Sir, we write to you about two cases of scurvy which recently presented to our unit. Despite a great reduction in its prevalence, this ancient disease still affects people in our developed world today. It is noteworthy that the Care Quality Commission has recently published a report showing 17% of hospitals investigated were not compliant in meeting the nutritional needs of patients.1 Furthermore, studies have shown that high proportions of elderly people already have low vitamin C levels on medical admission.2
The earliest symptom of scurvy, occurring only after many weeks of deficient intake, is fatigue. The most common cutaneous findings are perifollicular haemorrhages, ecchymoses, leg oedema, poor wound healing, and coiled body hairs. Gingival abnormalities include gingival swelling, purplish discoloration, and haemorrhages. Pain in the back and joints is common. Syncope and sudden death may occur.3 Scurvy is easily treated with vitamin C supplements and the inclusion of fresh fruit and vegetables in a daily diet.4
An 83-year-old female who lived in a care home was referred regarding 'erosions' in her mouth with associated difficulty in maintaining adequate nutritional intake. The patient's medical history included coronary artery bypass graft, stroke, nephrectomy, anaemia, osteoarthritis and dementia. There were no known allergies or use of alcohol and the patient had stopped smoking 40 years ago.
Clinical examination revealed blood crusted lips and generalised confluent ulceration affecting the buccal mucosa which also involved the gingiva. An elevated blood urea was noted, suggestive of renal dysfunction or poor fluid intake and her vitamin C levels were low. Clinical symptoms coupled with low ascorbic acid levels led to a diagnosis of scurvy. The patient was started on vitamin C supplements and a review a week later showed complete resolution of the oral lesions.
In another case, a 63-year-old female presented reporting a one month history of poor eating with reported weight loss due to swollen and bleeding gums. There was no relevant medical or social history except for a diet consisting mainly of plain pasta, devoid of fresh fruit and vegetables.
Clinical examination revealed the gingiva were swollen and bled spontaneously or on minor trauma (Fig. 1). All teeth were mobile. Initial blood tests revealed a Hb 7.9/dl and an otherwise normal FBP and coagulation screen. Medical examination revealed dependent oedema of the lower legs with bruising, perifollicular haemorrhaging and corkscrew hairs, (Fig. 2). A diagnosis of scurvy with secondary anaemia was made. The patient was admitted for further investigations and vitamin C supplementation was commenced. No other intervention was needed. At a four week review weight had been gained and only mild gingival inflammation secondary to her underlying periodontal disease was present.
As the UK's population is ageing, with increasing numbers residing in care homes, we feel it is important for clinicians to be aware that scurvy could be affecting our patients and particularly those who may be visited on a domiciliary basis.
Care Quality Commission. Dignity and nutrition inspection programme: national overview. October 2011. Available at: http://www.cqc.org.uk/sites/default/files/media/documents/20111007_dignity_and_nutrition_inspection_report_final_update.pdf.
Hirschmann J V, Raugi G J . Adult scurvy. J Am Acad Dermatol 1999; 41: 895–909.
Richardson T I L, Ball L, Rosenfeld T . Will an orange a day keep the doctor away? Postgrad Med J 2002; 78: 292–294.
Halligan T J, Russell N G, Dunn W J, Caldroney S J, Skelton T B . Identification and treatment of scurvy: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100: 688–692.
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Chapman, J., Marley, J. Scurvy and the ageing population. Br Dent J 211, 583–584 (2011). https://doi.org/10.1038/sj.bdj.2011.1061
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