Scurvy (Severe Vitamin C Deficiency)
What is scurvy?
Scurvy is a condition that arises with a severe lack of vitamin C in the diet. The deficiency of vitamin C (ascorbic acid) impacts on various organs and tissues in the body since vitamin C is an important micronutrient for health. It is important to note that scurvy arises only with a severe and prolonged deficiency of vitamin C and in some cases it can be serious enough to cause death. However, a better understanding of the pathophysiology has made scurvy easy to treat with simple measures like dietary modification and supplementation. Within days to weeks the symptoms resolve and there may be no permanent complications.
How common is scurvy?
In this day and age, vitamin C deficiency is uncommon and scurvy is a very rare condition. However, in the 16th to 18th century it was a commonly seen condition especially among seafarers who were out at sea for months and did not have access to foods rich in vitamin C such as citrus fruits. Scurvy is found more commonly in adult males and infants in the 6 to 12 month age group. In developed nations the reason for vitamin C is largely due to a diet lacking fruits and vegetables and not often part of overall malnutrition.
Functions of Vitamin C
In order to understand the implications of vitamin C deficiency, it is important to first understand the effects of this micronutrient. Vitamin C has the following functions in the human body :
- Has protective functions against the effects of certain free radicals thereby protecting the cell structure and DNA.
- Assists in the formation of collagen and therefore facilitates wound healing, bone integrity as well as bone formation in children.
- Helps with the absorption or iron from digested food in the gut.
- Assists with the metabolism of certain proteins and lipids and the production of some brain hormones (neurotransmitters).
- Often touted as being beneficial in the treatment of and recovery from common viral infections like the flu (seasonal influenza) and common cold although this is a controversial claim of its benefits.
Lack of Vitamin C
Vitamin C is a water-soluble vitamin and is not stored in the body in large quantities for prolonged periods of time. Since the human body cannot synthesize it, dietary intake of vitamin C on a regular basis is therefore necessary. Excess vitamin C is excreted in the urine thereby ensuring that the body has a total pool of about 1,500 milligrams (mg). Scurvy arises when a person’s diet is deficient of vitamin C for about 3 months and the total body pool of vitamin C declines to levels below 350 mg.
The signs and symptoms associated with scurvy are largely due to the impaired synthesis of collagen. It is essentially the ‘cement’ between cells that gives various tissues its firmness and strength. Weakening of these tissues, like the capillaries, leads to bleeding (hemorrhage), brittle bones and in children the normal growth of bone is affected. Iron absorption, immune function, the breakdown of cholesterol and formation of neurotransmitters are affected in scurvy thereby contributing to the clinical presentation.
Signs and Symptoms
The onset of scurvy depends on multiple factors – it can start within weeks after discontinuing or severely reducing vitamin C intake or it can occur within months thereafter. Generalized symptoms include weakness, fatigue, easily tired, weight loss and irritability. Other system specific symptoms include :
Mouth
- Gums become swollen and spongy, turn red to purple in color and bleed easily (scorbutic gums).
- Teeth become loose and may fall out.
Picture of scorbutic gums from Wikimedia Commons
Skin
- Small red to purple spots around the hair follicles is one of the main skin symptoms. It is usually first seen on the shins.
- Twisting of the hair of the affected follicles with the hair being delicate and breaking off easily.
- Tiny purple spots mesh together to form larger patches that appear like bruises (purpura).
Eyes
- Dry eyes with grittiness (like ‘sand in the eyes’).
- Increased sensitivity to light.
- Occasional blurring of the vision.
- Conjunctival bleeding.
Limbs
- Joint tenderness
- Swollen joints
- Bleeding into the joints (hemarthrosis) and compartments
- Difficulty walking due to severe pain
- Leg swelling
Heart and Lungs
- Low blood pressure
- Shortness of breath
Causes of Scurvy
Scurvy is a consequence of severe and prolonged deficiency of vitamin C (ascorbic acid). It mainly arises due to a decreased intake of vitamin C in the diet. Sometimes scurvy can arise as a consequence of increased vitamin C utilization or excretion despite the normal consumption of foods rich in vitamin C.
- Malnutrition associated with :
– Poverty
– Poor eating habits
– Eating disorders
– Fad diets
– Alcoholism
– Babies only having cow’s milk in first year of life
– Elderly who tend to limit intake of food for various reasons – tea and toast diet
– Prolonged loss of appetite with nausea and vomiting seen with chemotherapy and in AIDS patients
- Increased utilization or breakdown of vitamin C :
– Pregnancy
– Breastfeeding
– Higher than normal metabolic rate (hyperthyroidism)
– Cigarette smoking
- Decreased absorption of vitamin C :
– Celiac disease
– Cigarette smoking also tends to lower absorption
– Crohn disease
– Whipple disease
- Loss of vitamin C :
– Dialysis – peritoneal and hemodialysis
– Iron overload disorders
Tests and Diagnosis
The clinical features of scurvy coupled with a history indicating reduced intake, increased utilization, diminished absorption or higher than normal excretion of vitamin C should raise the suspicion of scurvy. Resolution of symptoms with the administration of vitamin C is one of the best ways to confirm a diagnosis of vitamin C. Measuring the levels of vitamin C (ascorbic acid) levels in the blood is not always the best tool for diagnosing scurvy as the blood levels reflect only the recent intake of vitamin C.
Scurvy Treatment
The treatment of scurvy is fairly simple. Commencing with a diet abundant in nutritious foods and rich in vitamin C items like fruits and vegetables should be instituted immediately. The patient needs to be educated about the importance of vitamin C, risk of nutritional deficiencies and therefore encouraged to maintain a nutritious diet for life. At the same time vitamin C can be administered in the form of supplements. The dosage for supplements include :
- Children : 150 to 300 mg per day
- Adults : 800 to 1,000 mg per day
To prevent excretion in the urine, the vitamin C supplement can be administered in smaller doses several times in a day rather than a single mega dose.
Foods to Eat for Vitamin C
Although vitamin C is present in many foods, the following fruits and vegetables are considered to be good sources of vitamin C and should be incorporated in the daily diet.
- Asparagus
- Bell pepper (green)
- Broccoli
- Cabbage
- Grapefruit
- Kiwi
- Lemon
- Lime
- Orange
- Tomatoes
- Sweet potato
Prognosis
The prognosis for scurvy is very good if proper management. Patients report that the symptoms improve within one to two weeks of commencing a nutritious diet and with vitamin C supplementation. Bleeding at various sites can cease within 24 hours of commencing supplementation.
References :
http://dermnetnz.org/systemic/scurvy.html
http://www.nhs.uk/conditions/Scurvy/Pages/Introduction.aspx
