Ecchymosis and Bilateral Leg Pain in an 11-Year-Old Girl With Developmental Delay

Jeffrey M. Kalczynski, DO; Bryan T. Luu, DO


May 24, 2023

Predominantly a historical disease, scurvy was a major cause of morbidity and mortality among sailors during the Renaissance. During the Age of Exploration, it was said that more people had died from scurvy than in all of the battles at that time. Captain James Cook, a British sailor, prevented scurvy among his crew by providing rations of lemon juice and fresh fruit and vegetables. In the 1700s, Dr James Lind of the Royal British Navy performed one of the first controlled trials in an attempt to find a cure for scurvy, which was unknown at that time. His Treatise of the Scurvy details his experiences with the disease and its prevention in the British Navy.[1]

Scurvy is caused by a deficiency of vitamin C (ascorbic acid), which acts as a reducing agent and is critically important in multiple biologic processes, including iron absorption and synthesis of collagen, neurotransmitters, and prostaglandins.[1] Collagen is a vital constituent of several organ systems and processes, specifically, in blood vessel walls, skin, hair, bone formation, and wound healing.[2] Signs and symptoms associated with scurvy arise from disruptions of these processes.[3]

The human body is able to store approximately 1500 mg of vitamin C. Without sufficient intake, the vitamin C reserve is depleted in about 4-12 weeks.[1] Clinical signs of vitamin C deficiency generally appear when the body's vitamin C level falls to < 350 mg of total body storage or < 0.2 mg/dL.

Scurvy has a highly distinct constellation of symptoms and can be diagnosed clinically without any laboratory testing, although in the patient in this case, a vitamin C level of < 0.1 mg/dL confirmed her clinical diagnosis. In the early stages of scurvy, patients may feel only increased irritability, generalized weakness, or fatigue. However, mucocutaneous symptoms begin to develop shortly afterward. Common manifestations are gingival swelling and bleeding, nonhealing ecchymoses, corkscrew hairs, perifollicular hemorrhage, and joint or bone pain and swelling in weight-bearing areas.[3] Many of the manifestations of scurvy are the result of blood vessel fragility.[4] The poor general nutrition status of affected patients frequently leads to symptoms such as pallor, sunken eyes, and scattered bruising.

In the later stages of scurvy, diffuse hemorrhaging occurs, leading to the progression of petechiae into purpura, multiple organ hemorrhage involving the eyes or kidneys, or painful hemarthrosis.[2] Large, nonhealing ulcerations of the skin and gingiva may even be mistaken for pyoderma gangrenosum or necrotizing gingivitis. Furthermore, the bones become brittle, increasing the risk for fracture.[2]


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