Vitamin C Deficiency

Aka: Vitamin C Deficiency, Ascorbic Acid Deficiency, Scurvy

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II. Pathophysiology: Vitamin C Deficiency

  1. Increased fragility of capillaries
  2. Poor Wound Healing

III. Risk factors

  1. Elderly edentulous patients who cook for themselves
  2. Alcoholism
  3. Mental illness
  4. Institutionalized patients
  5. Infant on processed milk without supplementation
  6. Unusual dietary habits
  7. Malabsorption syndromes

IV. Symptoms

  1. Children
    1. Irritability
    2. Tachypnea
    3. Decreased Appetite
    4. Leg tenderness
  2. External bleeding
    1. Gingival erythema and bleeding
    2. Hematuria
    3. Melena
  3. Other symptoms
    1. Fatigue
    2. Mood changes
    3. Joint Pain
    4. Orthostasis

V. Signs: Children and Adults

  1. Purpura (saddle distribution of nonpalpable lesions)
    1. Perifollicular Petechiae
    2. Onset on back of lower extremities (dependent regions)
    3. Coalesce into Ecchymoses
  2. Hemorrhages
    1. Hemorrhages into Muscles of extremities
    2. Hemorrhages into joints
    3. Splinter Hemorrhages into nail beds
    4. Gingival Hemorrhages
    5. Visceral Hemorrhages
    6. Intracranial Hemorrhage (especially children)
      1. Subdural Hemorrhage
      2. Retrobulbar Hemorrhage
      3. Subarachnoid Hemorrhage
  3. Gingivitis (only in patients with teeth)
    1. Bluish purple spongy swellings
    2. Most prominent near incisors
  4. Other changes
    1. Poorly healing wounds
    2. Xerosis
    3. Hyperkeratosis
    4. Alopecia
    5. Corkscrew hairs (or crinkly hairs, coiled hairs)
    6. Painful joint effusions
  5. Late stage changes
    1. Jaundice
    2. Peripheral Edema
    3. Fever

VI. Signs: Children (Bone changes)

  1. Changes in addition to those above
  2. Long bone periosteal changes
    1. Epiphyseal separation with painful swellings
    2. Bowing of long bones
  3. Sunken Sternum
    1. Forms scorbutic rosary at costochondral margin

VII. Differential Diagnosis

  1. Oral changes (Xerostomia)
    1. Sjogren's Syndrome
  2. Chest changes with sunken Sternum
    1. Rickets (Rachitic Rosary)
  3. Arthralgias
    1. Rheumatic Fever
    2. Septic Joint
    3. Osteomyelitis
  4. Purpura
    1. Henoch-Schonlein Purpura
    2. Thrombocytopenic Purpura

VIII. Radiology

  1. Epiphyseal separation
  2. Distal long bone changes (especially at knee)
    1. Ground-glass appearance of bone
    2. Cortex decreased to pencil point width

IX. Labs

  1. Ascorbic Acid concentration in buffy layer
  2. Urine Aminoaciduria
  3. Complete Blood Count
    1. Normocytic Normochromic Anemia
    2. Platelet Count is typically normal
  4. Prothrombin Time increased

X. Management

  1. Vitamin C (Ascorbic Acid) Replacement (preferred)
    1. Doses in excess of 1000 mg are not absorbed
    2. Adults: 200 mg orally daily
    3. Children: 100 to 200 mg orally daily
  2. Dietary Vitamin C
    1. Orange Juice or Tomato Juice >4 ounces per day

XI. Complications

  1. Risk of sudden death in late disease

XII. Prevention

  1. See Vitamin C for recommended daily needs

XIII. References

  1. Behrman (2000) Nelson Pediatrics, p. 182-4
  2. Cotran (1999) Robbins Pathologic Basis, p. 449-50
  3. Rees in Lee (1999) Wintrobe's Hematology, p. 1638
  4. Rendon et al. (2017) Crit Dec Emerg Med 31(6): 15-21
  5. Wilson (1991) Harrison's Internal Medicine 438-9
  6. Hirschmann (1999) J Am Acad Dermatol 41(6):895-906 [PubMed]
  7. Rajakumar (2001) Pediatrics 108(4):E76 [PubMed]

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