Scurvy, an old story in a new time: The hematologist's experience.

BACKGROUND: Scurvy is a rare entity in developed countries and the diagnosis may often be delayed resulting in unnecessary investigations and/or potentially severe complications. A recent increase in the number of patients diagnosed with scurvy in our hematology clinics indicated the need to review the literature on the diagnosis and optimal management of similar patients. METHODS: We conducted a retrospective chart review of patients referred to hematology at our tertiary care centre between 2010 and 2018, who were ultimately diagnosed with scurvy. Data collected from electronic medical records included baseline characteristics, clinical features on presentation, bloodwork results from initial consultation, treatment plan as well as response to treatment. FINDINGS: Twenty-two adults patient had a diagnosis of scurvy with a mean vitamin C level of 6 µmol/L. Iron deficiency anemia (54%) and gastrointestinal disorders (54%) were the most common comorbidities noted in our cohort. Proton-pump inhibitors use was noted in 54% of patients. Bleeding (45%) and bruising (45%) were the most commonly reported clinical features. Eleven patients received oral supplementation, five had intravenous (IV) vitamin C and six were not treated. Two patients required a transition from oral to IV supplementation. Vitamin C dosing ranged between 250 and 2000 mg and the frequency varied from daily for oral therapy to every few weeks or months for IV. INTERPRETATION: Awareness of scurvy and its associated risk factors and clinical presentation is important in the evaluation of a patient with bleeding tendency. Treatment plan should be individualized, and a careful review of patients' diet, medial history and medications is warranted.

End stage scurvy in the developed world: A diagnostic conundrum but not to be mistaken for pyoderma gangrenosum.

Scurvy is a clinical syndrome, resulting from ascorbic acid deficiency. Prevalence of the condition is now extremely low in the Western population and its diagnosis can be challenging without a high index of suspicion. When cases do present, they are often misdiagnosed initially. Therefore, a thorough history, physical exam, and laboratory evaluation are key to showing this now rare but extremely well-known disease. We report a case of scurvy manifesting as persistent non-healing lower-extremity ulcerations, initially mistaken for pyoderma gangrenosum. The patient responded to appropriate replacement therapy, but ulcers were slow to heal. As was the case in our patient, symptom reversal may require additional nutritional replacement. We encourage physicians to consider nutritional deficiencies in their differential diagnoses and highlight the incidence of malnutrition in the proper clinical setting to avoid diagnostic delay.

Neuropsychiatric scurvy.

BACKGROUND: Scurvy is a disease with well-known peripheral symptoms, such as bleeding and pain. METHODS: The clinical and historical evidence for a distinct form of scurvy affecting the central nervous system, called neuropsychiatric scurvy, is reviewed. Pathophysiologic factors are described, as well as its diagnosis and management.

Traumatic Injury in a Child with Scurvy: A Case Report.

This case report aimed to describe the clinical presentation, treatments and prognosis of a child who had scurvy and traumatic injury of the left thigh. A 30-month-old boy had presented with left hip pain two weeks after falling down on the floor while walking. He developed pain, warmness of the left hip and thigh, and finally was unable to bear weight. He also had a high fever gingival hemorrhage, dental caries, petechiae, positive rolling test and limited range of motion of the left hip. The radiographs revealed Wimberger's ring and Frenkel line as scurvy. Vitamin C supplement had been prescribed for one week. However, there was no clinical response and magnetic resonance imaging (MR) suggested subperiosteal abscess as well as osteomyelitis of bilateral femurs and tibias. Debridement and biopsy of the left femur were performed and found only subperiosteal blood. A clinical improvement was noted on the second day after surgery. Vitamin C level was reported at 0.03 mg/dl which was very low. Bacterial culture was negative and the pathological findings were callus formation with hemorrhage. The patient continued the treatment for two months and all conditions were healed eventually. In severe scurvy with trauma, prolonged subperiosteal hematoma was susceptible to infection, and may need debridement simultaneously with vitamin C supplement to shorten the clinical course.

Scurvy: a new problem for patients with chronic GVHD involving mucous membranes; an easy problem to resolve.

Vitamin C deficiency in developed countries is typically observed in patients with unique clinical conditions such as cystic fibrosis or anorexia nervosa, or in patients on long-term tube feeds. We report here a clinical observation in six pediatric and adolescent patients (median age 17.5 yr, range 9.8-23.5 yr) with chronic GVHD with mucous membrane involvement found to be vitamin C deficient. These patients' baseline serum vitamin C levels ranged from <0.12 to 0.94 mg/dL (normal value 0.20-1.90 mg/dL), with a mean level 0.56 ± 0.36 mg/dL and a median level 0.6 mg/dL. Among these patients, signs and symptoms of mucositis failed to respond to standard chronic GVHD therapy. After receiving treatment with 2000 mg of ascorbic acid by mouth, daily patients displayed increased serum vitamin C levels. Clinically, this correlated with a remarkable improvement in patients' mucositis and ability to eat.

[Vitamin C]. / Vitamine C.

Vitamin C is a water soluble vitamin which is mainly fresh fruits and vegetables foodborne. Vitamin C deficiency is most often due to a lack of daily amount. Scurvy is characterized by the occurrence of fatigue, myalgia, arthralgia, purpura, bleeding disorders, and later by dental manifestations. Biological signs are nonspecific: anemia, hypocholesterolemia, hypoalbuminemia. Clinical suspicion is confirmed by the decrease in ascorbic acid level (< 2 mg/L). It must be interpreted in light of the acute phase reactants. The treatment is the administration of 1 g of vitamin C per day for 15 days. Vitamin C depletion (ascorbic acid: 2 to 5 mg/L) could induce long-term complications. The recommended dietary allowance of vitamin C protect from these risks.

[Eat a citrus fruit, stay healthy--a case report of scurvy].

Scurvy is a disease that results from a vitamin C deficient diet. Since vitamin C is available in many food products, and especially in citrus fruits, the disease is rare in developed countries. Clinical manifestations of scurvy include general weakness, cutaneous and gum bleeding, pain in the lower limbs and inability to stand and walk (pseudo paralysis). The diagnosis of scurvy requires a high level of clinical suspicion, typical radiographic features and low Levels of vitamin C in the plasma. We report a case of a 7-year-old patient with a medical history of hydrocephalus, failure to thrive and severe psychomotor retardation due to complications of prematurity. On admission she had gum bleeding, severe anemia, pain in the lower limbs and refused to stand and walk. According to her parents, her diet was restricted, without vegetables or fruit consumption. Our investigation ruled out coagulopathy, malignancy and infection. Serum vitamin C levels were low and radiographic findings were consistent with the diagnosis of scurvy. The patient improved rapidly after the initiation of vitamin C supplements. Despite being rare, scurvy should be considered in the differential diagnosis of bleeding and pain in the lower limbs, especially in a malnourished patient.

Scurvy and cloudberries: a chapter in the history of nutritional sciences.

We translated two Latin texts about scurvy. One is by Ambrosius Rhodius, who in 1635 published his doctoral thesis on scurvy. This contains aspects of 16th- and 17th-century folklore medicine. The other is a 1593 letter by Henrik Høyer (Hoierus), a German physician in Bergen, Norway. The letter states that in Norway grew a plant, Chamaemorus Norvegicus, whose berries had curative abilities against scurvy. Rhodius lists symptoms of scurvy and suggests ingestion of fatty and smoked foods as etiological agents. He thought that a malfunction of the spleen was involved in this disease, so that the undigested parts of the chylus perturbed liver function. Plants with curative abilities were "those that abound in volatile salts." He listed seven facilitating causes of scurvy and its therapies. These included blood-letting after laxatives and root extracts. The star of the show was the cloudberry, which had miraculous effects on scurvy patients. Palliative care included a bath containing decoction of brooklime, water cress, mallow, hogweed, roman chamomile, and similar plants. Before bathing, the person was to drink an extract of wormwood, scurvy grass, or elder. As medication for gums and teeth, Rhodius recommended rosemary, hyssop, bistort, sage, nasturtium, waterweed, creeping Jenny, and scurvy grass. He referred to medications described by Albertus, Sennertus, and in antiquity by Hippocrates and Galenus. We discuss the manuscripts by Høyer and Rhodius in light of earlier treatments and opinions about scurvy.

A rare case of scurvy in an otherwise healthy child: diagnosis through oral signs.

The purpose of this paper was to report the case of a 2-year-old Caucasian female who was referred with a presumed diagnosis of pediatric rheumatoid arthritis. The patient presented widespread gingival swelling with bleeding, sharp pain, and halitosis. The patient also presented pain and swelling of the right knee joint, and psychomotor restlessness associated with muscular frailty. Little compliance on the part of both the patient and parents was also noted. Oral manifestations, together with an accurate medical history, led to the diagnosis of infantile scurvy, caused by an inadequate dietary supply of vitamin C. Administering 250 mg of ascorbic acid orally twice a day led to the remission of gingival swelling and of the other symptoms. The parents were advised to feed the child appropriate foods. Nutritional problems are traditionally linked to an insufficient availability of food, but can also be associated with child- or family-related psychological problems.

Scurvy presenting as lower limb ecchymoses in the setting of metastatic colorectal cancer.

A 58-year-old woman presented with a 1-week history of lower limb bruising. She had a medical history of recurrent metastatic colon cancer with a sigmoid colectomy and complete pelvic exenteration leading to colostomy and urostomy formation. She had malignant sacral mass encroaching on the spinal cord. This caused a left-sided foot drop for which she used an ankle-foot orthosis. She was on cetuximab and had received radiotherapy to the sacral mass 1 month ago. On examination, there were macular ecchymoses with petechiae on the lower limbs. There was sparing of areas that had been compressed by the ankle-foot orthosis. Bloods showed mild thrombocytopaenia and anaemia with markedly raised inflammatory markers. Coagulation studies consistent with inflammation rather than disseminated intravascular coagulation. She was found to have Klebsiella bacteraemia secondary to urinary source. Skin biopsy showed dermal haemorrhage without vessel inflammation. Vitamin C levels were low confirming the diagnosis of scurvy.

Ocular Surface Disease in Rodents (Guinea Pigs, Mice, Rats, Chinchillas).

This article discusses the clinical appearance, differential diagnoses, and treatment considerations of corneal disease in the most common domesticated species of rodent: mouse, rat, chinchilla, and guinea pig. Many corneal diseases are related to inbred strains of either research or pet rodents. Diseases are complicated by husbandry and treatment-related challenges in this small, social species. This article is broken down by species, first discussing normal anatomy, then discussing commonly encountered diseases, and concluding with treatment considerations.

Severe scurvy in a patient with eosinophilicoesophagitis.

While scurvy is considered to be a rare disease in the modern era, the disease still presents in certain populations with nutritional deficiencies such as those with poor nutritional absorption secondary to gastrointestinal disorders and in patients with poor nutritional intake. We present a case of scurvy in a patient who had eosinophilic oesophagitis which limited his oral intake. He presented with the classic symptoms of scurvy including a perifollicular rash, arthralgia, gingivitis and anaemia. He was treated with intravenous vitamin C initially followed by an oral course after which he showed improvement. This case demonstrates that it is important to consider vitamin C deficiency in patients with who present with anaemia and bleeding stigmata specifically in those who have poor nutritional intake. Furthermore, additional consideration should be given to patients with malnutrition as part of the preoperative evaluation.

Outbreak of scurvy in Tana River County, Kenya: A case report.

Over a five-month period, clinicians in Tana River County Kenya observed an increasing number of patients presenting to health facilities with a common collection of symptoms including fevers, joint pains and gum hypertrophy. After initial investigative and management strategies failed to reveal a diagnosis, patients were empirically commenced on ascorbic acid for presumed scurvy. This strategy resulted in the rapid resolution of symptoms in 65 patients within two weeks.