Clinical Picture

A classic case of scurvy

Shari Lipner

A 40-year-old woman with a history of chronic intravenous vitamin C followed by daily oral supple­ Lancet 2018; 392: 431
pancreatitis and gastro-oesophageal reflux disease mentation and her symptoms resolved within a few Department of Dermatology,
presented with fatigue, malaise, dizziness, difficulty weeks. Weill Cornell Medical School,
New York, NY, USA
ambulating, diarrhoea, easy bruising, and a diffuse rash Contributors (S Lipner PhD)
involving her extremities and trunk that had been SL was responsible for both the clinical care of the patient and for the
writing of the manuscript. Written consent from the patient for Correspondence to:
present for several days. She explained that she had Dr Shari Lipner, Weill Cornell
publication was obtained.
limited her diet to consist mostly of bread, rice, Dermatology, York Avenue,
dumplings, and the occasional egg white to reduce the © 2018 Elsevier Ltd. All rights reserved. New York, NY 10021, USA
shl9032@med.cornell.edu
symptoms she suffered from her gastro-oesophageal
reflux disease. Her diet was also devoid of red meat, fish,
chicken, fruits, and vegetables. A B
On physical examination, she had extensive,
non-palpable, perifollicular haemorrhages involving
her extremities (figure), ecchymosis (figure), and
gingival bleeding. Corkscrew hairs, visible with
the unaided eye, were seen all over her skin—although
they were much more apparent with dermoscopy
(figure). Her laboratory results showed haemoglobin
8·3 mg/dL, haematocrit 25·2%, and a plasma vita­
min C concentration of <5 μmol/L (normal range
23–50 μmol/L). Endoscopy of the upper gastrointestinal
tract and colonoscopy of the lower bowel did not find a
source of bleeding.
A biopsy of the skin from her right lower leg showed
a corkscrew shaped profile of the hair follicle, and C D
histopathological examination showed follicular
hyperkeratosis and plugging (figure). Taken together,
the clinical, laboratory, and histopathological findings
were consistent with a diagnosis of scurvy. Vitamin C
must be obtained from dietary sources and it is essential
for hydroxylation of proline and lysine residues for the
synthesis of collagen. It is also important for immune
system function and iron absorption. Scurvy rarely
affects adults but may be seen in some individuals with
malnutrition or malabsorption. Signs and symptoms
usually occur by the third month of inadequate
consumption, and treatment is with vitamin C
Figure: A classic case of scurvy
supplementation. Early diagnosis and treatment of Perifollicular haemorrhages on both legs (A), ecchymosis (B), corkscrew hairs seen with dermoscopy (C),
scurvy can be life-saving, so recognition of the physical and follicular hyperkeratosis and plugging (indicated by arrow) at histopathological examination of the skin
findings is important. This patient was given (haematoxylin and eosin stain). Original magnification × 10 (D).

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