Image Diagnosis: Spontaneous Hematoma from Scurvy

A 58-year-old alcoholic man presented with pain, swelling, and bruising of his right leg. He had no history of trauma or injury. His medical history was significant for frequent spontane ous hematomas in his legs (Figure 1), the first and most dramatic of which was a large thigh hematoma occurring 4 years earlier. This area became infected, developing necrotizing fasciitis that required emergency surgery. On physical examination, he had hyperplastic gums and no teeth. He had no body hair below his head. The calf of his right leg was enlarged and tender, with more swelling medially than laterally. Dependent bruising was noted in the popliteal fossa initially as his leg was elevated; several days later, when he started ambulating, bruising became apparent around his ankle. His initial blood alcohol level was 0.28%, and his Aspartate Aminotransferase and Alanine Aminotransferase levels were 90 and 61 international units/microliter, respectively. His platelet count and coagulation studies were normal. His body mass index was 30 kg/m 2 . Color flow Doppler ultrasound of his right leg was performed, and no deep venous thrombosis was identified. Imaging of his leg by a contrast-enhanced computerized tomography scan (Figure 2) showed a large hematoma in the right calf (white arrows), measuring 7.5 x 3.5 x 12.6 cm (anterior-posterior, transverse, and caudal-cranial dimensions, respectively). Extravasation of intravenous contrast was seen, indicating active bleeding (black arrowhead). There were no aneurysms or other vascular malformations in or near the hematoma. This patient drank a 1.75-liter bottle of vodka daily and smoked cigarettes. He ate mostly precooked hash brown potatoes, pasta, and occasional canned tuna. He did not eat fresh vegetables and rarely ate fruit.