Hemarthrosis as initial presentation of scurvy

Vitamin C deficiency or scurvy is a disease now rarely seen except for certain populations at risk. When it occurs, diagnosis can be difficult as it can mimic other disorders. Its manifestations are primarily due to an abnormality in collagen formation causing bleeding in the skin, joints, muscles, or gastrointestinal tract and dystrophic hair deformities. We describe a case of scurvy in a 43-year-old man who presented with new onset hemarthrosis with no history of bleeding disorder. He was found to have perifollicular hyperpigmentation and corkscrew hairs, highly suggestive of scurvy. He admitted to completely eliminating fruits and vegetables from his diet and his serum vitamin C level was markedly decreased. Treatment with daily vitamin C supplement led to relief of symptoms and resolution of skin changes.     

Scurvy, a re-emerging disease

BACKGROUND: Scurvy is the clinical manifestation of vitamin C deficiency. It is historically linked to the era of great maritime expeditions. But it is remerging in Western countries as in France. SITUATION: Nowadays, scurvy mainly affects homeless populations of large occidental cities and the isolated and malnourished inhabitants of developing countries. The clinical presentations of scurvy are numerous and often misleading and its evolution without treatment is always lethal. After years of wanderings and research, the physiopathological mechanisms of scurvy were finally understood, due to the will of outstanding personalities who took the risk to brave the established superstitions in order to apply a strict medical approach. PERSPECTIVES: Scurvy must still be prevented in at risk-populations. Indeed a pocket meal enriched with vitamin C is distributed to homeless people in Paris.     

Ulcères nécrotiques et purpuriques des membres inférieurs révélant un scorbut : à propos de deux observations

BackgroundScurvy is a clinical syndrome resulting from ascorbic acid deficiency. Although presently rare in the developed world, it continues to occur within certain susceptible populations, particularly the elderly and those with dietary habits with low vitamin C intake.CasesTwo men aged 87 and 69 were referred with multifactorial, progressive ulceration of the lower limbs, without scarring, in a context of arterial disease and other associated comorbidities. In both cases, the level of vitamin C was undetectable. An improvement in the necrotic component and in the purpura was promptly observed after vitamin C supplementation.ConclusionsDiagnosis of scurvy can be challenging. This report highlights the importance of maintaining a high index of suspicion for scurvy in atypical necrotic ulcerations of lower extremities with poor response to standard therapy especially in populations at high risk of vitamin C deficiency. Early diagnosis can improve patient prognosis.     

Scurvy: historically a plague of the sailor that remains a consideration in the modern intensive care unit

We report the case of the case of a 56 year old female with sepsis on a background of rheumatoid arthritis and steroid use manifesting with overt clinical features of scurvy. Ascorbic acid assays were able to demonstrate severe deficiency and confirm a diagnosis of scurvy. Clinical resolution of signs and symptoms following commencement of vitamin C replacement was rapid. The intensivist and dietitian need to consider this diagnosis even in the first world setting, particularly in the presence of sepsis, inflammatory conditions, steroid use and importantly malnutrition.     

A case of scurvy with alveolar hemorrhage]

A 53-yr-old man with a history of chronic renal failure was admitted to the hospital of Hyogo College of Medicine on March 24th, 1999, because of severe continuous hemoptysis. On February 14th, 1999, the patient had undergone a cadaveric kidney transplantation in the urology department of another hospital. He did not experience any immunological reactions due to tissue rejection. On admission, subcutaneous bleeding at the site of an injection received 1 month before was noticed on his left arm. Petecheae of the extremities and a conjunctival hemorrhage were also noted. However, coagulation and fibrinolysis tests were essentially normal. These findings indicated that the hemorrhages were due to vessel weakness. Scurvy was diagnosed since his serum vitamin C was extremely low (0.2 microgram/ml). The patient was given ascorbic acid (1 g/day), and his condition improved dramatically. Ten years ago, the patient had had renal failure, which had been treated with chronic maintenance dialysis and dietary restriction. It has been postulated that a diet lacking in vitamin C or the steroid treatment he received after kidney transplantation may have induced the scurvy.     

Quel bilan devant une haemolacria ? À propos d’un cas et revue de la littérature

IntroductionHemolacria is a rare hemorrhagic syndrome characterized by bloody tears. The most common etiologies are inflammation, infection or laceration. However, other rarer diseases may also cause this clinical manifestation.Case reportWe describe the case of a 14-year-old male patient hospitalized for hemolacria. A history of von Willebrand disease was present in his family, diagnosed in his mother and sister, but absent in our patient. A vitamin C dosage was obtained in our patient and revealed scurvy consecutive to malnutrition. After having excluded other bleeding symptoms like bruises we retained vitamin C deficiency as the etiology of the hemorrhagic syndrome.ConclusionBloody tears are a rare clinical manifestation and the etiology may be difficult to determine. Bloody tears are a rare clinical manifestation of hemorrhagic syndrome. To determine the underlying etiology, screening should consider all possible causes including the rarest.     

Hypovitaminosis C in hospitalized patients

BACKGROUND: In recent years, cases of scurvy have mainly been described in populations at risk. The prevalence and risk factors for hypovitaminosis C among hospitalized patients in a department of internal medicine are largely unknown. METHODS: We determined serum ascorbic acid level (SAAL) and searched for clinical and biological signs of scurvy in 184 patients hospitalized during a 2-month period. RESULTS: The prevalence of hypovitaminosis C (depletion: SAAL<5 mg/l or deficiency: SAAL<2 mg/l ) was 47.3%. Some 16.9% of the patients had vitamin C deficiency. There was a strong association between hypovitaminosis C and the presence of an acute phase response (p=0.002). Other univariate risk factors for vitamin C depletion were male sex (p=0.02), being retired (p=0.037), and infectious diseases (p=0.002). For vitamin C deficiency, the significant univariate risk factors included the same ones found for vitamin C depletion, plus being unemployed (p=0.003) and concomitant excessive alcohol and tobacco consumption (p<0.0001). Logistic regression showed that being retired (p=0.015) and concomitant excessive alcohol and tobacco consumption (p=0.0003) were significant independent risk factors. Hemorrhagic syndrome and edema were described more often in patients with vitamin C deficiency than in those with vitamin C depletion or without hypovitaminosis. Clinical signs were more frequent for an ascorbic acid level below 2.5 mg/l. CONCLUSION: Hypovitaminosis C is frequent in hospitalized patients but should be interpreted according to the presence or absence of an acute phase response. The main risk factors are living conditions and excessive alcohol and tobacco consumption.     

An apple a day ... chronic glossitis in a 4-year-old boy

We report a case of chronic glossitis in a 4-year-old boy due to scurvy. The boy showed up in our department with a patchy depapillated tongue. A detailed dietary history revealed an unbalanced diet without any fruit or vegetable. The biological investigations showed a low serum ascorbic acid. The boy was treated by oral ascorbic acid during 15 days. The glossitis improved within one week and serum levels of vitamin C returned to the normal range. In industrial countries, scurvy became a rare disease in healthy children. However, since a few years, cases are reported in children and teenagers with unbalanced diet coming from economically favoured families. These extreme cases are one of the signs of a more general deterioration of dietary habits in paediatric populations in our societies. This emphasizes the importance of effective nutritional education programs aimed towards both parents and children.     

An Unbalanced Diet Limited to the Consumption of Boiled Vegetables Led to the Onset of Scurvy

Scurvy is a rare disease caused by a vitamin C deficiency. Vitamin C is a water-soluble vitamin found in vegetables and fruits, but it is lost after boiling. A 59-year-old man presented with gingival pain after having a tooth extracted five years previously. Following the procedure, his diet comprised boiled vegetables to prevent pain. He then experienced bilateral lower leg pain, and computed tomography revealed intramuscular bleeding. His serum vitamin C level was below the detectable limit. His symptoms immediately improved with vitamin C administration. This case emphasized that consuming only boiled vegetables can lead to the onset of scurvy.     

Body pool and synthesis of ascorbic acid in adult sea lamprey (Petromyzon marinus): An agnathan fish with gulonolactone oxidase activity

Although many vertebrates can synthesize ascorbic acid (vitamin C), it is still unclear from the evolutionary perspective when the ability to synthesize the vitamin first appeared in the animal kingdom and how frequently the trait has been lost. We report here ascorbic acid biosynthesis ability in sea lamprey (Petromyzon marinus) which represent the most ancient vertebrate lineage examined thus far for presence of gulonolactone oxidase, the enzyme catalyzing the terminal step in biosynthesis of vitamin C. This finding supports the view that the ancestors of living vertebrates were not scurvy prone and that the loss of gulonolactone oxidase activity subsequently occurred several times in vertebrate phylogeny. Adult sea lamprey allocate significant amounts of ascorbic acid to the gonads to guaranty high-quality gametes. Tissue stores of ascorbate were maintained by de novo synthesis (1.2–1.3 mg of ascorbic acid/300-g sea lamprey per day at 15°C) while sea lamprey fast during spawning migration. We estimate that the in vivo daily renewal rate of ascorbate is 4–5% of the whole-body ascorbate pool based on measurement of its biosynthesis and concentration in the whole animal.     

Has lack of vitamin C any role in the aetiology of tropical pyomyositis?

The plasma concentration of vitamin C of 14 patients with tropical pyomyositis without clinical evidence of scurvy and that of II age and sex-matched controls was determined in order to ascertain whether or not there was a deficiency of the vitamin in this condition. The results show that the mean plasma concentrations of vitamin C of patients were slightly higher (15.9 +/- 6.4 g/l) than those of controls (12.0 +/- 4.5 g/l). The differences, however, were not statistically significant (P greater than 0.25). It is therefore concluded that lack of vitamin C does not play a part in the aetiology of tropical pyomyositis.     

Induction of clinical response and remission of inflammatory bowel disease by use of herbal medicines: A meta-analysis

AIM:To evaluate the efficacy and tolerability of herbal medicines in inflammatory bowel disease(IBD)by conducting a meta-analysis.METHODS:Electronic databases were searched for studies investigating efficacy and/or tolerability of herbal medicines in the management of different types of IBD.The search terms were:"herb"or"plant"or"herbal"and"inflammatory bowel disease".Data were collected from 1966 to 2013(up to Feb).The"clinical response","clinical remission","endoscopic response","endoscopic remission","histological response","histological remission","relapse","any adverse events",and"seriousadverse events"were the key outcomes of interest.We used the Mantel-Haenszel,Rothman-Boice method for fixed effects and DerSimonian-Laird method for random-effects.For subgroup analyses,we separated the studies by type of IBD and type of herbal medicine to determine confounding factors and reliability.RESULTS:Seven placebo controlled clinical trials met our criteria and were included(474 patients).Comparison of herbal medicine with placebo yielded a significant RR of 2.07(95%CI:1.41-3.03,P=0.0002)for clinical remission;a significant RR of 2.59(95%CI:1.24-5.42,P=0.01)for clinical response;a non-significant RR of 1.33(95%CI:0.93-1.9,P=0.12)for endoscopic remission;a non-significant RR of 1.69(95%CI:0.69-5.04)for endoscopic response;a non-significant RR of 0.64(95%CI:0.25-1.81)for histological remission;a non-significant RR of 0.86(95%CI:0.55-1.55)for histological response;a non-significant RR of 0.95(95%CI:0.52-1.73)for relapse;a non-significant RR of 0.89(95%CI:0.75-1.06,P=0.2)for any adverse events;and a non-significant RR of 0.97(95%CI:0.37-2.56,P=0.96)for serious adverse events.CONCLUSION:The results showed that herbal medicines may safely induce clinical response and remission in patients with IBD without significant effects on endoscopic and histological outcomes,but the number of studies is limited to make a strong conclusion.     

Reduced mononuclear leukocyte ascorbic acid content in adults with insulin-dependent diabetes mellitus consuming adequate dietary vitamin C

Several recent studies suggest that vitamin C (ascorbic acid [AA]) status may be altered in insulin-dependent diabetes mellitus (IDDM). We measured the AA content of mononuclear leukocytes (MN-AA) as an indicator of tissue vitamin C status in adults with IDDM and nondiabetic adults matched for age and sex. Dietary vitamin C intake and plasma AA were analyzed to ensure that vitamin C availability was adequate. Dietary vitamin C intakes were above recommendations and were not different between the groups. MN-AA was reduced by 33% on average (P less than .05) in adults with IDDM (1.75 microgram/mg total protein [TP]) when compared with nondiabetics (2.60 micrograms/mg TP). When MN-AA is indexed to the dietary vitamin C intake (MN-AA/100 mg diet C), the storage deficit in adults with IDDM averages 50% (P less than .05). This observation suggests an impaired tissue AA storage in adults with IDDM and supports the theory that intracellular scurvy contributes to the chronic degenerative complications of the disease.     

Scurvy in a Patient with Depression

Scurvy is a nearly-forgotten disease in developed countries where adequate nutrition is easily available. It still may occur, however, when, for a variety of reasons, people fail to eat a diet containing adequate vitamin C. We report the case of a 52-year-old patient with depression who developed scurvy.     

Role of vitamins in gastrointestinal diseases

A tremendous amount of data from research was published over the past decades concerning the roles of different vitamins in various gastrointestinal diseases.For instance,most vitamins showed an inverse relationship with the risk of colorectal carcinoma as well as other malignancies like gastric and esophageal cancer in observational trials,however interventional trials failed to prove a clear beneficial preventive role.On the other hand,more solid evidence was obtained from high quality studies for a role of certain vitamins in specific entities.Examples for this include the therapeutic role of vitamin E in patients with nonalcoholic steatohepatitis,the additive role of vitamins B12 and D to the standard therapy of chronic hepatitis C virus,the role of vitamin C in reducing the risk of gallstones,the positive outcome with vitamin B12 in patients with aphthous stomatitis,and the beneficial effect of vitamin D and B1 in patients with inflammatory bowel disease.Other potential uses are yet to be elaborated,like those on celiac disease,pancreatic cancer,pancreatitis,cholestasis and other potential fields.Data from several ongoing interventional trials are expected to add to the current knowledge over the coming few years.Given that vitamin supplementation is psychologically accepted by patients as a natural compound with relative safety and low cost,their use should be encouraged in the fields where positive data are available.     

Macrophage functions in aging: effects of vitamin C deficiency

Groups of young adult and senescent guinea pigs were fed normal and vitamin C deficient diets for 4 weeks and tested for their peritoneal macrophage functions. Serum levels of vitamin C in deficient animals indicated a progressive state of ascorbic acid deficiency and correlated well with the clinical signs and symptoms of scurvy. Fewer macrophages were obtained from the peritoneal cavities of deficient animals and morphologically they were smaller in size. Adverse effects of vitamin C deficiency were enhanced in aged animals. Significantly greater number of aged animals died by 4 weeks of deficiency. Deficient senescent animals had greater decline in macrophage random migration and bactericidal capacity. Following phagocytic stimuli, superoxide anion generation also significantly decreased. Data suggest that vitamin C deficiency might affect macrophage functions in the aged more profoundly and could compromise parameters of host defenses effective against microbial infections.     

Effect of dietary ascorbic acid on the incidence of spontaneous mammary tumors in RIII mice.

A study of the effect of different amounts of L-ascorbic acid (vitamin C), between 0.076% and 8.3%, contained in the food has been carried out with ten groups of RIII mice (seven ascorbic acid and three control groups), with 50 mice in each group. With an increase in the amount of ascorbic acid there is a highly significant decrease in the first-order rate constant for appearance of the first spontaneous mammary tumor after the lag time to detection by palpation. There is also an increase in the lag time. The mean body weight and mean food intake were not significantly different for the seven ascorbic acid groups. Striking differences were observed between the 0.076% ascorbic acid and the control groups (which synthesize the vitamin): smaller food intake, decreased lag time, and increased rate constant of appearance of the first mammary tumor. This comparison cannot be made experimentally for guinea pigs and primates because the control groups would develop scurvy.     

Cook's Endeavour,ship of discovery or ship of distemper: an assessment after 250 years

The 250‐year anniversary of Cook's landfall at Botany Bay on 28 April 1770, approximately half way through a global circumnavigation, was an extraordinary maritime undertaking. An enterprise of astronomy, cartography, cultural–botanical documentation and revelation achieved without a death from infectious disease and only 10 mild cases of scurvy in a ship's company of 95 men. The subsequent homeward journey was far less endurable, marked by shipwreck, unforeseen prolonged delays and fatal epidemics of flux and malaria. Mild scurvy within a handful of souls in a crew experimenting with several putative antiscorbutics, yet at voyage's end the precise treatment of scurvy remained enigmatic.