Abstract

Scurvy, a disease secondary to severe Vitamin C deficiency, first appeared in Egyptian medical scrolls 3500 years ago. Currently, in industrialized countries, the prevalence of vitamin C deficiency is <5%. Scurvy, which presents with mucosal, skeletal and skin changes, is usually a clinical diagnosis, and is rarely biopsied. We present a patient with scurvy in which the characteristic histological findings were instrumental to the disease diagnosis.

 A 31-year-old otherwise healthy male with severe alcohol use disorder presented with complaints of headache, dizziness and arthralgia for 2 weeks. Physical exam was remarkable for bilateral ankle swelling, pale conjunctiva with petechiae, and scattered non-blanching petechial rash on the bilateral lower-extremities. Laboratory investigation revealed a normocytic anemia with hemoglobin of 6.3g/dl, requiring transfusion.  Imaging showed bilateral ankle fractures. The clinical differential diagnosis included vasculitis, hemolytic uremic syndrome and thrombotic thrombocytic purpura (HUS-TTP), hepatitis, HIV-AIDS, meningococcemia, endocarditis, and vitamin/mineral deficiency.  Clinical examination of the skin of the lower extremities revealed “corkscrew hairs” surrounded by petechiae. A skin biopsy revealed numerous extravasated erythrocytes in the dermis, concentrated around a twisted and distorted hair follicle, consistent with scurvy.  Laboratory testing of Vitamin-C showed strikingly low levels (5umol/L, range23-224umol/L).

Social history revealed that the patient drank 6 beers/day and maintained a diet consisting of “Only hamburgers and French fries”. This patient’s story is remarkable because it highlights the importance of clinical and histologic examination of the skin, which lead to the diagnosis of scurvy, an ancient and uncommon disease, that can be debilitating, but is easily treatable.