Why is scurvy uncommon today

Frank R. Ricaurte moc. Received Aug 26; Accepted Sep This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract Scurvy is a rather uncommon disease today, and its symptoms can certainly be exhibited with vitamin C deficiency. Keywords: scurvy, anemia, vitamin c supplementation, deficiency, perifollicular, hemorrhage. Introduction The manifestation of scurvy comes from a lack of vitamin C, indicating that patients with the condition do not consume a sufficient amount of the vitamin in their diets [ 1 ].

Open in a separate window. Figure 1. Anterior right arm with petechiae and microhemorrhages around the hair follicles. Figure 2. Conclusions This case emphasizes the recognition required to identify scurvy and the potential consequences that would result if its diagnosis was otherwise not made. Human Ethics Consent was obtained by all participants in this study. References 1. Scurvy: reemergence of nutritional deficiencies. Can Fam Physician. Scurvy is still present in developed countries.

J Gen Intern Med. Overview of Water-soluble Vitamins. Scurvy in in the USA. Is vitamin C enough? A case report of scurvy in a five-year-old girl and review of the literature. BMC Pediatr. Old world meets modern: a case report of scurvy. Preceding upper respiratory tract infection URTI and gastroenterology or genitourinary symptoms were also absent.

Apgar at 1 and 5 min after birth was 5 and 6 respectively. He stayed ventilated in NICU for 2 months, and developed retinopathy of prematurity and retinal detachment, subsequently losing vision in the left eye. He was known to have global developmental delay with non-revealing neurological or metabolic work up. The delay had therefore been attributed to complications of prematurity. Although the family had a normal diversified diet, the child was exclusively milk-fed.

He was not able to eat or chew hard food because of bad dental hygiene. Family history was unremarkable for neurological, metabolic or bleeding problems. The patient came to the clinic on a wheelchair and was pale. He was agitated but conscious, alert and oriented. His weight was There was hard swelling over the left thigh, which was mildly tender and diffusely swollen, and the patient refused to ambulate. It was difficult to assess his motor system because of his pain.

Skin examination revealed extensive ecchymoses, follicular hyperkeratosis and follicular purpura with corkscrew hairs white arrow , and neurotic excoriations black arrow Fig. Gingival swelling and intermittent fragility bleeding were present Fig. Red reflex was absent over the left eye, normal over right. There were no abnormal findings on chest, cardiovascular and abdominal examination. Patient at presentation.

Immediate admission for evaluation was arranged and he had been evaluated by specialists in areas including hematology, dermatology, neurology, gastroenterology and nutrition. Peripheral smear showed moderate anisopoikilocytosis. Hemoccult blood was negative. C-reactive protein, coagulation profile, and chemistry including calcium, phosphorus, and magnesium were also normal. Serum iron level was 2.

Radiographs revealed a questionable right fibular fracture that was not confirmed on a technetium 99 m bone scan. Ascorbic acid vitamin C supplement was initiated at mg twice daily for 3 days, then mg daily for 2 weeks and maintained onmg daily for 3 months.

By 4 weeks, the patient was ambulating freely, and skin lesions and gingival swelling improved. Three months later, he came to the clinic walking. Humans lack the ability to synthesize vitamin C, because of mutation in the gene coding for l-gulonolactone oxidase, the enzyme required for the biosynthesis of vitamin C [ 6 ]. However, vitamin C is an essential micronutrient.

Scurvy occurs as a result of decreased vitamin C consumption or absorption. The prevalence of scurvy in children is not known, but certain populations are at risk.

The two largest cohorts of scurvy cases in children have been reported by Noble et al. Of the cases reviewed by RatanachuEk et al.

The earliest manifestations of scurvy are nonspecific constitutional symptoms, such as asthenia, anorexia, and weight loss.

As in our case, inability to walk is a very common presenting musculoskeletal symptom in children with scurvy [ 8 ]. Poorly formed collagen leads to dystrophic or corkscrew hairs, gingival hyperplasia, and weakened blood vessel walls, causing bleeding in the skin, joints, and other organs [ 10 ].

Follicular hyperkeratosis and perifollicular hemorrhages are also common, particularly over the lower limbs, as was a prominent feature in our case. Subperiosteal hematomas may be palpable as painful swellings over the distal end of the femur and tibia. Intramuscular hematomas may cause compartment syndrome [ 9 ]. Our patient had large, uncomplicated intramuscular hematoma that resolved spontaneously.

Laboratory test abnormalities in scurvy are nonspecific; anemia is frequent manifestation. Our patient had severe hemolytic anemia that required multiple blood transfusions. In severe cases, anemia can lead to cardiac hypertrophy and high output heart failure [ 6 ]. The causes for anemia in scurvy could be multifactorial, resulting from blood loss, concomitant vitamin deficiencies, and decreased iron absorption [ 11 ]. An elevated erythrocyte sedimentation rate and C-reactive protein level can be seen in some cases [ 12 ].

In our case, the sedimentation rate was mildly elevated, which could cause confusion with an inflammatory process. Radiographic changes may include osteonecrosis, osteopenia, and cortical thinning with periosteal proliferation. Many signs have been reported in the literature, such as the Frankel sign zone of calcification at the margin of growth plate , Wimberger sign calcification around the epiphysis and scurvy line lucency adjacent to metaphyseal sclerotic line [ 13 ].

In our case, all of these findings were absent. We speculate that a good level of vitamin D halted these changes. A meticulous history, including dietary history and physical examination, can help to reach the diagnosis of scurvy. Usually, work up is not necessary to confirm diagnosis of scurvy.

Vitamin or mineral deficiencies other than vitamin C deficiency may accompany scurvy, therefore the prudent clinician will also check for concomitant micronutrient deficiencies, testing levels of zinc, iron, folate, and vitamin B In our case, RBC folate and serum iron were low.

Known risk factors for scurvy in children are oral aversions, cerebral palsy, developmental delay, and autism. Our patient had developmental delay as a result of complicated prematurity. Scurvy is preventable disease. Treatment of scurvy is based on replenishing the level of vitamin C to counteract the symptoms. There is no established regimen for vitamin C supplementation in scurvy. Once vitamin C deficiency has been treated, prevention and correction of underlying conditions are required in order to prevent recurrence.

Following treatment with vitamin C, spontaneous bleeding, oral symptoms and constitutional symptoms begin to improve within days, while bony changes and ecchymoses may take several weeks to resolve [ 12 ]. Overall improvement of symptoms after the administration of ascorbic acid is a confirmatory approach for the diagnosis. Scurvy can present to rheumatologists with different manifestations, which mandates careful assessment of the diet for each child attending rheumatology clinic.

The possibility of scurvy in modern times should not be overlooked, in particular among susceptible populations.

A lack of vitamin C will also affect the immune system, absorption of iron, metabolism of cholesterol and other functions. It is also needed for synthesizing dopamine, norepinephrine, epinephrine, and carnitine, needed for energy production. Symptoms of vitamin C deficiency can start to appear after 8 to 12 weeks. Early signs include a loss of appetite, weight loss, fatigue , irritability, and lethargy.

Within 1 to 3 months , there may be signs of:. In time, the person will show signs of generalized edema, severe jaundice , destruction of red blood cells, known as hemolysis, sudden and spontaneous bleeding, neuropathy , fever , and convulsions. It can be fatal. Infants with scurvy will become anxious and irritable. They may experience pain that causes them to assume a frog-leg posture for comfort. There may also be subperiosteal hemorrhage, a type of bleeding that occurs at the ends of the long bones.

Animal studies have shown that vitamin C deficiency in a woman during pregnancy can lead to problems with fetal brain development.

Humans cannot synthesize vitamin C. It needs to come from external sources, especially fruits and vegetables, or fortified foods. The recommended dosage is:. Within 24 hours, patients can expect to see an improvement in fatigue, lethargy, pain, anorexia, and confusion. Bruising, bleeding, and weakness start to resolve within 1 to 2 weeks. After 3 months, a complete recovery is possible. Long-term effects are unlikely, except in the case of severe dental damage.

A physician will conduct a physical exam, and request lab tests to assess vitamin C levels in the blood. Scurvy can be prevented by consuming enough vitamin C, preferably in the diet, but sometimes as a supplement. The United States U.