Scurvy: hard to remember, easy to diagnose and treat

Currently, scurvy is an uncommon disease, but it still exists, especially in groups at risk for hypovitaminosis. 1--3 Due to low suspicion, its clinical manifestations are often not well interpreted, leading to an extensive search for differential diagnoses . The dermatological findings are fundamental clues, especially perifollicular purpura, which appears to be found only in this disease . There are usually associated systemic symptoms, and bleeding is common . The prognosis is excellent, with clinical response in the first days of vitamin replacement . The authors report the case of a male patient, 63 years, hypertensive, diabetic, with chronic renal failure on hemodialysis for five years. He complained of asymptomatic lesions with progressive increase in the last two months, mainly in the lower limbs. In addition, he reported weakness, episodes of epistaxis, and reported food intake limited to sandwiches and other carbohydrates, denying consumption of fruits and vegetables. On physical examination, he had purpuric areas, plaques and isolated, mostly punctiform with perifollicular location, affecting the lower limbs (Figs. 1 and 2), upper limbs, and back. Upon inspection of the oral cavity, no alterations were observed. Corkscrew hairs were observed at dermoscopy (Fig. 3). Extremely low plasma levels of ascorbic acid corroborated the diagnosis (0.08 mg/dL; reference value: 0.5--1.5 mg/dL). The anatomopathological exam showed folliculitis, perifolliculitis, and infundibular keratosis, common findings in scurvy. Days after oral supplementation of vitamin C, at a dose of 300 mg/day, resolution of the skin lesions was observed, in addition to improvement in asthenia and nasal bleeding. Gingival bleeding, historically the most classic manifestation of scurvy, was not observed in the present case, emphasizing that its absence does not exclude the diagnosis of the disease. Scurvy is caused by ascorbic acid (vitamin C) deficiency; vitamin C is found in fresh fruits and vegetables. 2,3 Throughout history, scurvy was mostly diagnosed during the great Irish potato famine between 1845 and 1849, when the population of that country was reduced by 20% to 25%, the American civil war, and more recently the Afghanistan war in 2002. Although uncommon and remembered for its historical significance, scurvy is not a non-existent disease, especially in individuals with unusual diets, the elderly, alcoholics, patients with neoplasms or intestinal absorption disorders, and patients on hemodialysis. The kidneys reabsorb vitamin C and excrete it in the urine only when it exceeds the serum level; however, in dialysis this clearance is indiscriminate, increasing the risk of deficiency. 3