A 51 ‐year‐old man was brought to the hospital after being found unconscious in the hallway of his transitional housing establishment. At the time of presentation, he was alert and interactive but made several odd statements. He reported a 1‐month history of a painless, nonpruritic rash that started on his thigh and spread to other parts of his body. He finally developed severe lightheadedness and daily episodes of syncope. The patient was unemployed and lived alone. He denied alcohol or illicit drug use. Physical examination was notable for profound orthostatic hypotension, poordentition with gingival bleeding, and widespread ecchymotic and purpuric rash. Results of laboratory studies were notable for a hematocrit of 24%, bilirubin of 5.5 mg/dL (indirect 4.7 mg/dL), and creatinine of 1.7 mg/dL. The patient's anemia, depletion of intravascular volume, and hemorrhagic rash led us to suspect scurvy. On further questioning, the patient stated that he ate a diet consisting almost exclusively of canned tuna fish and crackers. The diagnosis of scurvy was confirmed with a skin biopsy, which revealed perifollicular hemorrhage and a serum ascorbic acid level < 0.12 mg/dL (lower limit of normal is 0.20). The patient was treated with high‐dose ascorbic acid, and his symptoms fully resolved within 2 weeks. A psychiatric evaluation revealed he had paranoid schizophrenia with the delusion that gangsters threatened him physical harm if he expanded his diet beyond tuna fish and crackers.
Scurvy was the subject of the first randomized, controlled clinical trial, in 1753, in which Dr. James Lind described successfully treating sailors with citrus fruit. We discuss here a case of scurvy in a socially marginalized patient with undiagnosed psychiatric illness, someone who was stranded not at sea but at the outskirts of society. The earliest clinical manifestations of scurvy are often dermatologic — petechiae, perifollicular purpura, and ecchymoses — with gingival disease following. These changes occur because ascorbic acid is a co‐factor in collagen synthesis, and a deficiency results in pericapillary fragility and hemorrhage. Postural hypotension and syncope from hemorrhage or poor fluid intake are common. Sequelae may also include hemarthrosis, internal hemorrhage, or dementia. Laboratory data typically reveal anemia and hyperbilirubinemia from hemolysis. The serum ascorbic acid level is a specific test for scurvy but can be insensitive if there has been recent vitamin C intake. The diagnosis can also be supported by a skin biopsy, which typically reveals perifollicular hemorrhage. Scurvy is readily treated with ascorbic acid supplementation, and most patients recover fully.
Physicians must remain vigilant for scurvy in populations with risk factors such as psychiatric illness and socioeconomic marginalization.
N. Dey, None; T. Nazif, None; B. A. Sharpe, None.
To cite this abstract:Dey N, Nazif T, Sharpe B. Chicken of the “C”: One Man's Tale of Syncope. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 115. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/chicken-of-the-c-one-mans-tale-of-syncope/. Accessed January 29, 2020.