ReviewMusculoskeletal manifestations of scurvy
Introduction
Scurvy, the constellation of clinical manifestations caused by vitamin C deficiency, has been increasingly reported over the last few years [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]. Individuals with risk factors for poor nutrition, such as social isolation, poverty, and homelessness, provide most cases of scurvy, although no subset of the general population is exempt. Musculoskeletal manifestations may be the presenting symptoms.
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Historical perspective
Scurvy was known in Ancient Egypt, and a description ascribed to Hippocrates explains that “sufferers have a foul breath, boggy gums, and a propensity for nosebleeds; they may have leg ulcers.” Between the 15th and 18th centuries, scurvy took the lives of 50–80% of those who embarked on long sea voyages. In 1753, James Lind, a British Naval Surgeon, reported that eating oranges and lemons was effective against scurvy. Lemon juice was provided preventively to sea voyagers in Britain starting in
Metabolism
Vitamin C, or ascorbic acid, is a water-soluble compound vulnerable to heat, ultraviolet radiation, and oxygen. The total pool in the body is 1500–2500 mg and the daily turnover is 45–60 mg, i.e. about 3% of the total [14]. Vitamin C has a half-life of 10–20 days. Absorption occurs in the ileum via an active transport mechanism that becomes saturated when the oral intake exceeds 180 mg/day. The absorption rate is about 85%. Concentrations are in the 5–15 mg/l range in the plasma and
Epidemiology
Vitamin C deficiency remains common. Studies done in the 1970s in the United Kingdom found serum ascorbic acid levels lower than 2 mg/l in 50% of elderly individuals living at home [16]. In 1998, Johnston reported vitamin C deficiency (<2 mg/l) in 6% and depletion (<5 mg/l) in 30.4% of apparently healthy middle-class Americans [17]. In a study from the Val-de-Marne region near Paris, France, in 1108 nonhospitalized individuals, Hercberg found that serum ascorbic acid levels were lower than
Risk factors for vitamin C deficiency
An inadequate intake of fresh fruit and vegetables is by far the main cause of vitamin C deficiency. Males who live alone, older individuals, chronic alcoholics, and individuals who voluntarily eat a restrictive diet or eat only in fast-food restaurants are at high risk for low vitamin C intake. The two risk factors identified in our study [19] were being retired and abusing alcohol and cigarettes. Jacob et al. [22] reported that vitamin C deficiency was more common among males, whereas
Clinical manifestations
Models of scurvy have provided accurate information on the time to development of clinical manifestations. Serum ascorbic acid levels become undetectable 41 days after the initiation of a diet deficient in vitamin C, cell depletion occurs after 121 days, and the first skin lesions develop after 132 days. Dental abnormalities occur after 6 months. The constellation of clinical symptoms develops after 1–3 months of a diet containing no vitamin C at all, when the total body pool falls below 300 mg
Laboratory findings
Laboratory test abnormalities are nonspecific. A common finding is anemia, which may be hypochromic, normocytic, or macrocytic. Although bleeding may contribute to induce anemia, the main factor is concomitant iron and folic acid deficiency. Folic acid is found in the same foods as vitamin C and is required for iron absorption. Intravascular hemolysis may also cause anemia. Leukopenia is not infrequent. Serum cholesterol levels are often low and vary in lockstep with serum ascorbic acid levels.
Outcome
The outcome may be unfavorable if the diagnosis is missed. Severe bleeding may occur, and deficiencies in cell-mediated immunity and phagocytosis produce a risk of severe infection. Seizures and cardiac abnormalities may occur. ST-segment and T-wave changes are not infrequent, and sudden death has been reported [51]. During the 2003 war in Afghanistan, the World Health Organization identified 40 cases of fatal scurvy in the Taiwara area alone [52]. Vitamin C depletion (serum levels in the
Treatment
Supplementation with 1 g/day of oral vitamin C for 2 weeks is the usual treatment. Divided doses distributed throughout the day should be used, as the intestinal absorption (and renal excretion) mechanisms become saturated with intakes greater than 100 mg. Parenteral administration is required in patients with malabsorption. The bleeding stops within 48 h, and an overall improvement is noticeable within 2 weeks.
A balanced diet that provides a large amount of fresh fruit and vegetables is
Conclusion
Scurvy selectively affects the homeless, the poor, and the elderly. Other risk factors include chronic and wasting diseases, intentional dietary restrictions, and lack of education about dietary needs. The musculoskeletal and other clinical manifestations may be misleading, particularly as few physicians in industrialized countries have first-hand knowledge of scurvy. An early diagnosis is vital, as the specific treatment is simple, inexpensive, and effective in eliminating the symptoms.
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