Investigation of an outbreak of disease compatible with scurvy in a male penitentiary in the state of Ceará, Brazil, 2019-2020: a case-control study.

MAIN RESULTS: An outbreak of illness compatible with scurvy occurred among male prison inmates; most frequent signs/symptoms were edema and pain in lower limbs, difficulty in walking and hematoma/ecchymosis; the associated factor was age > 40 years. IMPLICATIONS FOR SERVICES: The results can contribute to the identification and description of scurvy outbreaks in other contexts and territories. Epidemiological studies of events like this enhance the practice of field epidemiology in health services. PERSPECTIVES: It is expected that the prevention of hypovitaminosis, such as scurvy, will be based on public policies aimed at the population deprived of liberty; and that the capabilities of health services to detect and respond to cases of the disease will be improved. OBJECTIVE: to identify the occurrence of an outbreak compatible with scurvy and exposure factors associated with typical signs/symptoms of hypovitaminosis that occurred in a male penitentiary in Ceará, Brazil between 2019-2020. METHODS: this was a population-based case-control study; we used clinical records and interviews with compatible cases - based on sign/symptom onset during the study period - and with controls; we carried out multivariate analysis. RESULTS: out of 62 cases, mean age was 40.6 years (SD = 10.8); main signs/symptoms were edema and pain in the lower limbs (100.0%), difficulty in walking (91.9%), hematoma/ecchymosis in the lower limbs (90.3%) and fever (88.7%); we identified being over 40 years old as an associated factor (aOR = 1.10; 95%CI 1.05;1.17; p-value = 0.001); and as protective factors: working (aOR = 0.11; 95%CI 0.03;0.36; p-value < 0.001) and taking part in classes (aOR = 0.21; 95%CI 0.08;0.59; p-value = 0.003) in the prison. CONCLUSION: we considered the penitentiary outbreak to be compatible with scurvy due to characteristic signs/symptoms, associated with the identified factors; we recommended regular provision of a diet rich in vitamin C to all male inmates and clinical follow-up of cases.

Investigação de surto de doença compatível com escorbuto em uma penitenciária masculina do Ceará, 2019-2020: um estudo de caso-controle / Investigation of an outbreak of disease compatible with scurvy in a male penitentiary in the state of Ceará, Brazil, 2019-2020: a case-control study / Investigación de un brote de enfermedad compatible con escorbuto en una penitenciaría masculina en el estado de Ceará, Brasil, 2019-2020: un estudio de casos y controlesInvestigação de surto

Objetivo: identificar ocorrência de surto compatível com escorbuto e fatores de exposição associados aos sinais/sintomas típicos de hipovitaminose, em penitenciária masculina, Ceará, Brasil, 2019-2020. Métodos: estudo de caso-controle populacional; foram utilizados registros clínicos e entrevistas com casos compatíveis - sinais/sintomas iniciados no período - e com controles; realizou-se análise multivariável. Resultados: 62 casos; idade média de 40,6 anos (DP = 10,8); principais sinais/sintomas foram edema e dor em membros inferiores (100,0%), dificuldade para deambular (91,9%), hematoma/equimose em membros inferiores (90,3%), febre (88,7%); identificou-se, como fator de exposição, média de idade > 40 anos (ORa = 1,10; IC95% 1,05;1,17; p-valor = 0,001); e como fatores protetores, trabalho (ORa = 0,11; IC95% 0,03;0,36; p-valor < 0,001) e participação em aulas (ORa = 0,21; IC95% 0,08;0,59; p-valor = 0,003) dentro da penitenciária. Conclusão: surto da penitenciária compatível com escorbuto pelos sinais/sintomas característicos, associados aos fatores identificados; recomendou-se oferta regular de dieta rica em vitamina C para todos os internos e acompanhamento clínico dos casos.

Objective: to identify the occurrence of an outbreak compatible with scurvy and exposure factors associated with typical signs/symptoms of hypovitaminosis that occurred in a male penitentiary in Ceará, Brazil between 2019-2020. Methods: this was a population-based case-control study; we used clinical records and interviews with compatible cases - based on sign/symptom onset during the study period - and with controls; we carried out multivariate analysis. Results: out of 62 cases, mean age was 40.6 years (SD = 10.8); main signs/symptoms were edema and pain in the lower limbs (100.0%), difficulty in walking (91.9%), hematoma/ecchymosis in the lower limbs (90.3%) and fever (88.7%); we identified being over 40 years old as an associated factor (aOR = 1.10; 95%CI 1.05;1.17; p-value = 0.001); and as protective factors: working (aOR = 0.11; 95%CI 0.03;0.36; p-value < 0.001) and taking part in classes (aOR = 0.21; 95%CI 0.08;0.59; p-value = 0.003) in the prison. Conclusion: we considered the penitentiary outbreak to be compatible with scurvy due to characteristic signs/symptoms, associated with the identified factors; we recommended regular provision of a diet rich in vitamin C to all male inmates and clinical follow-up of cases.

Objetivo: identificar la ocurrencia del brote compatible con escorbuto y los factores de exposición asociados con signos/síntomas típicos de hipovitaminosis que ocurrieron en una penitenciaría masculina en Ceará, Brasil entre 2019-2020. Métodos: estudio poblacional de casos y controles; se utilizaron historias clínicas y entrevistas con casos compatibles, con inicio de signos/síntomas durante el período de estudio, y controles; se realizó análisis multivariable. Resultados: de los 62 casos, edad media fue 40,6 años (DE = 10,8); principales signos/síntomas fueron edema y dolor en miembros inferiores (100,0%), dificultad para caminar (91,9%), hematoma/equimosis en miembros inferiores (90,3%) y fiebre (88,7%); la edad mayor de 40 años se identificó como factor asociado (ORa = 1,10; IC95% 1,05;1,17; p-valor = 0,001); y como factores protectores: trabajo (ORa = 0,11; IC95% 0,03;0,36; p-valor< 0,001) y participación en clases (ORa = 0,21; IC95% 0,08;0,59; p-valor = 0,003) dentro del centro penitenciario. Conclusión: el brote en centro penitenciario fue considerado compatible con escorbuto debido a los signos/síntomas característicos, asociados a los factores identificados; se recomendó oferta regular de dieta rica en vitamina C a todos los internos y seguimiento clínico de los casos.

An Epidemic of Scurvy, Identified Based on Lower Extremity Swelling, in a Southern Ethiopian Prison.

In October 2016, we received reports of five deaths among prisoners with leg swelling of unknown etiology in southwestern Ethiopia. A descriptive cross-sectional study was conducted to investigate the outbreak. A suspected case was defined as a prisoner with leg swelling of unknown etiology noted between May 15, 2016 and November 29, 2016. A total of 118 suspected cases were identified with unilateral or bilateral leg swelling without an identifiable cause from a total of 2,790 prisoners. Eight of the suspected cases were thoroughly examined, and seven of these suspected cases had clinical findings consistent with scurvy. Three of the clinical cases had undetectable vitamin C levels in the serum. The attack rate for the prison was 4.2% (118/2,790), and 11 deaths were identified, making the case fatality rate 9.3% (11/118). Clinical cases of scurvy had symptoms of fatigue, myalgia, arthralgia, and signs of follicular hyperkeratosis, petechiae, peripheral edema, and oral lesions. All clinical cases had severe anemia with hemoglobin < 6.0 g/dL. The diet provided by the prison excluded fruits and vegetables. Scurvy was determined to be the cause of the outbreak, and vitamin C supplementation was promptly initiated. All symptomatic prisoners improved, and no further cases were identified in a 4-week follow-up period of active surveillance.

Modern Day Scurvy in Pediatric Orthopaedics: A Forgotten Illness.

INTRODUCTION: Scurvy, or vitamin C deficiency, is rare. The goal of this study is to highlight the common risk factors and identify the orthopaedic presentation of scurvy in children. METHODS: A retrospective chart and radiograph review was performed of all patients consulted to the pediatric orthopaedic service from 2010 to 2019 who ultimately had the diagnosis of scurvy confirmed by an abnormally low serum vitamin C level. Data extracted included: patient age, sex, neurological conditions, prematurity, psychiatric conditions, dietary abnormalities, bone pain, arthritis, limb swelling, inability to walk, skin changes, child abuse evaluations, radiographic findings, additional vitamin deficiencies, lab studies, additional tests, response to treatment. Descriptive statistics were performed. RESULTS: Nine patients (7 males, 2 females) with scurvy were studied. The average age was 7 years (range 3 to 13 y). The average body mass index was 21.4 (range, 14 to 30). Five had autism, 2 had a neurological disorder. Two had been born premature. Two had a psychiatric disorder. Seven had an abnormal diet. One presented with bone pain. Four presented with limb swelling. Seven had unilateral and 2 had bilateral leg symptoms. Five presented with inability to walk. Six demonstrated skin changes with ecchymosis or petechiae. Three presented with gingival bleeding. Radiographic findings included subperiosteal hematoma in 2, ring epiphysis in 3, Pelkan spurs in 1, metaphyseal white lines (Frankel sign) in 6, and a metaphyseal zone of rarefaction (Trummerfeld zone) in 3. Seven had additional vitamin deficiencies including: A, B1, B6, B9, D, E, K, iron and zinc. Four had a bone marrow biopsy and 1 had lumbar puncture. All were anemic. The average erythrocyte sedimentation rate was 25.7 (range 6 to 35) and C-reactive protein was 1.5 (range 0.55 to 5.64). Six had a computed tomography, 3 had a magnetic resonance imaging. After treatment with vitamin C lasting 3.4 months (range, 2 wk to 7 mo), all symptoms gradually resolved, including leg pain and swelling. All children began to walk. CONCLUSION: The pediatric orthopaedic surgeon should have an increased awareness about the diagnosis of scurvy when consulted on a child with bone pain or inability to walk. The most common orthopaedic presentation was the refusal to bear weight, the most common radiographic finding was the metaphyseal line of increased density (Frankel sign) and treatment with vitamin c supplementation was excellent in all cases.

Nutritional Deficiency Disease Secondary to ARFID Symptoms Associated with Autism and the Broad Autism Phenotype: A Qualitative Systematic Review of Case Reports and Case Series.

BACKGROUND: The demographics, weight statuses, and dietary patterns of people with autism or the broad autism phenotype who experience a severe nutrient deficiency disease due to symptoms of avoidant/restrictive food intake disorder have not been well established. OBJECTIVE: The primary objective of this review was to examine the relationship between the demographics, weight statuses, dietary patterns, and nutrient deficiency diseases that characterize the most severe manifestations of avoidant/restrictive food intake disorder symptomology associated with autism or the broad autism phenotype. METHODS: A systematic review of English and non-English articles published up to August 29, 2019, on the Scopus, PubMed, and Cumulative Index to Nursing and Allied Health Literature Plus electronic databases was conducted. Additional cases were identified through the reference list of all included articles. The search terms used were "autis∗ AND (deficiency OR scurvy)". Only case reports or case series in which a person of any age who had been identified as having a formal diagnosis of autism or autism symptoms and a disease of nutritional deficiency due to self-imposed dietary restrictions were included. Data were independently extracted by 8 authors using predefined data fields. RESULTS: A total of 76 cases (patients were aged 2.5 to 17 years) from 63 articles that were published from 1993 through 2019 were found. More than 85% cases (65 of 76 patients) were from articles published in the past 10 years. The largest percentage of published cases (69.7% [53 of 76]) involved scurvy, a vitamin C deficiency. The second-largest percentage of published cases (17.1% [13 of 76]) involved eye disorders secondary to vitamin A deficiency. Other primary nutrient deficiencies reported were thiamin, vitamin B-12, and vitamin D. In 62.9% (22 of 35) of the patients for which a body mass index or a weight percentile for age was provided, the patient was within normal weight parameters, per Centers for Disease Control weight status categories. CONCLUSIONS: Based on the 63 articles extracted for this systematic review, nutritional deficiency diseases related to inadequate intakes of vitamin A, thiamin, vitamin B-12, vitamin C, and vitamin D were found in individuals with autism and the broad autism phenotype who had severe self-imposed dietary restrictions. When weight information was provided, most of the youth in these cases were not reported to be underweight. Individuals of any weight who present with symptoms of avoidant/restrictive food intake disorder can benefit from early and frequent screening for adequacy of micronutrient intake, regardless of whether they have a clinical diagnosis of autism.

The Scottish Scurvy Epidemic of 1847.

This paper examines the emergence of scurvy in several parts of Lowland Scotland during 1847. At ÿ rst the condition was not recognised because of a mistaken, persistent belief that scurvy was only seen at sea, despite the work of James Lind who showed that sea and land scurvy were one and the same. Professor Christison failed initially to recognise the disease and wrongly thought it was caused by a lack of milk in the diet; colleagues elsewhere correctly attributed scurvy to the loss of the potato in the diet of the poor.

Scurvy Outbreak Among South Sudanese Adolescents and Young Men - Kakuma Refugee Camp, Kenya, 2017-2018.

Scurvy is a relatively rare micronutrient deficiency disease that can occur among refugees dependent on food aid (1). Inadequate access to fresh fruits and vegetables in refugee camps can result in scurvy (2,3). Kakuma Refugee Camp in Kenya's Turkana District is home to 148,000 refugees, mostly from Somalia and South Sudan, who receive food assistance. In August 2017, a number of South Sudanese adolescent and young adult male refugees were evaluated at a health clinic in the camp for calf pain, chest pain, and gingival swelling. Because the symptoms were nonspecific, no diagnosis was made, and some patients received antibiotics and analgesics. All were managed as outpatients, but symptoms did not improve. During subsequent months, more young men with similar symptoms were reported. On January 20, 2018, the United Nations High Commissioner for Refugees (UNHCR) was informed and conducted clinical examinations. Signs and symptoms included lower limb pain and swelling (in some cases involving joints), lethargy, fatigue, gingival swelling and pain, hyperkeratotic skin changes, and chest pain. Based on these clinical findings, micronutrient deficiency, particularly vitamin C deficiency (scurvy), was considered a possible diagnosis, and an investigation of a possible outbreak was conducted. The suspected scurvy cases all occurred in young men from South Sudan who were living and cooking together in one geographic section of the camp. All patients who received treatment with vitamin C noted improvement of symptoms within <1 week. Patients were provided with food and cash assistance, the latter to allow dietary diversification (i.e., fresh fruits and vegetables). However, both forms of assistance were inadequate to allow access to sufficient amount of calories and the dietary diversification needed for intake of micronutrients, such as vitamin C. It is important to consider these needs when determining the amount of food or cash assistance provided to adolescents and young adult male refugees.

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.

Assessing childhood stress in early mediaeval Croatia by using multiple lines of inquiry.

ABSTRACT: Childhood stress, using both subadult and adult remains from early mediaeval (8th-11th c. CE) sites on the eastern Adriatic coast is analysed in this report. A total of 242 individuals (83 subadults, 69 adult females, and 90 adult males) were assessed for the presence of linear enamel hypoplasia, cribra orbitalia, sub-periosteal new bone formation, and scurvy. In addition, the dietary profile of nine subadults was assessed by the analysis of carbon and nitrogen stable isotopes from bulk collagen. Over three quarters of individuals with preserved permanent dentition (44/56 or 78.6%) exhibited evidence of linear enamel hypoplasia, while analysis of the onset of this condition shows that all defects formed between 1.2 and 5.6 years of age. Cribra orbitalia was identified in 60 out of 190 individuals with preserved frontal bones (31.6%). Sub-periosteal new bone formation was recorded in 42.6% of analysed subadults (29/68) with fourteen cases still active at the time of death. Additionally, scurvy was identified in three subadults. The isotopic study of carbon and nitrogen suggests that diet of the analysed subadults was based on terrestrial C3 resources, with a varying input from C4 and a low intake of marine resources. The presented study strongly indicates that a large majority of the analysed individuals suffered from poor health during their childhood as indicated by the high frequencies of linear enamel hypoplasia, cribra orbitalia and sub-periosteal new bone formation.

Scurvy at the agricultural transition in the Atacama desert (ca 3600-3200 BP): nutritional stress at the maternal-foetal interface?

Studies of contemporary populations have demonstrated an association between decreased dietary diversity due to resource scarcity or underutilization and an increase in diseases related to poor micronutrient intake. With a reduction of dietary diversity, it is often the women and children in a population who are the first to suffer the effects of poor micronutrient status. Scurvy, a disease of prolonged vitamin C deficiency, is a micronutrient malnutrition disorder associated with resource scarcity, low dietary diversity, and/or dependence on high carbohydrate staple-foods. The aim of this paper is to assess the potential impact of nutritional transition on the prevalence of diseases of nutritional insufficiency in an archaeological sample. Here, we report palaeopathological findings from an Early Formative Period transitional site located in coastal Northern Chile (Quiani-7). The subadult cohort from this site is composed of four perinates who exhibit a number of non-specific skeletal changes suggestive of a systemic pathological condition. One of these is associated with an adult female exhibiting diagnostic skeletal lesions of scurvy. We argue that the lesions exhibited by these perinates may represent maternal transmission of vitamin C deficiency but acknowledge that there are difficulties in applying current diagnostic criteria for scurvy to individuals this young.

Modern American scurvy - experience with vitamin C deficiency at a large children's hospital.

BACKGROUND: Until recently scurvy has been viewed in developed countries as a disease of the past. More recently there have been reports of case series of children with scurvy who have had a delayed diagnosis after an extensive diagnostic workup that included imaging. Most of these children have had underlying neurologic conditions such as autism. OBJECTIVE: To review the medical records of children diagnosed with vitamin C (ascorbic acid) deficiency based on serum ascorbic acid levels at a large pediatric health care system, to determine imaging findings and utility of imaging in management, and to identify at-risk pediatric populations. MATERIALS AND METHODS: We retrospectively identified cases of vitamin C deficiency in children tested for serum ascorbic acid levels during the last 5 years. We used the criteria of normal ascorbic acid >23 µmol/L and included children with ascorbic acid levels <23 µmol/L. We evaluated their clinical history, underlying medical condition, imaging studies obtained and imaging findings. RESULTS: We identified 32 children with vitamin C deficiency. All of these children had underlying medical conditions, most commonly iron overload from multiple transfusions related to sickle cell anemia or thalassemia (20), neurologic disorders (4) and bone marrow transplant/chemotherapy (3). No cases of scurvy from dietary deficiency in otherwise normal children were identified. All except two children had multiple imaging studies, primarily related to their underlying conditions. Three of these children had extensive imaging workups related to diffuse musculoskeletal pain. Imaging findings included ill-defined sclerotic and lucent metaphyseal bands (mainly at the knee) on radiography and MRI studies that showed diffuse increased T2-weighted signal in the bilateral lower-extremity long-bone metaphyses, periosteal reaction and adjacent soft-tissue edema. CONCLUSION: Vitamin C deficiency is not uncommon in large pediatric health care facilities, and it is frequently missed on clinical evaluation and diagnostic imaging. At-risk populations include those with iron overload, neurologic conditions and history of chemotherapy. Scurvy related to dietary deficiency in otherwise normal children was not encountered. When characteristic MRI findings are seen, particularly in children with a predisposing condition for vitamin C deficiency, scurvy should be considered and a serum ascorbic acid level checked to potentially confirm a diagnosis prior to further invasive tests.

Now you see/C it.

Bleeding disorders are common. In addition to thinking about disorders relating to abnormal platelets or clotting factors, clinicians should consider disorders of vascular integrity in their differential diagnosis. We present a patient with atypical, spontaneous bleeding that was due to scurvy, an often overlooked cause. Clinicians should be aware of the risk factors for the development of scurvy, such as poor dietary intake, male gender, smoking, alcohol abuse, as well as its classic manifestations, including gingival bleeding, spontaneous bruising, corkscrew hairs, and poor wound healing, A heightened awareness may lead to earlier diagnosis and treatment.

Seasonal variation in night blindness incidence among Union soldiers in the US Civil War.

BACKGROUND: During the US Civil War, medical officers typically attributed night blindness among soldiers to malingering. A dietary basis was not generally suspected or appreciated. DESIGN/METHODS: Incident cases of night blindness, scurvy, and diarrheal diseases, as well as mean troop strength among Union troops, were abstracted by month and race from tabulations of the US Surgeon General for the period from July 1861 through June 1866. Monthly incidence rates and annual incidence rates are presented as time series by race. RESULTS: Night blindness incidence was seasonal. Seasonal patterns of night blindness incidence were similar for white and black soldiers, although the peak incidence rates were approximately 2-3 times higher in black soldiers. The seasonal effect for white Union soldiers increased progressively to 1864. The seasonal pattern for night blindness roughly parallels that for scurvy and for diarrheal diseases. The peak season for night blindness incidence was summer, and the next highest season was spring. The mode of monthly incidence rates for diarrheal diseases slightly anticipated that for night blindness and scurvy. In addition, there was greater relative variation in monthly incidence for night blindness and scurvy than for diarrheal diseases. CONCLUSIONS: Nutritional night blindness occurred in a seasonal pattern among soldiers forced to subsist on nutritionally inadequate diets. The seasonal pattern is consistent with seasonal variations in the availability of foodstuffs with high vitamin A or provitamin A content, superimposed on marginal vitamin A reserves, and possibly exacerbated by co-occurring seasonal patterns of diarrheal disease.

[Claude Balme, a caregiver of the Egyptian expedition of Bonaparte (1766-1850)]. / Claude Balme, un soignant de l'expédition d'Égypte de Bonaparte (1766-1850).

The author explains military surgeon Balme's biograpyhy, especially during Bonaparte's Egyptian campaign (1798-1801). As there is some possible confusion with another Claude Balme, some archives deserve to be closely scrutinized. Through Balme's reports the author insists on his courageous part in several scurvy or plague epidemics. He was himself marked on his face; he ended his life in Lyons as a town-councillor.

[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.