Scurvy, should we be Less Surprised?

Abstract

The authors present a case of a 77-year-old male with an alcohol use disorder, living alone, in poor sanitary conditions in a suburban area, admitted to hospital due to a spontaneous hematoma on his left lower limb with no neurovascular complications. Additional workup concluded pancytopenia (Hb 6.4 g/dL; Htc 19%; leuc 2600/L; plat 126000/L), macrocytosis (VGM 113 fL), hyperbilirubinemia (total 2.64 mg/dL), prolonged prothrombin time (INR 1.47), hypoalbuminemia (2.8 mg/dL) and fibrotic changes in hepatic architecture on ultrasound. Upon thorough examination, an extensive purpuric lesion on both lower limbs associated with perifollicular haemorrhagic papules, corkscrew hair, gingival hypertrophy, and lack of teeth was noted. Even though it is rarely seen nowadays, the semiology findings suggested vitamin C (ascorbic acid) deficiency, known as scurvy. This diagnosis was confirmed via laboratory testing that quantified seric vitamin C <1 mg/L (ref value 2-15 mg/dL), as well as vitamin B12 value of 186 ng/L (ref value 193-982 ng/L) and folic acid value of <1ng/mL (ref value 3-17 ng/mL). Vitamin supplementation and healthy nutrition were begun showing a favourable outcome with hematoma, purpura, and pancytopenia regression. The clinical manifestations of vitamin deficiency, like scurvy, can be vast and overlooked, if this outdated diagnosis is not considered, leading to unnecessary investigation and erroneous diagnoses.