Case Presentation: A 35-year-old woman with a history of congenital renal dysplasia complicated by end stage renal disease (ESRD) on hemodialysis, chronic macrocytic anemia, and malnutrition with folate, vitamins B12 and A deficiencies, presented with fatigue, dyspnea, and new rash. One week prior to presentation, the patient started experiencing progressive dyspnea on exertion. At her last hemodialysis session, her hemoglobin had decreased to 7 g/dL from her baseline of 9 g/dL. She denied orthopnea, lower extremity edema, infectious symptoms, or bleeding. Additionally, she noted the development of a new pruritic rash on her legs three days prior to presentation. Her physical exam was notable for perifollicular erythema and petechiae with corkscrew hairs on her legs (Figures 1 and 2). Her mouth had mild gingival erythema. Labs were notable for a macrocytic anemia with hemoglobin of 5 g/dL and an undetectable vitamin C level. Based on the patient’s dermatologic findings, labs, and anemia, a diagnosis of vitamin C deficiency, commonly referred to as scurvy, was made. Initially, there was concern for malabsorption given the patient’s multiple nutritional deficiencies, but upper endoscopy was only notable for mild erythema in the stomach without histological evidence of malabsorption on stomach and duodenal biopsies. The patient was discharged on oral vitamin C.

Discussion: Scurvy is a disease characterized by a state of low vitamin C that is diagnosed based on clinical features, dietary history, and resolution of symptoms with supplemental vitamin C. Common symptoms of scurvy include perifollicular hemorrhage, petechiae, gingiva bleeding, corkscrew hairs, anemia, weakness, and fatigue (1, 2). It was first recognized in the 15th century and became well known and well recognized due to its prevalence amongst seafarers (3). However, it is now frequently overlooked as it is rarely encountered in developed countries. Despite its rarity, there are several at-risk patient groups, including those with advanced age, psychiatric comorbidities, substance abuse, malabsorption, cancer, unstable housing, and renal failure on hemodialysis (4). Hemodialysis patients have been shown to have plasma vitamin C levels < 10 µmol/L compared to normal levels of 30-60 µmol/L. The vitamin C deficiency occurs via several mechanisms. First, vitamin C and other water-soluble vitamins are eliminated from the blood during dialysis (4). It has been estimated that a single session of HD can cause a 50% drop in the Vitamin C level. ESRD patients also have limited intake of vitamin C in their diet by avoiding foods high in potassium, such as fruits and vegetables (2, 4). These patients also generally have decreased appetite due to a persistent catabolic state. Not only is scurvy overlooked due to its rarity, but many of the symptoms of scurvy can overlap with common ESRD symptoms, such as anemia, fatigue, and shortness of breath, which may result in underdiagnosis of vitamin C deficiency. This case is an important reminder that while scurvy is a rare condition in the developed world, hemodialysis patients are at increased risk even without scarcity of nutritional resources.

Conclusions: Scurvy is a rare condition and may be overlooked due to overlap with common ESRD symptoms. While classically taught as a condition found in the developing world, scurvy should be considered in patients on hemodialysis.

IMAGE 1: Figure 1. Perifollicular hemorrhage and corkscrew hairs are characteristic of vitamin C deficiency.

IMAGE 2: Figure 2. Perifollicular hemorrhage and corkscrew hairs are characteristic of vitamin C deficiency.