A Case of Scurvy in an Elderly Patient
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CASE PRESENTATION
A 70-year-old man was brought to the emergency room by his neighbor, who reported a 10-day history of progressive fatigue, leg pain, and generalized weakness. The patient had suffered an ischemic stroke 7 months before and was dependent on his neighbor for his daily care. His past medical history was significant for hypertension. His caretaker also commented on the patient’s decline in function during the last month, noting some “bloody stools,” shortness of breath, “easy bruising,” leg swelling, and a recent “red rash” on his arms and legs. The patient had no known allergies, and his daily medications were aspirin 81 mg orally, lansoprazole 30 mg orally before meals, and hydrochlorothiazide 25 mg orally. He denied use of tobacco or illicit drugs. He drank 1-2 cans of beer per day. The patient was admitted to the Medicine service.
The patient’s initial vital signs were: heart rate 100 beats/min, blood pressure 110/65 mm Hg, respiratory rate 18 breaths/min, and temperature 36.8 degrees C. His height was 1.88 m, and he weighed 67 kg (body mass index = 19). Physical examination revealed lethargy, cachexia, left hemiparesis, poor dentition, gingival erythema, and pitting edema (2+). The skin examination showed small petechiae in the upper and lower extremities and large ecchymoses below the knees bilaterally. He was found to be anemic (hemoglobin 9.1 g/dL, mean corpuscular volume 88) with normal differential, platelet count, prothrombin time (PT), and partial thromboplastin time (PTT). His electrolytes (sodium, potassium, calcium, magnesium, phosphate) were all within normal limits. His chest x-ray was normal, and a computed tomography scan of the brain failed to identify recent lesions. Stool specimen was positive for blood. Urinalysis revealed a urinary tract infection, and appropriate antibiotic therapy was started. Iron and ferritin levels were low normal. B12 and folate levels were also normal. Albumin count was 3.0 g/dL. Work-up for hepatitis, hemolysis, and vasculitis were negative. Idiopathic thrombocytopenic purpura and thrombotic thrombocytopenic purpura were ruled out since the PT and PTT were normal. Doppler ultrasonography of the lower extremities was negative for deep vein thrombosis.
The patient was referred to a gastroenterologist for endoscopy. Esophagogastroduodenoscopy (EGD) revealed mild esophagitis at the gastro-esophageal junction (Los Angeles class A) and normal stomach and duodenum. Colonoscopy revealed diverticulosis of the sigmoid colon and internal hemorrhoids. A source of bleeding was not identified.
Considering the patient’s poor nutritional status, a serum ascorbic acid (vitamin C) level was ordered. It was found to be less than 0.02 mg/dL (normal = 0.2-2.0 mg/dL). The diagnosis of scurvy and malnutrition was made. We re-examined the patient and identified corkscrew-like hairs. A dietary history showed that the patient’s diet consisted entirely of bread, cheese, pasta, canned meatballs, and beer. The patient was started on a high-protein diet with vitamin C supplementation (1 g daily). His improvement was dramatic. After the 10th day of his hospitalization, the patient was back at his baseline with total resolution of his fatigue, extremity pain, generalized weakness, and skin lesions. He was discharged home under the care of a visiting nurse. His hemoglobin was 12.8 g/dL at his 1-month follow-up visit.
DISCUSSION
Hypovitaminosis C or scurvy (called “the despicable disease”)1 has been described for centuries, first in 1541 by a Dutch physician named Echthius in Cologne, Germany, who thought it was an infectious disease. In 1540, the French explorer Jacques Cartier was told of a remedy for scurvy made of pine tree needles from Native Americans in Canada. The first English reference to the disease appeared in the Oxford English Dictionary in 1565.
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