Case Presentation: A 71-year-old woman presented with one month of progressive dyspnea, fatigue, weight loss, bilateral lower extremity edema, and new “purple and red spots” on her extremities. Her medical history included breast cancer more than two decades ago for which she underwent surgery and radiation therapy. She had since been out of care.
On physical examination, she was afebrile with normal vital signs but cachectic appearing. She had a systolic flow murmur with an otherwise normal cardiopulmonary examination; she had bilateral lower extremity pitting edema. A diffuse non-blanching petechial rash was present on all four extremities. She also had purpura over her shins and ecchymotic patches on her posterior ankles, hands, and pre-auricular regions. She had perifollicular hemorrhages on her scalp and splinter hemorrhages of her nail beds.
An extensive workup was pursued to evaluate for endocarditis, indolent infection, vasculitis, connective tissue disease, and malignancy. Initial laboratory data revealed lymphopenia and a hypoproliferative normocytic anemia with a normal ferritin level. Serum inflammatory markers were not elevated. Whole-body computed tomography was unrevealing. A transthoracic echocardiogram was normal. Blood cultures and the remainder of the infectious and rheumatologic workup was negative. Skin biopsy revealed lobar panniculitis without evidence of vasculitis. A bone marrow biopsy was declined by the patient.
Upon further review of her diet, the patient reported purposeful avoidance of dairy, meat, and citrus-containing fruits. Given this history, a nutritional deficiency was suspected as the unifying explanation of her multiple complaints and clinical findings. The serum vitamin C level was undetectable, confirming the diagnosis of scurvy. The patient was started on Vitamin C supplementation and her symptoms resolved within a week.
Discussion: Scurvy is a result of vitamin C (ascorbic acid) deficiency. It is a disease that is well-documented throughout history but is now rare, especially in developed nations. However, it remains prevalent in certain groups: the impoverished, malnourished, and elderly – especially among those who are isolated, institutionalized, or chronically ill. Impaired collagen synthesis and dysfunctional connective tissue account for the cutaneous manifestations of scurvy which include follicular hyperkeratosis, perifollicular hemorrhage, petechiae, coiled hairs, and ecchymoses. Other symptoms – many of which were present in this patient – include gingivitis, arthralgias, edema, generalized weakness, dyspnea, and anorexia. The diagnosis of scurvy is made clinically with a history of a restricted diet and the aforementioned clinical findings. A low serum vitamin C level can confirm the diagnosis.
Conclusions: This patient presented with clinical features that were consistent with scurvy, but appropriately concerning for more sinister systemic processes such as vasculitis, endocarditis, malignancy, or connective tissue disease. Although a more extensive work-up may have been warranted, a higher clinical suspicion for scurvy initially may have prevented unnecessary testing, decreased length of stay, and shielded the patient from the emotional distress she faced. In addition to reviewing the complex clinical presentation of scurvy, this case highlights the importance of recognizing populations at risk of nutritional deficiencies and using the diagnostic power of the history and physical examination to reach a diagnosis.
To cite this abstract:Nishtala, A; Malcolm, K; Patel, S. WHEN YOU CAN’T C THE DIAGNOSIS. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 755. https://www.shmabstracts.com/abstract/when-you-cant-c-the-diagnosis/. Accessed September 23, 2019.