Scurvy rare, but cases still are popping up

Authors of several case reports are calling for physicians to be alert to this possibility among elderly and other vulnerable patients.

By — Posted Sept. 22, 2008

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The 5-year-old with behavioral developmental disorder appeared to be getting worse. Over six weeks, he lost interest in climbing and running. He complained of leg pain. He stopped talking and became lethargic as well as bedbound. He also bruised easily. A battery of tests revealed nothing -- nothing, that is, until his vitamin C levels were checked.

It turned out he had scurvy -- a disease usually associated with long sea journeys of centuries past. "We commented at the time that if this patient had arrived in a schooner we might have made the diagnosis sooner," said James Noble, MD, assistant professor of clinical neurology at Columbia University Medical Center in New York. This child developed it because, unbeknown to his parents and in spite of the fact he had access to foods with vitamin C, he was living on crackers and ice cream.

The details of this case were published in the March 2007 Pediatrics, one of a handful of recent reports indicating that even if scurvy is not common, it happens.

"We should remember the diseases of dietary deficiency. These diseases still occur, even in the U.S.," said Robert Centor, MD, director of the division of general internal medicine at the University of Alabama at Birmingham.

Dr. Centor authored a case report in last month's Journal of General Internal Medicine detailing the story of a 57-year-old man complaining of shortness of breath and a large swollen bruise stretching from thigh to ankle. Divorced and toothless, his diet was composed of processed food but no fresh produce. He, too, had scurvy.

Another case, published in the August 2007 Journal of the American Academy of Dermatology, documented a scurvy diagnosis traced to psychosis. The 51-year-old male patient was convinced that "the mob" would harm him if he ate anything other than tuna and crackers.

No data are available on scurvy's prevalence, although anecdotal evidence suggests that most physicians will see at least one case in their careers. Some see many more.

"People think it is not a problem at all in this country, but when it occurs, it's huge," said Toby Maurer, MD, lead author of the Journal of the American Academy of Dermatology paper and associate professor of dermatology at the University of California, San Francisco. She sees two or three patients with this problem a year.

According to National Health and Nutrition Examination Survey data, about 14% of men and 10% of women are deficient in vitamin C. Few progress to scurvy, but some do. According to the Centers for Disease Control and Prevention's National Center for Health Statistics compressed mortality file, 57 people died of ascorbic acid deficiency from 1979 to 2005.

Even if these conditions are not widespread, they warrant notice. "We probably don't recognize it nearly as much as we should," Dr. Noble said. "Myself included."

But the quandary of scurvy is that, although it is easy and inexpensive to prevent and treat, its low frequency means that it is often costly to diagnose. The man in the Journal of General Internal Medicine report had a wide array of tests carried out, including a comprehensive metabolic panel, an electrocardiogram, an echocardiogram, several x-rays, and a computed tomography scan. He also was assessed for infections such as HIV. Because he had a history of alcoholism, his liver function was checked. After several weeks of outpatient care, the child in the Pediatrics paper was hospitalized for nine days before his vitamin C levels were checked.

"What's striking about these case reports is the million-dollar workup that people receive," Dr. Noble said.

For this reason, experts urge more attention to potential nutritional deficiencies among those most at risk.

"This is a pretty rare condition. We're not seeing people with scurvy right and left. But, having said that, this is a significant condition that's easily treated if you make the diagnosis. All doctors need to have a high index of suspicion in certain kinds of patients," said Robert Brodell, MD, professor of internal medicine and dermatology at Northeastern Ohio Universities College of Medicine. He published his own case study in the August 2002 Nutrition in Clinical Practice.

The at-risk patient population includes those who are older, live alone, or are mentally ill. Children with various behavioral and learning disorders also might restrict their diet.

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External links

"Scurvy Is Still Present in Developed Countries," abstract, Journal of General Internal Medicine, August (link)

"Scurvy and Rickets Masked by Chronic Neurologic Illness: Revisiting 'Psychologic Malnutrition,' " abstract, Pediatrics, March 2007 (link)

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