only of crumpets. The internal medicine department investigations revealed severe anemia and a hematology consultation suspected a systemic vasculitis. Prothrombin and partial thromboplastin levels, hepatitis markers, antineutrophil cytoplasm antibodies (c-ANCA), antineutrophil perinuclear antibodies (p-ANCA), antinuclear antibodies (ANA), a comprehensive metabolic panel including iron, folic acid and B12 vitamin were within normal levels. The full blood count results were: hemoglobin 5.2 g/dL, hematocrit 16.9%, platelet 185 × 10³/mL. Physical examination revealed ecchymoses and edema on the lower extremities, especially involving the joints, diffuse perifollicular petechia with “corkscrew” hairs and hyperplastic haemorrhagic gingivitis, resulting in tooth loss (figures 1A, B). In the dermatology department, a punch biopsy was performed which showed perivascular lymphocyte infiltration, extravasated erythrocytes and hemosiderin deposition. Serum vitamin C levels were at an almost undetectable level [< 0.1 (0.5-1.8 mg/dL)]. The diagnosis was scurvy and she was treated with 1,000 mg/day vitamin C orally, which led to a dramatic improvement within 2 weeks. She was also referred to a psychiatrist, but found to be mentally healthy.

Vitamin C is a water-soluble essential vitamin with various functions in the human body. It is responsible for the hydroxylation of collagen, the metabolism of tyrosine, the biosynthesis of carnitine and norepinephrine, and the amidation of peptide hormones; it also promotes iron absorption by reducing dietary iron from the ferric to the ferrous form [1]. Patients with vitamin C deficiency produce an abnormal collagen that affects blood vessel integrity, leading to capillary fragility, perivascular edema and red cell extravasations [2].

Vitamin C is present mainly in fruit and vegetables and may easily be lost during cooking and processing [3]. A daily intake of 10 mg will maintain the total body vitamin C pool above 300 mg. Scurvy develops after 60-90 days of a diet free of vitamin C, when the total body pool is depleted below this value [4]. At-risk groups include the poor, alcoholics, individuals with allergies to multiple fruit and vegetables, cancer patients, people with gastrointestinal disease, anatomical abnormalities, psychiatric disorders or chronic dental problems [1].

Scurvy may develop with non-specific symptoms like weakness, fatigue, shortness of breath and aching in the limbs. Skin changes usually occur in the early phases of the disease and form the basis for diagnosis. As a consequence of defective collagen formation, blood vessel fragility manifests as petechiae, purpura and large ecchymoses [5]. The initial skin change is follicular hyperkeratosis with “corkscrew hairs”; later perifollicular haemorrhages occur [6]. Patients with preexisting periodontal disease have more pronounced complications on the oral mucosa like gingivitis, bleeding gums and loosening of teeth [1, 5]. Normochromic and normocytic anemia is a common finding, due to blood loss, concomitant folate deficiency, or decreased iron absorption in the small bowel [1].

Our case had the typical clinical picture of scurvy (extensive ecchymoses, follicular petechia, chronic gingivitis) but lacked the typical history; she was a housewife living in the centre of a big city; with no psychiatric or chronic illnesses, no drug abuse nor alcohol intake but only an inadequate diet, due to chronic gingivitis. This case also implies that dermatology consultations may be more helpful than unnecessary laboratory work-ups for patients with skin lesions.

Disclosure

References

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