10.5826/dpc.1401a30
text/xml
2160-9381
3550
en
Emma Shudell
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
scurvy
A Case Series of Scurvy Presenting as Bruising 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2024-01-31
2023-05-18
2024-01-31
2024-02-21
e2024030
Dermatol Pract Concept
Emma Shudell
2024/01/31
10.5826/dpc.1401a30
e2024030
Mater Misercordiae University Hospital, Dublin, Ireland
2160-9381
scurvy
en
e2024030
Alnaimat S, Oseni A, Yang Y, et al. Missing Vitamin C: A Case of Scorbutic Cardiac Tamponade. JACC Case Rep. 2019;1(2):192-196. DOI: 10.1016/j.jaccas.2019.07.006. PMID: 34316783. PMCID: PMC8301525.
A Case Series of Scurvy Presenting as Bruising 
https://dpcj.org/index.php/dpc/article/download/3550/2454
       A Case Series of Scurvy Presenting as Bruising
       Claire Quigley1, Helena Yhoo1, Liana Victory1, Stephanie Bowe1, Ciara Devenney1,
                                        Emma Shudell1


1 Mater Misercordiae University Hospital, Dublin, Ireland



Key words: Atypical bruising, nutritional deficiency, scurvy
Citation: Quigley C, Yhoo H, Victory L, Bowe S, Devenney C, Shudell E. A Case Series of Scurvy Presenting as Bruising. Dermatol Pract
Concept. 2024;14(1):e2024030. DOI: https://doi.org/10.5826/dpc.1401a30
Accepted: June 29, 2023; Published: January 2024
Copyright: ©2024 Quigley et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Dr. Claire Quigley, Mater Misercordiae University Hospital, Dublin, Ireland. Email: clairequigley@mater.ie




Introduction                                                             was taking daily Vitamin B, C and D supplementation. She
                                                                         reported a 4 month history of widespread bruising. Physi-
Vitamin C is essential in collagen formation, leukocyte                  cal examination revealed extensive ecchymoses on her lower
function and other enzymatic processes. Defects in collagen              limbs (Figure 1), abdomen and flanks bilaterally. Laboratory
disrupt the integrity of hair, connective tissue, and blood              investigations were grossly normal, except for a low level of
vessels, leading to characteristic cutaneous manifestations of           vitamin C measuring 3 mg/L (reference range 4 – 15 mg/L).
scurvy [1]. Scurvy is often considered a historic disease, as-           We increased the dose of her vitamin C supplementation to
sociated with gingivitis, loose teeth and fatigue. A recent re-          2000 mg daily for 3 months and her ecchymoses resolved.
view showed that available evidence indicates that vitamin C             This patients history of extensive bowel resection is likely
deficiency is common in low- and middle-income countries                 responsible for her vitamin C deficiency.
and not uncommon in high income settings [2]. This case                       Patient #2 was an 81-year-old female with a background
series describes scurvy manifesting as unexplained bruising,             diagnosis of mycosis fungoides on treatment with bexaro-
highlighting that although challenging to recognize due to a             tene. On routine review she complained of nausea, diarrhea,
low index of suspicion, scurvy should remain within our dif-             bilateral swollen lower legs and ecchymoses. Bexarotene
ferential as it is easy to diagnose and treat, once considered.          was held. Her nausea and diarrhea settled but a cause for
                                                                         her bruising and oedema remained elusive. Laboratory in-

Case Presentation                                                        vestigations were normal except a vitamin C level returned
                                                                         as 3 mg/L (reference range 4 – 15 mg/L). We commenced
Patient #1 is a 22-year-old female, with history of panproc-             1000 mg/day of vitamin C and her ecchymoses and oedema
tocolectomy and end-ileostomy formation for Crohn. She                   resolved one month later.




Research Letter | Dermatol Pract Concept. 2024;14(1):e2024030                                                                           1
Figure 1. Patient #1. Bilateral perifollicular purpura on lower limbs.



    Patient #3 is a 77-year-old female with a history of lupus,                     Figure 2. Patient #3. Facial ecchymoses.

Sjogren syndrome, pulmonary fibrosis and Crohn disease.
Extensive facial ecchymoses (Figure 2) were noted at rou-                We recommend keeping scurvy within the differential
tine review. A skin biopsy from her left cheek revealed red              when considering indistinct presentations. Patients typically
cell ­extravasation in the upper dermis but no vasculitis or             see resolution of symptoms within weeks of commencing
features suggestive of lupus and a DIF was negative. Once                supplementation.
again, investigations found a Vitamin C level of 3 mg/L (ref-
erence range 4-15mg/L). Similarly, Vitamin C 1000 mg/day                 References
was started and her symptoms improved.
                                                                         1. Souza PRM, Dupont L, Rodrigues FE. Scurvy: hard to remember,
                                                                            easy to diagnose and treat. An Bras Dermatol. 2021;96(2):257-
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Clinical manifestations of scurvy typically occur within                 2. Rowe S, Carr AC. Global Vitamin C Status and Prevalence of
                                                                             Deficiency: A Cause for Concern? Nutrients. 2020;12(7):2008.
12 weeks of inadequate intake. Risk factors include low
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                                                                             PMC7400810.
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cutaneous findings, however bruising in isolation, as in the                 PMID: 24996243.
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                                                                             Fam Physician. 2008;54(10):1403-1406. PMID: 18854467;
ing. Follicular hyperkeratosis and perifollicular hemorrhage
                                                                             ­PMCID: PMC2567249.
are pathognomonic on examination [3]. Scurvy is often
                                                                         5. Alnaimat S, Oseni A, Yang Y, et al. Missing Vitamin C: A Case of
considered to have a relatively benign symptomatology but                     Scorbutic Cardiac Tamponade. JACC Case Rep. 2019;1(2):192-
late stage deficiency can be severe; reported manifestations                  196. DOI: 10.1016/j.jaccas.2019.07.006. PMID: 34316783.
include generalized edema, jaundice, spontaneous bleeding,                    PMCID: PMC8301525.
neuropathy, fever, convulsions, and death [4]. One published
report discusses cardiac tamponade caused by scurvy [5].




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