A 45 y.o. male with a history of gastric bypass comes in with a rash on his legs.
What is your differential? Hint: vasculitis and hematologic problems have been ruled out.
the patient has petechial hemorrhages
Our patient has scurvy; a nutritional disorder caused by vitamin C deficiency. It was a common disease in the ancient world, especially among sailors until the time of Captain Cook. Cook in 1768 insisted that the sailors on his vessels eat cress, sauerkraut and a kind of orange extract.
Vitamin C deficiency affects the skin and soft tissue with bleeding-related complaints and weakness. It maintains the structure of collagen making it important for maintaining the structure of blood vessels. It also aids in healing and absorption of other vitamins like E and folic acid.
gum edema in scurvy
In its mild form weakness, myalgias and fatigue occur with swelling and edema in the osteoid matrix of bone. Swelling also occurs in the muscles due to perivascular edema . In later stages perifollicular hemorrhage, purpura and gum swelling occurs. In the most severe cases hemopericardium and death have been reported.
It only takes 40-90 days for scurvy to occur ,and yet if recognized and treated, the symptoms dissipate in 14 days.
High risk groups for scurvy include: the elderly, alcoholics, the homeless, those with malabsorption (gastric bypass, celiac disease), and hemodialysis. A single dialysis session can cause a 50% drop in the vitamin C level.
corkscrew hairs are found in scurvy because of defective collagen
In the human diet 90% of vitamin C comes from citrus fruit and vegetables like tomatoes, peppers, broccoli and cauliflower.
FUN FACT
Rodents,bats, monkeys, apes and humans do not synthesize vit C. There was thought to be an evolutionary advantage with the loss of Vit C synthesis because a new enzyme Glut-1 arose on RBCs recycling Vit C making the daily requirement 100 times less than in animals that produce it. The advantage of this increase in micronutrient uptake was useful in times of food scarcity.
Our patient was given oral Vit C and recovered without incident.
Amisha F, Ghanta S, Kumar A, et al. Scurvy in the modern world: extinct or not? Cureus 2022 Feb 26;14(2):e2262. Doi:10.7759/cureus.22622.
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Glaeser A. Scurvy in a hemodialysis patient. Proceedings of UCLA Health 2023. Vol 27