Scurvy

Overview

Scurvy is a disease resulting from a severe deficiency of vitamin C (ascorbic acid), an essential nutrient that humans cannot produce internally and must obtain through diet. While historically associated with long sea voyages where sailors lacked access to fresh fruits and vegetables, scurvy still occurs today in developed countries among certain at-risk populations. The condition develops when vitamin C intake falls below 10 mg per day for several weeks to months.

Vitamin C plays a crucial role in the synthesis of collagen, a protein essential for the structure and strength of connective tissues throughout the body. Without adequate vitamin C, collagen production is impaired, leading to the breakdown of various tissues including blood vessels, skin, tendons, ligaments, and bones. This explains the wide range of symptoms associated with scurvy, from bleeding gums and easy bruising to joint pain and poor wound healing.

The disease progresses through stages, beginning with non-specific symptoms like fatigue and malaise, advancing to more characteristic signs such as bleeding gums and skin changes, and potentially leading to serious complications if left untreated. Fortunately, scurvy is both preventable and treatable with proper nutrition or supplementation. The condition typically responds rapidly to vitamin C replacement, with many symptoms improving within days to weeks of treatment initiation.

Symptoms

Scurvy symptoms develop progressively as vitamin C stores become depleted. Early symptoms are often non-specific, making initial diagnosis challenging.

Early Symptoms (1-3 months of deficiency)

Classic Symptoms

• Bleeding gums: Swollen, spongy, purple gums that bleed easily
• Loose teeth: Due to gum disease and bone loss
• Easy bruising: Spontaneous bruises from minor trauma
• Petechiae: Small red or purple spots on skin
• Corkscrew hairs: Coiled body hairs with surrounding hemorrhage
• Poor wound healing: Old wounds may reopen
• Dry, rough skin: Especially on legs
• Sharp abdominal pain
• Knee lump or mass - Due to bleeding into joints

Advanced Symptoms

• Joint pain and swelling: Especially knees and ankles
• Anemia: From chronic bleeding and poor iron absorption
• Shortness of breath: Due to anemia
• Leg swelling (edema): From capillary fragility
• Fever: Low-grade in some cases
• Convulsions: In severe cases
• Depression: Common psychological symptom

Complications if Untreated

• Severe anemia
• Secondary infections
• Spontaneous bleeding
• Heart problems
• Death (in extreme cases)

Causes

Scurvy is caused exclusively by inadequate intake or absorption of vitamin C (ascorbic acid). Understanding the various factors that lead to this deficiency is crucial for prevention and treatment.

Primary Cause

The fundamental cause of scurvy is consuming less than 10 mg of vitamin C daily for approximately 1-3 months. The recommended daily allowance is 90 mg for men and 75 mg for women.

Dietary Insufficiency

• Limited food variety: Diets lacking fruits and vegetables
• Food insecurity: Poverty limiting access to fresh produce
• Restrictive diets: Extreme dieting or food fads
• Cultural dietary patterns: Traditional diets low in vitamin C sources
• Prolonged reliance on processed foods: Lacking fresh nutrients
• Improper food storage: Vitamin C degrades with time and heat

Malabsorption Issues

• Gastrointestinal disorders: Crohn's disease, ulcerative colitis
• Celiac disease: Damages intestinal absorption
• Chronic diarrhea: Reduces nutrient absorption
• Gastric bypass surgery: Alters absorption pathways
• Excessive alcohol use: Impairs absorption and increases requirements

Increased Requirements

• Smoking: Increases vitamin C needs by 35 mg/day
• Pregnancy and lactation: Higher nutritional demands
• Hyperthyroidism: Increased metabolic rate
• Chronic infections: Depletes vitamin C stores
• Burns or major surgery: Increased healing requirements
• Cancer: Both disease and treatment increase needs

Lifestyle Factors

• Alcoholism with poor nutrition
• Drug addiction affecting dietary habits
• Homelessness limiting food access
• Institutional diets lacking variety
• Social isolation affecting meal preparation

Risk Factors

While scurvy can affect anyone with inadequate vitamin C intake, certain groups are at higher risk:

High-Risk Populations

• Elderly individuals: Poor diet, dental problems, social isolation
• Alcoholics: Poor nutrition, impaired absorption
• People with eating disorders: Severely restricted diets
• Individuals with mental illness: Self-neglect, poor dietary choices
• Refugees and displaced persons: Limited food access
• Infants fed only cow's milk: Low in vitamin C

Medical Conditions

• Malabsorption syndromes
• Inflammatory bowel disease
• End-stage renal disease on dialysis
• Cancer, especially during treatment
• HIV/AIDS
• Anorexia nervosa
• Severe food allergies limiting diet

Socioeconomic Factors

• Poverty and food insecurity
• Homelessness
• Living in food deserts
• Lack of nutrition education
• Cultural dietary restrictions
• Institutionalization with poor meal planning

Lifestyle Risk Factors

• Tobacco smoking (depletes vitamin C)
• Excessive alcohol consumption
• Fad diets excluding fruits/vegetables
• Prolonged parenteral nutrition without supplementation
• Living alone with mobility issues

Diagnosis

Diagnosing scurvy requires clinical suspicion based on symptoms and dietary history, confirmed by laboratory testing and response to treatment.

Clinical Evaluation

Medical History

• Detailed dietary assessment
• Duration and progression of symptoms
• Social circumstances affecting nutrition
• Medical conditions affecting absorption
• Medications and supplements
• Substance use history

Physical Examination

• Skin inspection: Petechiae, ecchymoses, corkscrew hairs
• Oral examination: Gum swelling, bleeding, tooth mobility
• Musculoskeletal: Joint swelling, tenderness
• General appearance: Pallor, edema
• Vital signs: May show tachycardia if anemic

Laboratory Tests

• Serum ascorbic acid level: <0.2 mg/dL indicates deficiency
• Leukocyte ascorbic acid: More accurate but less available
• Complete blood count: May show anemia
• Iron studies: Often concurrent iron deficiency
• Coagulation studies: May be abnormal
• Inflammatory markers: ESR, CRP may be elevated

Imaging Studies

• X-rays: May show subperiosteal hemorrhages
• Bone changes: Ground glass appearance, white line of Fraenkel
• Joint effusions: From bleeding into joints
• MRI: Can show muscle/soft tissue hemorrhages

Differential Diagnosis

Conditions that may mimic scurvy:

• Bleeding disorders (hemophilia, von Willebrand disease)
• Vasculitis
• Thrombocytopenia
• Leukemia
• Child abuse (in pediatric cases)
• Rheumatologic conditions

Treatment Options

Scurvy treatment is straightforward and highly effective, with most patients showing rapid improvement once vitamin C replacement begins.

Vitamin C Replacement

Initial Treatment

• Adults: 1-2 grams daily for 3 days, then 500 mg daily
• Children: 100-300 mg daily based on age
• Route: Oral preferred; IV for severe cases or malabsorption
• Duration: Continue until symptoms resolve (usually 1-3 months)
• Forms: Ascorbic acid tablets, powder, or liquid

Maintenance Therapy

• 100-200 mg daily after initial treatment
• Higher doses for smokers (add 35 mg/day)
• Dietary counseling for long-term management
• Regular monitoring in at-risk populations

Supportive Care

• Pain management: For joint and muscle pain
• Dental care: Address gum disease and tooth problems
• Wound care: For non-healing wounds
• Iron supplementation: If concurrent anemia
• Nutritional support: Address other deficiencies
• Physical therapy: For joint stiffness

Dietary Management

High Vitamin C Foods

• Citrus fruits: Oranges, grapefruits, lemons
• Berries: Strawberries, raspberries
• Tropical fruits: Kiwi, mango, papaya
• Vegetables: Bell peppers, broccoli, Brussels sprouts
• Leafy greens: Kale, spinach
• Tomatoes: Fresh or juice

Response to Treatment

• 24-48 hours: Constitutional symptoms improve
• 1 week: Bleeding stops, pain decreases
• 2 weeks: Gums begin healing
• 3 weeks: Skin changes resolve
• 3 months: Complete recovery in most cases

Monitoring

• Clinical improvement assessment
• Repeat vitamin C levels if needed
• Address underlying risk factors
• Ensure dietary compliance
• Screen for other nutritional deficiencies

Prevention

Scurvy is entirely preventable through adequate dietary intake of vitamin C or appropriate supplementation in at-risk individuals.

Dietary Prevention

• Daily intake: 90 mg for men, 75 mg for women
• Eat variety: Include fruits and vegetables daily
• Fresh is best: Vitamin C degrades with storage and cooking
• Raw when possible: Heat destroys vitamin C
• Proper storage: Keep produce cool and use quickly
• Frozen options: Often retain high vitamin C levels

Supplementation Guidelines

• Consider for high-risk individuals
• Smokers need additional 35 mg daily
• Multivitamins usually contain adequate amounts
• Stand-alone vitamin C supplements available
• Avoid megadoses (can cause kidney stones)

Special Populations

• Infants: Breast milk or fortified formula
• Elderly: Ensure access to fresh produce
• Institutionalized: Menu planning with adequate vitamin C
• Alcoholics: Routine supplementation recommended
• Post-surgical: Increased intake for healing

Public Health Measures

• Nutrition education programs
• Food assistance programs
• Fortification of common foods
• Access to fresh produce in underserved areas
• Screening high-risk populations

When to See a Doctor

Early recognition and treatment of scurvy prevents complications and ensures rapid recovery:

Seek Medical Attention For

• Persistent fatigue with poor diet history
• Bleeding gums not related to dental disease
• Easy bruising or spontaneous bleeding
• Non-healing wounds
• Joint pain and swelling
• Skin changes (petechiae, corkscrew hairs)
• Unexplained anemia

Emergency Symptoms

• Severe bleeding from any site
• Difficulty breathing
• Chest pain
• Severe abdominal pain
• Confusion or altered mental state
• High fever with other symptoms

High-Risk Groups Should Seek Care For

• Any concerning symptoms with poor nutrition
• Difficulty eating fresh foods
• Chronic conditions affecting absorption
• Recent major surgery or illness
• Substance abuse with poor diet

Related Conditions

Scurvy often occurs alongside other nutritional deficiencies and may share symptoms with various conditions:

Differential Diagnoses

• Bleeding Disorders
• Vasculitis
• Leukemia
• Rheumatoid Arthritis
• Hemophilia
• Thrombocytopenia

Frequently Asked Questions

References

1. Maxfield L, Crane JS. Vitamin C Deficiency. StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.
2. Agarwal A, Shaharyar A, Kumar A, Bhat MS, Mishra M. Scurvy in pediatric age group - A disease often forgotten? J Clin Orthop Trauma. 2015;6(2):101-107.
3. Léger D. Scurvy: reemergence of nutritional deficiencies. Can Fam Physician. 2008;54(10):1403-1406.
4. Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academies Press; 2000.
5. Olmedo JM, Yiannias JA, Windgassen EB, Gornet MK. Scurvy: a disease almost forgotten. Int J Dermatol. 2006;45(8):909-913.