The scourge of scurvy, which is caused by vitamin C deficiency, may be re-emerging amid the cost of living crisis and the rise in weight loss (bariatric) surgery, suggest doctors in the journal BMJ Case Reports after treating a middle-aged man with the condition.
Scurvy is eminently treatable, but because it’s a disease of the past, first associated with sailors during the Renaissance era, it may be mistaken for other conditions, especially inflamed blood vessels (vasculitis), potentially risking fatal bleeding if left untreated, highlight the authors.
Signs can appear as early as a month after a daily intake of less than 10mg of vitamin C.
The authors treated a middle-aged man whose legs were covered with tiny painful red-brown pinpoints, resembling a rash. Blood was also present in his urine and he was anaemic.
He tested negative for inflammatory, autoimmune, and blood disorders, and scans revealed no evidence of internal bleeding. Similarly, a skin biopsy returned no diagnostic clues.
His rash continued to spread while he was in hospital. And further questioning revealed that he was short of cash and neglected his diet, eating little in the way of fruit and vegetables.
He said that he sometimes skipped meals altogether.
He had also stopped taking the nutritional supplements prescribed for him after previous weight loss surgery, because he said he couldn’t afford them.
Blood tests to assess his general nutritional status indicated no detectable levels of vitamin C and very low levels of other key nutrients. He was diagnosed with scurvy and treated with daily vitamin C (1 000 mg), vitamin D3, folic acid and multivitamin supplements, after which his painful rash and other symptoms cleared up.
This is just one case report, and while it’s not clear what the current prevalence of scurvy is, it’s still relatively rare.
But the authors point out: “Scurvy is still seen as a disease of the past, especially in developed countries.” The rising cost of living also makes it harder for families to afford good quality nutritious foods, while there have been numerous reports of scurvy arising from complications after bariatric surgery, they add.
Other risk factors for scurvy include alcoholism, smoking, eating disorders, low household income, obesity, kidney dialysis and drugs that interfere with vitamin C absorption, such as steroids and those that curb stomach acid production (proton pump inhibitors), they highlight.
“Our patient had multiple risk factors, namely, poor dietary habits, obesity, previous bariatric surgery, use of proton pump inhibitors and low-income status. His history of iron, vitamin D and folate deficiencies were also clues to his underlying nutritional deficiency,” they concluded.
Study details
Scurvy – a re-emerging disease with the rising cost of living and number of bariatric surgical procedures
Andrew Dermawan, Sehrina Eshon, Kevin Danagher and Sivanthi Senaratne.
Published in The BMJ Case Reports Volume 17 Issue 8
Abstract
This case presents a male in his early 50s with a bilateral painful petechial rash in the lower limbs, which occurred spontaneously without trauma. He also had macroscopic haematuria and macrocytic anaemia with mild neutropenia and lymphopenia. Vasculitis, autoimmune and haematological screens were negative. CT scan of his abdomen and lower limbs did not show any intra-abdominal bleeding or lower limb vasculitis. Skin biopsy was also unremarkable. His petechial rash continued to progress during admission. Further history revealed poor oral intake and cessation of his post-sleeve gastrectomy supplements due to financial constraints. A nutritional panel showed undetectable vitamin C levels, along with other nutritional deficiencies. He was diagnosed and treated for scurvy with ascorbic acid (vitamin C) 1000mg daily, and his painful rash and haematuria resolved.
Scurvy is a re-emerging disease with the rising cost of living. It can present as early as a month after a vitamin C-deficient diet. Petechial skin lesions often occur, especially in the lower extremities and may be mistaken for systemic vasculitis. The diagnosis is often made after an extensive diagnostic workup including imaging and biopsies, thus delaying treatment. Risk factors for scurvy include poor nutrition, gastric bypass surgery, dialysis, alcoholism, psychiatric history and eating disorders. This disease is easily reversible with supplementation, with a dramatic response seen within 24 hours. Failure to treat may lead to catastrophic haemorrhage, hence, early recognition and prompt treatment are vital.
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Bleeding tendency and low vitamin C requirements – US meta-analysis