A Veteran With Lesions, Alcohol Use, and Opioid Dependence

R. Hal Scofield, MD

Disclosures

October 27, 2021

This patient has perifollicular hemorrhages, which are characteristic of scurvy. The signs and symptoms of scurvy were known to the ancient Egyptians and Greeks. In 1747, British Royal Navy physician James Lind performed a small clinical trial among sailors with scurvy and determined that it was a nutritional deficiency. The vitamin itself (L-ascorbic acid) was discovered and eventually synthesized in the 20th century.[19]

Conditions associated with vitamin C deficiency include inflammatory bowel disease, end-stage renal disease on hemodialysis, cystic fibrosis, anorexia nervosa, cancer, and alcoholism.[20,21,22,23] Scurvy is diagnosed occasionally in children with unusual diets and who commonly present with a limp.[24] Alcoholism with poor nutritional intake is the most frequent association in the developed world.[25] Analogous to thiamine deficiency, symptoms of scurvy appear within 2 or 3 weeks of consuming a diet that lacks vitamin C.

The presentation in scurvy is related to impaired collagen and connective tissue synthesis. Common symptoms in adults are musculoskeletal pain, weakness, fatigue, and arthralgia. Myopathy is an uncommon presentation.[26] Although these vague symptoms make vitamin C deficiency difficult to diagnose, the characteristic skin findings, including follicular hyperkeratosis, perifollicular hemorrhage (as seen in this patient), and coiled hairs, permit a clinical diagnosis.[27]

Serum levels of L-ascorbic acid are low in a substantial minority of the population — up to 25% in one study.[28] Thus, scurvy is probably underdiagnosed, although studies documenting the epidemiology and resultant underdiagnosis are not common. Screening of all patients referred for evaluation of petechial bleeding at a large urban teaching hospital resulted in the discovery of four patients with scurvy over a 1-year period.[27]

The finding of perifollicular hemorrhage prompted a clinical diagnosis in this patient. Vitamin C was replaced orally, with rapid resolution of the ecchymoses. Serum vitamin C levels were undetectable.

The patient rapidly improved with repletion of both thiamine and vitamin C. No evidence of alcohol withdrawal was noted. He and his wife were counseled about nutrition. He agreed to attend an alcohol cessation program and was discharged without any neurologic deficits.

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