Mr. B is a 45‐year‐old man with a history of depression, anxiety, and severe gastroesophageal reflux disease who presented to the emergency department for evaluation of a rash on his right ankle. He was given an empiric course of doxycycline for possible Lyme disease; Lyme titers eventually returned negative. He returned 2 weeks later with dyspnea on exertion as well as increasing pain and swelling of his right leg. Physical exam was notable for a markedly edematous right lower extremity, ecchymosis, and a rash consisting of small, noncoalescing macules. Laboratory studies were notable for a hematocrit of 26% (37% in the ED 2 weeks prior). He was hospitalized for evaluation of his progressive rash and anemia. Initially, this was thought to be a systemic vasculitis. Although his serum iron was low, the rest of the workup, including a rheumatologic panel, was unrevealing. Imaging of his right calf was notable only for diffuse, nonspecific edema — there was no evidence for hematoma. A skin biopsy revealed evidence of perifollicular hemorrhages. Further laboratory studies revealed undetectable vitamin C levels and a vitamin B‐12 deficiency.Because of his GERD, Mr. B had been limiting his diet to bland carbohydrates and meats. Finding a vitamin replacement therapy he could tolerate was a challenge; however, he eventually was able to take a B vitamin and orange juice. At a follow‐up visit, his symptoms of dyspnea on exertion, pain, and swelling had resolved. Repeat laboratory tests revealed resolution of his anemia as well as repletion of his vitamin C level.
Scurvy is a clinical condition caused by a dietary lack of vitamin C. Without ascorbic acid, collagen is unable to appropriately crosslink and thus cannot form a strong triple helix. This effect is most prominent in the capillaries, resulting in the bleeding diatheses seen with scurvy. In 1 case series the most common signs and symptoms were bruising and nonspecific pedal edema. Gingival mucosal involvement is also common. Less commonly, hemarthrosis, adrenal hemorrhage, and even intracerebral hemorrhages can occur. Dermatologic findings often include perifollicular hemorrhages, hyperkeritotic papules with corkscrew hairs, and ecchymosis. Our patient presented with the most common signs and symptoms, although he lacked gingival involvement. Capillary bleeding in the skin can be confused a systemic vasculitis, and as in our case, a skin biopsy may be necessary to identify perifollicular hemorrhages and a subsequent search for vitamin C deficiency.
Vitamin C deficiency has multiple dermatologic manifestations that can easily be ascribed to another cause. The anemia can be rapid and severe requiring hospitalization. This case illustrates the importance of having a broad differential for a rash. It is important to be aware of the signs and symptoms of scurvy because although it is rare, it is easily diagnosed and treated.
B. Vaughn, none; A. Carbo, none.