Case Presentation: A 56-year-old woman with a history of Parkinson’s disease and seizures presented with a month of dyspnea and associated easy bruising. She had previously presented to the emergency room two weeks before her current presentation with swelling of her right lower extremity and bruising. Workup at this time included a lower extremity doppler and CT angiogram of the extremity which were negative for venous or arterial thrombus. The patient lived alone and endorsed daily smoking (1 pack per day) and alcohol use (6 beers) for the past 30 years. She also endorsed a limited diet that consisted mostly of bread, cheese, and bacon. She denied any recent travel. On admission, vital signs were stable with temperature 36.3 degrees Celsius, heart rate 88, blood pressure 140/42, respiratory rate 16, SpO2 93%; physical examination revealed petechiae on bilateral upper extremities and a large hematoma of the distal right lower extremity with 2+ pulses distally throughout. Laboratory studies were remarkable for Hgb 7.7 g/dL (previously 10.9 g/dL one week earlier), platelets 193 K/cumm, MCV 85.7 fL, PT 15.3 seconds, INR 1.4, normal LFTs, normal creatinine, and normal TSH. Further hematologic workup suggested no evidence of hemolysis, but there was evidence of a mixed picture of iron deficiency anemia and anemia of chronic disease (Fe 29 mcg/dL, ferritin 243 ng/mL, TIBC 255 mcg/dL, transferrin 11%). Chest X-ray and CT of chest, abdomen, and pelvis were unremarkable. The differential diagnosis included adverse medication reaction (levetiracetam or aspirin), platelet qualitative disorders (acquired Von Willebrand syndrome or acquired Glanzmann thrombasthenia), or nutritional deficiencies (Vitamin K or C deficiency). On further questioning the patient confirmed her diet was very limited and she never ate fruits or vegetables. Vitamin labs were obtained which included a normal B12 and folate, but an undetectable vitamin C level. The patient was discharged home on vitamin C and iron supplementation. On her return to the primary care clinic, her hemoglobin improved to 11.0 g/dL. She is taking supplements as prescribed and has started to incorporate more fruits and vegetables into her diet.

Discussion: Vitamin C deficiency, also known as scurvy, is a rare diagnosis in resource-rich countries. However, the diagnosis should be considered in individuals with poor access to food or a diet lacking fresh produce. At-risk populations include individuals with dementia or cognitive impairment, eating disorders, reduced mobility, low socioeconomic status, malabsorptive conditions, and patients on dialysis. Clinically apparent Vitamin C deficiency can develop after 1-3 months of poor intake. Vitamin C is a component in collagen formation; deficiency can lead to tissue and vascular fragility, which can manifest as easy bruising as demonstrated in our patient. Iron absorption is also affected by vitamin C, and deficiency can lead to anemia. Resolution of symptoms will typically occur approximately 2-3 months after initiating vitamin repletion.

Conclusions: Vitamin C deficiency is a condition that should be considered in patients with risk factors for malnutrition who present with dermatologic manifestations and anemia.