Abstract
A 22-year-old male non-smoker was referred to our rheumatology department due to suspected vasculitis. His medical history was notable for pyruvate dehydrogenase deficiency and Crohn’s disease. The Crohn’s disease was diagnosed at the age of 16 years. It had been in clinical and colonoscopic remission since treatment with infliximab was initiated when he was 17 years old. His surgical history revealed that he suffered severe burns of the lower limbs at the age of 14, which were treated with skin grafts.
He presented with a 9-month history of transient yet increasingly frequent spontaneous bruising and ecchymoses of the lower limbs and bleeding gums while brushing his teeth. His history was also notable for a lifelong diet all but devoid of fresh fruit and vegetables except for bananas and cooked spinach. On physical examination, numerous bruises were seen on the legs localized predominantly on the scarred sites where skin grafts were obtained (Panel A). The complete blood count, coagulation tests, renal and liver function tests, as well as markers of inflammation, anti-nuclear antibodies, antibodies against multiple extractable nuclear antigens, complement components C3c, C4, anti-neutrophil cytoplasmic antibody, and antiphospholipid antibodies were within normal limits.
Panel A and B.
Scurvy was suspected and oral vitamin C supplementation of 1 g daily was started empirically, since the measurement of an ascorbic acid level was not routinely available at our hospital. No new bruises developed and nearly all the ecchymoses regressed after 2 months of treatment, which supported the diagnosis of scurvy (Panel B).
Vitamin C deficiency is rare in the developed world. However, scurvy can be precipitated by a vitamin C deficient diet, and additional risk factors include Crohn’s disease and smoking. 1 The diagnosis of scurvy is usually based on a history of the patient’s dietary habits, clinical features (easy bruising, skin ecchymosis and petechiae, bleeding of the gums, fatigue, arthralgias), and rapid resolution of symptoms after vitamin C supplementation.
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Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.