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Scurvy: A case in a young healthy woman
Volume 27 Number 5, Part 1 November 1992
Brief communications 9
773
I
Scurvy: A case in a young healthy woman M A J Ron M. Shelton, M C , U S A F , a'* and M A J Michael T. Ryan, M C , USAFb, **
Langley Air Force Base, Virginia A healthy-appearing young woman was diagnosed with scurvy. T h e only physical signs were a few petechiae, one ecchymotic patch, and several corkscrew hairs located mainly on her thighs. There was no history of alcoholism, fad diets, anorexia, bulimia, or mental illness. A low serum vitamin C level eonfirmed the diagnosis, and it returned to normal after 1 m o n t h of ascorbic acid supplementation. T h e cause of the patient's scorbutic state remains an enigma. CASE R E P O R T A 20-year-old white woman had red spots on her legs of 1 month's duration. Her only medication was birth control pills. There was no history of fatigue or weight loss. She denied anorexia, fad diets, or bulimia and stated that she ate well-balanced meals, including green vegetables and fruit. She was a college student who worked part-time as a teacher. Physical examination revealed small erythematous perifollicular accuminate papules on the anterior thighs, medial aspect of the legs, nape of the neck, and forearms. Several petechiae and one blanchable violaceous patch were present on the left anterior thigh. Coiled hairs were located subcorneally within l to 2 mm, skin-colored papules (Fig. 1). There were no periungual telangiectases or sprinter hemorrhages. The gums were not friable. No acid-worn incisors, keratotic knuckles, or other signs of anorexia or bulimia were observed. A complete blood cell count was entirely normal. A chemistry panel was normal except for a total bilirubin of 2.6 mg/dl. The direct bilirubin was 0.7 mg/dl. A serum ascorbic acid level was less than 0.1 mg/dl (normal 0.4 to 2.0 mg/dl).
From the DermatologyServicea and the PathologyService,b First Medical Group. Theopinionsexpressedhereinrepresentthoseof the authorsand do not necessarilyrepresentthoseof the UnitedStatesAir Forceor the Department of Defense. No reprintsavailable. *Dr. Sheltonis currentlya fellowin the Departmentof Derrnatologic Surgery. Universityof California,San Francisco. **Dr. Ryanis currentlya fellowin the Departmentof Dermatopathology, Armed ForcesInstituteof Pathology,Washington,D.C. 16/54/38320
Fig. 1. Skin of right anterior thigh reveals two purpuric macules (arrowheads)and barely elevated papule containing coiled hair (arrow).
A punch biopsy specimen from the buttock revealed a coiled hair within the stratum corneum (Fig. 2), and scattered extravasated erythrocytes in the dermis were noted. These clinical and laboratory findings led to the diagnosis of scurvy. Our patient was treated with ascorbic acid, 500 rag/ day. After 1 month, her serum ascorbic acid level rose to 0.8 mg/dl, and the petechiae resolved. However, a few coiled hairs were still present on the buttocks.
774
Journal of the American Academy of Derma tology
Brief communications
Fig. 2. Punch biopsy specimen from the buttock. Multiple cross sections of hair shaft are noted in stratum corneum. (Hematoxylin-eosin stain; X40.) DISCUSSION Lind first described scurvy in 1753. Surprisingly, the disease is still found in urban areas, l It occurs mostly in the elderly, especially bachelors; the poor; the mentally ill; alcoholics; and those who consume fad diets. 2 It can also occur as a result of esophageal reflux) Clinical manifestations include follicular hyperkeratosis; perifollicular hemorrhage; hypertrophic gums that bleed easily; softened teeth; yellow skin; hemorrhages of conjunctival, subungual, subcutaneous, intramuscular, and subperiosteal tissue; weakness; fatigue; dyspnea on exertion; fever; weight loss; depression; joint swelling; arthralgias; leg edema; epistaxis; diarrhea; and a Sj6gren-like syndrome. Rarely, convulsions, 4 hypotension, and death can result, s The physical signs of scurvy in this patient were subtle. Occasionally follicular hyperkeratosis and
corkscrew hairs are the only manifestations of scurvy, especially when the diagnosis is made early in the course of the disease. 5 We do not know the cause of the ascorbic acid deficiency in our patient. However, our report suggests that scurvy may occur more often than commonly appreciated even in young, healthy persons. REFERENCES
1. Wa[lerstein RO, Walierstein RO Jr. Scurvy. Semin Hematol 1976;13:211-8. 2. Miller SJ. Nutritional deficiency and the skin. J AM ACAD DEKMATOL 1989;21:1-30. 3. Leung FW, Guze PA. Adult scurvy. Ann Emerg Med 1981;10:652-5. 4. Ellis CE, Vanderveen EE, Rasmussen JE. Scurvy: a case caused by peculiar dietary habits. Arch Dermatol 1984; 120:1212-4. 5. Chazan JA, Mistitis P. The pathophysiology of scurvy. Am J Med 1963;34:350-8.
Brief communications 9
773
I
Scurvy: A case in a young healthy woman M A J Ron M. Shelton, M C , U S A F , a'* and M A J Michael T. Ryan, M C , USAFb, **
Langley Air Force Base, Virginia A healthy-appearing young woman was diagnosed with scurvy. T h e only physical signs were a few petechiae, one ecchymotic patch, and several corkscrew hairs located mainly on her thighs. There was no history of alcoholism, fad diets, anorexia, bulimia, or mental illness. A low serum vitamin C level eonfirmed the diagnosis, and it returned to normal after 1 m o n t h of ascorbic acid supplementation. T h e cause of the patient's scorbutic state remains an enigma. CASE R E P O R T A 20-year-old white woman had red spots on her legs of 1 month's duration. Her only medication was birth control pills. There was no history of fatigue or weight loss. She denied anorexia, fad diets, or bulimia and stated that she ate well-balanced meals, including green vegetables and fruit. She was a college student who worked part-time as a teacher. Physical examination revealed small erythematous perifollicular accuminate papules on the anterior thighs, medial aspect of the legs, nape of the neck, and forearms. Several petechiae and one blanchable violaceous patch were present on the left anterior thigh. Coiled hairs were located subcorneally within l to 2 mm, skin-colored papules (Fig. 1). There were no periungual telangiectases or sprinter hemorrhages. The gums were not friable. No acid-worn incisors, keratotic knuckles, or other signs of anorexia or bulimia were observed. A complete blood cell count was entirely normal. A chemistry panel was normal except for a total bilirubin of 2.6 mg/dl. The direct bilirubin was 0.7 mg/dl. A serum ascorbic acid level was less than 0.1 mg/dl (normal 0.4 to 2.0 mg/dl).
From the DermatologyServicea and the PathologyService,b First Medical Group. Theopinionsexpressedhereinrepresentthoseof the authorsand do not necessarilyrepresentthoseof the UnitedStatesAir Forceor the Department of Defense. No reprintsavailable. *Dr. Sheltonis currentlya fellowin the Departmentof Derrnatologic Surgery. Universityof California,San Francisco. **Dr. Ryanis currentlya fellowin the Departmentof Dermatopathology, Armed ForcesInstituteof Pathology,Washington,D.C. 16/54/38320
Fig. 1. Skin of right anterior thigh reveals two purpuric macules (arrowheads)and barely elevated papule containing coiled hair (arrow).
A punch biopsy specimen from the buttock revealed a coiled hair within the stratum corneum (Fig. 2), and scattered extravasated erythrocytes in the dermis were noted. These clinical and laboratory findings led to the diagnosis of scurvy. Our patient was treated with ascorbic acid, 500 rag/ day. After 1 month, her serum ascorbic acid level rose to 0.8 mg/dl, and the petechiae resolved. However, a few coiled hairs were still present on the buttocks.
774
Journal of the American Academy of Derma tology
Brief communications
Fig. 2. Punch biopsy specimen from the buttock. Multiple cross sections of hair shaft are noted in stratum corneum. (Hematoxylin-eosin stain; X40.) DISCUSSION Lind first described scurvy in 1753. Surprisingly, the disease is still found in urban areas, l It occurs mostly in the elderly, especially bachelors; the poor; the mentally ill; alcoholics; and those who consume fad diets. 2 It can also occur as a result of esophageal reflux) Clinical manifestations include follicular hyperkeratosis; perifollicular hemorrhage; hypertrophic gums that bleed easily; softened teeth; yellow skin; hemorrhages of conjunctival, subungual, subcutaneous, intramuscular, and subperiosteal tissue; weakness; fatigue; dyspnea on exertion; fever; weight loss; depression; joint swelling; arthralgias; leg edema; epistaxis; diarrhea; and a Sj6gren-like syndrome. Rarely, convulsions, 4 hypotension, and death can result, s The physical signs of scurvy in this patient were subtle. Occasionally follicular hyperkeratosis and
corkscrew hairs are the only manifestations of scurvy, especially when the diagnosis is made early in the course of the disease. 5 We do not know the cause of the ascorbic acid deficiency in our patient. However, our report suggests that scurvy may occur more often than commonly appreciated even in young, healthy persons. REFERENCES
1. Wa[lerstein RO, Walierstein RO Jr. Scurvy. Semin Hematol 1976;13:211-8. 2. Miller SJ. Nutritional deficiency and the skin. J AM ACAD DEKMATOL 1989;21:1-30. 3. Leung FW, Guze PA. Adult scurvy. Ann Emerg Med 1981;10:652-5. 4. Ellis CE, Vanderveen EE, Rasmussen JE. Scurvy: a case caused by peculiar dietary habits. Arch Dermatol 1984; 120:1212-4. 5. Chazan JA, Mistitis P. The pathophysiology of scurvy. Am J Med 1963;34:350-8.