A 42 y.o. male with a hx of tonsillar ca sp resection and recurrent esophageal strictures presents with knee and ankle pain; a rash is noted on the legs.

What is your differential?

Hint: he has a normal platelet count

Our patient had scurvy.  His ascorbic acid level was  <0.1.  This resulted in hemarthosis with knee and ankle pain and petechiae on his legs.   His diet for the past year consisted of 2 monster drinks per day along with chocolate milk.  The usual suspects causing petechiae include capillary fragility, thrombocytopenia, coagulation abnormalities and platelet defects.  In this case,  Vit C is known to cause defective collagen synthesis and vessel fragility. The key to the case was his diet which made scurvy most likely.

Vitamin C deficiency killed more than two million sailors between 1571-1862.  Dr. Lind of the Royal Navy in 1747 identified citrus fruit as a cure for scurvy.  The Wager, a ship out of  Portsmouth,  was sent to harass the Spanish on the west coast of South America.  Here is how a crewman described scurvy in his log:

The crew became weak.  There skin began to turn blue and then black. Their ankles swelled and ulcers developed. The men lost their hair and teeth. They suffered terrific joint pains and hallucinations.  Finally,  in the last stages of scurvy, death resulted.  Scurvy was the great enigma of the Age of Sail,  killing more mariners than all other threats including gun battles, storms and other diseases combined.

It takes about three months to become Vit C deficient.. Poor wound healing, swollen gums and petechiae are often noted.    Vit C is essential in collagen synthesis and joint aches and hemathroses develop. .Our patient presented with a hemarthrosis and knee pain.  Corkscrew hair and perifollicular hemorrhages may develop.

While scurvy is much less common in the modern world, it is estimated to exist in 12% of  adults who are screened on a geriatric ward.  It is also reported in the pediatric population where children eating mainly carbohydrates are affected.

Our patient  was deficient not only in vitamin C, but vit D, folate, phosphorous and iron which were all supplemented. He was treated with a G tube. All of his symptoms resolved.

Svirbely J, Szent-Gyorgyi A. The chemical nature of vitamin C. Biochem J. 1933.27(1):279-85.

Perry M, Page N, Manthey D, Zavitz J. Scurvy:dietary discretion in a developed country  Clin Pract Cases Emerg med 2018 May;2(2):147-150.

Ceglie G, Macchiarulo G, Marchili M, et al. Scurvy:still a threat in the well-fed first world?archives of Disease in Childhood. Volume 2019;104:381-383.

Raynaud-Simon A, Cohen-Bittan J, Gouronnec A, et al. Scury in hospitalized elderly patients. JNHA:Nutrition 2010 Volume 14:407-410.

 Raynaud-Simon, Cohen Vit K  and zinc deficiencies also cause bleeding. Infectious causes include menigococcemia, RMSF,  vasculitis includes leukocytoclastic henoch schonlein purpura.

Grann D. The Wager A tale of shipwreck, mutiny and murder. Doubleday : New York 2023.