scurvy

What is scurvy

Scurvy is a condition that develops in people who do not consume an adequate amount of vitamin C (ascorbic acid) in their diet 1). Although scurvy is relatively rare in the United States, scurvy continues to be a problem in malnourished populations around the world (such as impoverished, underdeveloped third world countries). Early features of the scurvy disease include general weakness, fatigue and aching limbs. If left untreated, more serious problems can develop such as anemia, gum disease, and skin hemorrhages. Scurvy is fatal if it is not treated. Symptoms generally develop after at least 3 months of severe or total vitamin C deficiency. Scurvy can be cured with vitamin C supplements taken by mouth. Once recovery is complete, dietary modifications to ensure the “recommended daily intake” of vitamin C is reached will prevent relapse. Except in the case of severe dental disease, permanent damage from scurvy does not usually occur 2).

The human body lacks the ability to synthesize and make vitamin C (ascorbic acid) and therefore depends on exogenous dietary sources to meet vitamin C needs. Your body’s pool of vitamin C can be depleted in 1-3 months. Ascorbic acid (vitamin C) is prone to oxidation in your body, and your body stores are affected by environmental and lifestyle factors (e.g., smoking), biological conditions (e.g., inflammation, iron excess), and pathologic conditions (e.g., malabsorption) that may alter its oxidation. Consumption of fruits and vegetables or diets fortified with vitamin C is essential to avoid ascorbic acid deficiency 3).

Scurvy develops 1 to 3 months after initiating a vitamin C-deficient diet 4). Individuals may complain of lethargy, fatigue, malaise, emotional lability, arthralgias (joint pain), weight loss, anorexia, and diarrhea. They also may experience easy bleeding, bruising, and poor wound healing.

Your body needs vitamin C to work properly. Without enough vitamin C in your body, you can start to feel very ill. The symptoms of scurvy include:

  • feeling tired and weak
  • aching legs and arms
  • swollen and bleeding gums
  • red or blue spots on the skin, usually on the shins
  • bruising easily
  • wounds taking a long time to heal

Sources of vitamin C

Vitamin C is found in many different fruits and vegetables, including:

  • blackcurrants
  • citrus fruits – oranges, limes and lemons
  • berries
  • kiwifruit
  • tomatoes
  • broccoli
  • sprouts
  • red, yellow and green capsicum

Cutting and heating foods changes vitamin C and makes it less effective. So it helps to eat fruits and vegetables raw, or lightly cooked, and don’t cut them too long before eating them.

You should be able to get all the vitamin C you need from your diet.

See a doctor if you’re at risk of scurvy and you:

  • feel very tired and weak all the time
  • feel irritable and sad all the time
  • have severe joint or leg pain
  • have swollen, bleeding gums – sometimes teeth can fall out
  • develop red or blue spots on the skin, usually on your shins
  • have skin that bruises easily

These might be symptoms of scurvy.

Scurvy is easily treated by adding some vitamin C to your diet, such as fresh fruit and vegetables.

Your doctor may also recommend taking vitamin C supplements until you feel better.

Your doctor might arrange a blood test to confirm you have scurvy if they’re not sure.

Most people treated for scurvy feel better within 48 hours and make a full recovery within 2 weeks.

Your doctor may refer you to a specialist for treatment, support or advice. This depends on what’s causing your scurvy.

Is scurvy contagious?

No. Scurvy is a clinical syndrome that results from vitamin C deficiency.

Scurvy is caused by the deficiency of which vitamin?

Scurvy is a clinical syndrome that results from vitamin C deficiency.

Who is at risk of vitamin C deficiency?

Vitamin C deficiency is rare. Vitamin C deficiency usually arises in the setting of decreased intake or increased requirements or losses. Persons at risk for inadequate intake of vitamin include patients in the following groups:

  • Find it difficult to maintain a healthy diet of fresh fruit and vegetables (e.g. elderly people, low-income households, people with an eating disorder)
  • Those who smoke heavily or are dependent on alcohol or drugs
  • Have a health condition that makes it difficult to digest food, such as celiac disease, ulcerative colitis or Crohn’s disease
  • Those with alcoholism, anorexia, or cancer
  • Eat very little food at all – possible reasons include treatments that make you feel very sick all the time (such as chemotherapy) or an eating disorder such as anorexia
  • Practicing food fads – with very few or no sources of vitamin C
  • Those with presumed food allergies
  • Receiving unsupplemented parenteral nutrition
  • Those on restricted diets secondary to inflammatory bowel disease, gastrointestinal reflux or Whipple disease
  • Taking medications such as aspirin, indomethacin, oral contraceptives, tetracyclines, and corticosteroids.
  • Those who have renal failure due to filtration of water-soluble vitamin C during dialysis
  • Those with a complication of interleukin-2 treatment of metastatic renal cell carcinoma
  • Receiving liver transplants
  • Have a poor diet and are pregnant or breastfeeding – your body needs more vitamin C at these times
  • Babies and young children who aren’t getting the recommended amount of vitamins

What does vitamin C do?

Vitamin C is important for:

  • keeping your skin, bones and connective tissue healthy
  • helping wounds heal
  • helping prevent infections
  • helping you absorb iron from your food

Vitamin C is a water-soluble vitamin, antioxidant, and essential co-factor for collagen biosynthesis, carnitine and catecholamine metabolism, and dietary iron absorption 5). Humans are unable to synthesize vitamin C, so it is strictly obtained through dietary intake of fruits and vegetables. Citrus fruits, berries, tomatoes, potatoes, and green leafy vegetables are excellent sources of vitamin C. Although most vitamin C is completely absorbed in the small intestine, the percentage of absorbed vitamin C decreases as intraluminal concentrations increase. Proline residues on procollagen require vitamin C for the hydroxylation, making it necessary for the triple-helix formation of mature collagen. The lack of a stable triple-helical structure compromises the integrity of the skin, mucous membranes, blood vessels, and bone. Consequently, a deficiency in vitamin C results in scurvy, which presents with hemorrhage, hyperkeratosis, and hematological abnormalities.

How much vitamin C do I need?

The amount of vitamin C you need each day depends on your age. Average daily recommended amounts for different ages are listed below in milligrams (mg).

You should be able to get all the vitamin C you need from your daily diet.

Vitamin C can’t be stored in the body, so you need it in your diet every day.

Table 1. Vitamin C requirement by age group

Life StageRecommended Amount
Birth to 6 months40 mg
Infants 7-12 months50 mg
Children 1-3 years15 mg
Children 4-8 years25 mg
Children 9-13 years45 mg
Teens 14-18 years (boys)75 mg
Teens 14-18 years (girls)65 mg
Adults (men)90 mg
Adults (women)75 mg
Pregnant teens80 mg
Pregnant women85 mg
Breastfeeding teens115 mg
Breastfeeding women120 mg

Footnote: If you smoke, add 35 mg to the above values to calculate your total daily recommended amount.

[Source 6) ]

What happens if I take too much vitamin C?

Taking too much vitamin C can cause diarrhea, nausea, and stomach cramps. In people with a condition called hemochromatosis, which causes the body to store too much iron, high doses of vitamin C could worsen iron overload and damage body tissues.

Taking less than 1,000mg of vitamin C supplements a day is unlikely to cause any harm.

Taking large amounts (more than 1,000mg per day) of vitamin C can cause:

  • stomach pain
  • diarrhea
  • flatulence

These symptoms should disappear once you stop taking vitamin C supplements.

What causes scurvy

You can develop scurvy if you don’t have enough vitamin C in your diet for at least 3 months. You can’t store vitamin C in your body for long, so you need to take it in regularly. Vitamin C, which is also known as ascorbic acid, is found mainly in fruit and vegetables.

Good sources of vitamin C include oranges, lemons, limes, guavas and kiwi fruit. Vegetables like broccoli, cauliflower, cabbage, Asian greens and tomatoes also have a lot of vitamin C. You can find vitamin C in many other fruits and vegetables and in fresh fruit and vegetable juices. The richest source is the bush food known as the Kakadu plum, salty plum or gubinge.

You are more at risk of getting scurvy if you:

  • eat a diet without many fruit and vegetables
  • cook your vegetables for long periods, since this destroys vitamin C
  • have a health condition that makes it difficult to digest food, like Crohn’s disease or ulcerative colitis
  • are on a very restrictive diet
  • have an eating disorder like anorexia nervosa
  • smoke, drink a lot of alcohol, or take drugs

You can also develop scurvy if you have a bad diet and you are pregnant or breastfeeding. Young children can get scurvy too.

You can even develop scurvy if you are overweight. You might consume a lot of calories, but if you don’t eat enough fresh fruit and vegetables you still might not be getting enough vitamin C.

Scurvy prevention

Eating a healthy, balanced diet, with plenty of fruit and vegetables, is the best way to prevent scurvy.

It’s best to steam vegetables rather than boil them. Or, you could eat vegetables raw or in a soup or stew. If you prefer to boil them, do it lightly.

Your doctor might refer you to a nutritionist, or another specialist, to help you improve your diet.

Scurvy symptoms

Vitamin C deficiency manifests symptomatically after 8 to 12 weeks of inadequate intake and patients initially complain of weakness, fatigue, listlessness and aching limbs, especially in the legs. If left untreated, scurvy can progress to the following more severe problems. After these initial symptoms, dermatologic findings include poor wound healing, gingival swelling with loss of teeth, mucocutaneous petechiae, ecchymosis, and hyperkeratosis. Because of the disruption of disulfide bond formation both corkscrew and swan-neck hairs occur. Perifollicular hemorrhages often are localized to the lower extremities, as capillary fragility is unable to withstand the gravity-dependent hydrostatic pressure. This can result in “woody edema.” Nail findings include koilonychia and splinter hemorrhages. Beyond mucocutaneous manifestations, multiple other organ systems also are involved. Rheumatologic problems occur, including painful hemarthrosis and subperiosteal hemorrhage. This bleeding results from vascular fragility from impaired collagen formation. Osseous pathology also occurs and presents with fractures in brittle bones from disrupted endochondral bone formation. A “scorbutic rosary” at the costochondral junction and sternal depression may occur. Ocular manifestations of hemorrhage include flame hemorrhages, cotton-wool spots, and retrobulbar bleeding into optic nerves, resulting in atrophy and papilledema. The late disease may be life-threatening with anasarca, hemolysis, jaundice, and convulsions.

  • Skin problems – one of the first signs of scurvy is the development of perifollicular hyperkeratotic papules (phrynoderma), often on the shins. These appear as reddish/bluish bruise-like spots surrounding hair follicles. The central hairs are twisted like corkscrews that may break easily. The papules may join together to form large areas of palpable purpura or ecchymoses (bruises).
  • Oral problems – gums may swell and become red, soft and spongy. Any slight friction may cause the gums to bleed. Often this results in poor oral hygiene and dental diseases.
  • Musculoskeletal problems – bleeding in the joints causes extreme discomfort and pain. Joints may be swollen and tender and the pain can be so severe that patients cannot walk.
  • Eye problems – patients may complain of dryness, irritation, light intolerance, transient visual blurring and stickiness. Haemorrhaging (bleeding) beneath the conjunctiva and within the optic nerve sheath may also occur.
  • Anemia – this develops in 75% of patients as a result of blood loss into tissue, altered absorptions and metabolism of iron and folate, gastrointestinal bleeding and intravascular hemolysis.
  • Heart and lung problems – shortness of breath, low blood pressure, and chest pain leading to shock and death.

The cutaneous manifestations of scurvy include phrynoderma, corkscrew hairs, perifollicular hemorrhage and purpura, edema of the lower extremities, and splinter hemorrhages. Phrynoderma, or enlarged hyperkeratotic hair follicles, initially present on the posterolateral arms. This subsequently generalizes to involve the buttocks, posterior thighs, calves, shins, and back. Corkscrew hairs represent fractured and coiled hairs due to impaired keratin cross-links by disulfide bonds. With time, significant vascular congestion occurs, particularly in the lower extremities, leading to perifollicular hemorrhage and edema. This purpura is occasionally palpable, mimicking a cutaneous vasculitis. Blood vessel wall fragility also results in splinter hemorrhages of the nail bed. Oral disease is prominent among those with pre-existing poor dentition. Individuals may develop a hemorrhagic gingivitis, where the gingiva is initially red, swollen, and shiny and later becomes purple, necrotic, and prone to bleeding. Additionally, poorly formed soft teeth are prone to infection. Musculoskeletal disease is frequently seen in children. Hemorrhage can be intramuscular, intra-articular, or subperiosteal, leading to pain and pseudoparalysis. Bowing of the long bones, depression of the sternum, and swelling of the costochondral junctions are noted on physical examination. Radiographic findings include a transverse metaphyseal radiolucent band (scurvy line or Trummerfeld zone), widening at the zone of calcification (white line of Frankel), a ring of increased density around the epiphysis (Wimberger ring) and metaphyseal spurs with marginal fractures (Pelkan spurs). Conjunctival, intraocular, intracerebral, and gastrointestinal bleeding have been reported.

Figure 1. Corkscrew hair

Corkscrew hair

Figure 2. Inflamed marginal gingiva in scurvy

inflamed marginal gingiva in scurvy

Figure 3. Perifollicular hemorrhagic papules

Perifollicular hemorrhagic papules
[Source 7) ]

Figure 4. Hyperkeratotic hair follicles

hyperkeratotic hair follicles
[Source 8) ]

Figure 5. Extensive bruising

extensive bruising

Footnote: A 59 year old woman presented to our department with a month’s history of extensive bruising of the legs and a more recent haemarthrosis of the right knee. Full blood count, blood film, and clotting screen were normal, but she had longstanding oesophageal reflux, a very restricted diet, and undetectable serum concentration of vitamin C. Her doctor diagnosed scurvy and treated her with vitamin C. Hemorrhagic symptoms settled within two weeks, as did her gastrointestinal symptoms. She now has a more normal diet.

[Source 9) ]

Scurvy diagnosis

The diagnosis of scurvy is primarily a clinical one, based on a dietary history of inadequate vitamin C intake and the signs and symptoms described above. To diagnose scurvy, your doctor will examine you and ask questions about your diet. They might also arrange a blood test to test for vitamin C.

Diagnosis begins with the evaluation of risk factors and a physical examination. Dermoscopy can be used to aid in diagnosis, confirming follicular purpura and corkscrew hairs with a 4 mm punch biopsy of affected areas showing similar findings by histopathology. Serum testing for low plasma vitamin C (less than 0.2 mg/dL) is usually consistent with scurvy; however, as stated above, recent intake or supplementation may elevate plasma levels and not be reflective of a prior prolonged deficit. The level of vitamin C in leukocytes is more accurate when assessing the sparse vitamin C stores as they are less affected by acute dietary changes. A leukocyte vitamin C level of 0 mg/dL is indicative of latent scurvy. Zero to 7 mg/dL is consistent with deficiency, and greater than 15 mg/dl is adequate.

In addition to assessing vitamin C levels, screening for concomitant other vitamin deficiencies should be undertaken. As deficiency is primarily related to poor intake, those affected also may have poor intake of other essential vitamins and minerals. Vitamin B12, folate, calcium, zinc, and iron have been notably low in this patient population. Additionally, vitamin C’s role in iron absorption cause those with scurvy to be more prone to bleeding and iron deficiency, in particular, should be assessed.

Scurvy treatment

Direct replacement of vitamin C is standard, with up to 300 mg daily for children and 500 mg to 1000 mg daily for adults. The endpoint of replacement is one month or upon resolution of clinical signs and symptoms. Alternative treatment regimens for adults include one to 2 g for up to 3 days followed by 500 mg daily for a week followed by 100 mg daily for up to 3 months. In addition to immediate supplementation, educate the patient on lifestyle modifications to ensure adequate intake, and recommend cessation of alcohol, and tobacco use.

In the abscence of deficiency, daily requirements are up to 45 mg per day in children, 90 mg per day for men, 75 mg per day for women, and up to 120 mg per day for women who are lactating.

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