Scurvy

Background

• Nutritional deficiency of Vitamin C (Ascorbic acid)
• Vitamin C is typically found in fruits and vegetables.
• Vitamin C is a cofactor for hydroxylation of proline and lysine amino acids in procollagen molecules, which is required for cross-linking collagen's triple helix.
• Scurvy therefore leads to unstable collagen and collagen fragility.
  • Leaking of vascular structures
    • Gingival bleeding
    • Petechiae
    • Easy bruising
• Vitamin C is also required for the disulfide bonding in hair leading to corkscrew appearance of hair.
• 16th-19th century sailors with scurvy found to have developed tooth decay, bruising, lassitude, and often died from massive hemorrhage

Risk Factors

• Eating disorders or select eating habits
• Infants who only consume pasteurized milk
• Autism
• Alcohol disorder
• Isolated elderly persons with poor nutrition

Clinical Features

Corkscrew hair in a patient with scurvy.

Petechiae in a patient with scurvy.

Bruising in a patient with scurvy.

Gingival bleeding in a patient with scurvy.

• Gingival bleeding
• Easy bruising
• Petechiae
• Corkscrew hair
• Perifollicular hemmorrhage
• Weakness, fatigue, and muscle cramping
  • Vitamin C is cofactor for enzymes involved in biosynthesis of carnitine, which is essential for release of energy via transport of fatty acids into mitochondria
• Mood disturbance, cognitive impairment, delusions and depression
  • Vitamin C is a modulator of neurotransmitter synthesis and release (e.g. Dopamine)
• Anemia
  • Vit C promotes intestinal absorption of Iron and prevents oxidative damage to the red-cell cytoskeleton

Differential Diagnosis

Petechiae/Purpura (by cause)

• Abnormal platelet count and/or coagulation
  • Septicemia
  • Idiopathic thrombocytopenic purpura (ITP)
  • Hemolytic uremic syndrome
  • Leukemia
  • Coagulopathies (e.g. hemophilia)
  • Henoch-Schonlein Purpura (HSP)
  • Acute hemorrhagic edema of infancy (AHEI)
• Hypersensitivity vasculitis
• Primary vasculitides
  • Wegener's
  • Microscopic polyangiitis
  • Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
• Secondary vasculitides
  • Henoch-Schonlein purpura
  • Connective tissue disorder
    • Systemic lupus erythematosus
  • Scurvy
  • Infectious disease
    • Hepatitis B
    • Hepatitis C
• Trauma

Dentoalveolar Injuries

• Dental fracture
• Dental subluxation
• Dental avulsion
• Bleeding dental socket

Odontogenic Infections

• Acute alveolar osteitis (dry socket)
• Acute necrotizing ulcerative gingivitis (trench mouth)
• Dental abscess
  • Periapical abscess
  • Periodontal abscess
• Ludwig's angina
• Pulpitis (dental caries)
• Pericoronitis
• Peritonsillar abscess (PTA)
• Retropharyngeal abscess
• Vincent's angina - tonsillitis and pharyngitis

Other

• Scurvy
• Gingival hyperplasia
  • Phenytoin
  • Cyclosporine
  • Nifedipine, Amlodipine
  • Leukemia

Vitamin deficiencies

• Vitamin A deficiency
• Vitamin B deficiencies
  • Vitamin B1 deficiency (Thiamine)
    • Beriberi
    • Wernicke-Korsakoff syndrome
  • Vitamin B3 deficiency (Pellagra)
  • Vitamin B9 deficiency (Folate)
  • Vitamin B7 deficiency (Biotin)
  • Vitamin B12 deficiency
• Vitamin C deficiency (Scurvy)
• Vitamin D deficiency (Rickets)
• Vitamin E deficiency
• Vitamin K deficiency
• Zinc deficiency
  • Acrodermatitis enteropathica

Evaluation

• Guided by clinical suspicion but confirmed with laboratory analysis of vitamin C levels.

Management

• Vitamin C supplementation.
  • 1 gram of oral vitamin C daily

Disposition

• Depends on the manifestations of vitamin C and their severity

References

1. Kluesner, Nicholas and Miller, daniel. “Scurvy: Malnourishment in the land of the plenty.” The journal of emergency medicine. Vol 46. no 4. pages 530-532. 2014.
2. Maltos, andre, et al. “Scurvy in a patient with AIDS: case report.” Revista de sociedade brasileira de medicina tropical 44(1): 122-123. 2011.