Case Presentation: A 48-year-old man with a C5 spinal cord injury at birth complicated by spastic quadriparesis, contractures, and chronic musculoskeletal pain presented with two weeks of progressive diffuse pain, functional decline, poor oral intake, nausea, easy bruising, and gingival bleeding. He was admitted to the hospital for acute on chronic pain and work-up of these other symptoms. His chronic pain was managed with baclofen, gabapentin, hydrocodone-acetaminophen, and intermittent botulinum toxin injections. He denied fevers or infection but noted fatigue, scattered petechiae, and worsening dental pain from known molar small periapical lucencies untreated due to insurance barriers. On examination, he was thin (BMI 17.9 kg/m²), mildly dehydrated, and chronically ill-appearing, with numerous petechiae and ecchymoses on the extremities and inflamed gingiva with visible soft tissue overgrowth over the molars. Neurologic exam showed chronic spastic quadriparesis without new deficits. Laboratory studies revealed normocytic anemia (Hgb 10.9 g/dL), low total protein (6.1 g/dL), elevated C-reactive protein (12.9 mg/L), low serum iron (39 µg/dL) and transferrin saturation (14%) with normal ferritin (47 ng/mL), and mild hypokalemia (3.1 mmol/L). Coagulation studies and platelet count were normal. Given easy bruising, gingival bleeding, petechiae, low BMI, and poor nutrition, vitamin C deficiency (scurvy) was initially suspected. He reported a diet limited to processed grains, occasional dairy, and nutritional shakes with minimal fruit or vegetables. Serum ascorbic acid was ultimately found to be undetectable (< 0.1 mg/dL), confirming the diagnosis. He was started on vitamin C 500 mg orally twice daily and evaluated by a dietitian while admitted, with improvement of his pain, nausea, and appetite noted on outpatient follow-up.
Discussion: This case highlights a rare but clinically relevant diagnosis of vitamin C deficiency in a medically complex, immobile patient in a developed country [1]. Vitamin C is a cofactor for proline and lysine hydroxylation in collagen synthesis; its deficiency weakens connective tissue integrity, producing fragile capillaries, poor wound healing, and musculoskeletal pain [2]. Impaired iron absorption may contribute to secondary anemia [3]. Classical findings such as petechiae, ecchymoses, bleeding gums, fatigue, and elevated inflammatory markers were all present in this patient but can be mistaken for hematologic or rheumatologic disease [1][4]. Hospitalists frequently care for patients with functional limitations, restricted diets, or barriers to dental and nutritional care, making awareness of micronutrient deficiencies crucial [5]. Early recognition allows rapid reversal with supplementation, preventing unnecessary diagnostic workups and readmissions [1][6].
Conclusions: Vitamin C deficiency should remain in the differential for patients with unexplained bruising, bleeding, or diffuse pain, particularly in those with chronic disability, malnutrition, or other social barriers to receiving nutrition.