Le scorbut n'a pas disparu : histoire d'une maladie réémergente

BACKGROUND

Scurvy is the clinical manifestation of vitamin C deficiency. It is historically linked to the era of great maritime expeditions. But it is remerging in Western countries as in France.

SITUATION

Nowadays, scurvy mainly affects homeless populations of large occidental cities and the isolated and malnourished inhabitants of developing countries. The clinical presentations of scurvy are numerous and often misleading and its evolution without treatment is always lethal. After years of wanderings and research, the physiopathological mechanisms of scurvy were finally understood, due to the will of outstanding personalities who took the risk to brave the established superstitions in order to apply a strict medical approach.

PERSPECTIVES

Scurvy must still be prevented in at risk-populations. Indeed a pocket meal enriched with vitamin C is distributed to homeless people in Paris.

Scorbut en soins intensifs malgré un apport vitaminique

INTRODUCTION

Scurvy can occur in hospitalized patients despite vitamin supplementation.

OBSERVATION

A 63 Year-old patient who had spent several weeks in intensive care developed an unexplained anemia and ecchymoses. Despite daily administration of 130 mg/day of vitamin C since his admission, his ascorbic acid blood levels had collapsed. Administration of 1g/day relieved the symptoms within four weeks.

DISCUSSION

Whether a deficiency had existed prior to admission or not, scurvy developed during the week of intensive care despite parenteral nutrition supplying a daily dose of 130 mg of vitamin C. Such deficiencies decompensated in surgical situations remain a reality in developed countries.

CONCLUSION

In certain pathological contexts and in all the growing number of cases in elderly patients and many surgical indications, the need for vitamin C supplementation has to be defined. The needs at that particular time must be taken into account and the prior nutritional status.

Diagnostic pitfalls: case report of scurvy in a man with spinal cord injury

BACKGROUND

A 49-year-old man with spinal cord injury (SCI) developed a progressive purpuric rash and painful swelling of the lower extremities, in addition to chronic purpura over the ischial tuberosities.

DESIGN

Case report.

FINDINGS

Following an extensive workup for presumed vasculitis, a skin biopsy showed evidence of scurvy. Risk factors for scurvy included limited means of transportation, living alone, and alcohol abuse.

CONCLUSIONS

Scurvy can be confused with disorders common among SCI patients, such as vasculitis, venous thrombosis, occult trauma, and pressure injury. Scurvy should be considered in the differential diagnosis of skin lesions, especially in individuals who abuse alcohol and live alone.

[History of scurvy therapy and the injustice done to Dr. Maksim Nikolić-Miskovićev of Sremski Karlovci in the 19th century]

This paper reviews historical aspects regarding medical knowledge on scurvy, vitamin C deficiency, and its etiological factors. This disease used to affect naval-crews on long lasting sea voyages, soldiers during times of war and the poor. Although efficient therapy of scurvy (fresh vegetables, lemon juice) was known in the mid-18th century, its etiology was not known. It was believed to be caused by the cold, moist winds, unhealthy evaporations, malnutrition and it was called "alkaline disease". It was established that acid substances like lemon juice, had beneficial effects on the disease. However, it was soon generally accepted that it was caused by deficient diet. In 1830, Dr. John Elliotson, Professor of Medicine at London University supported this opinion. In 1928, Albert Szent Gyordyi, professor of Chemistry and Biochemistry at Szeged and Budapest Universities, isolated vitamin C from green pepper, vegetable proved to be rich with vitamin C. Due to this discovery, and some discoveries regarding biological processes, he was awarded the Nobel Prize for medicine and physiology in 1937. Back in 1864, a military doctor in Belgrade, Dr. Maksim Nikolić-Miskovićev from Sremski Karlovci, wrote to Ministry of Defence of the Serbian Principality. He informed the authorities about a successful, quick and cheap cure for scurvy-pepper juice. A medical board headed by Dr. Vladan Dordević was formed to evaluate his discovery. Dr. Nikolić-Miskovićev was underestimated and laughed at, and his discovery was completely forgotten. The aim of this paper was to correct injustice done to Dr. Maksim Nikolić-Miskovićev.

Scurvy: forgotten but not gone

Scurvy is still seen sporadically in the developed world. At a time when subclinical vitamin C deficiency in the general population is being recognized increasingly, the need for clinicians to be aware of this disease remains. We present the case of a 9-year-old boy admitted to hospital with musculoskeletal pain, weakness and changes in the skin and gums. After extensive investigation, he was found to have vitamin C deficiency resulting from a restricted eating pattern. Musculoskeletal complaints are a common mode of presentation of scurvy in children. Failure to appreciate this fact and the risk factors for poor vitamin C intake in the paediatric age group can result in unnecessary and invasive investigations for apparent 'multisystem' disease.

[A case of scurvy with alveolar hemorrhage]

A 53-yr-old man with a history of chronic renal failure was admitted to the hospital of Hyogo College of Medicine on March 24th, 1999, because of severe continuous hemoptysis. On February 14th, 1999, the patient had undergone a cadaveric kidney transplantation in the urology department of another hospital. He did not experience any immunological reactions due to tissue rejection. On admission, subcutaneous bleeding at the site of an injection received 1 month before was noticed on his left arm. Petecheae of the extremities and a conjunctival hemorrhage were also noted. However, coagulation and fibrinolysis tests were essentially normal. These findings indicated that the hemorrhages were due to vessel weakness. Scurvy was diagnosed since his serum vitamin C was extremely low (0.2 microgram/ml). The patient was given ascorbic acid (1 g/day), and his condition improved dramatically. Ten years ago, the patient had had renal failure, which had been treated with chronic maintenance dialysis and dietary restriction. It has been postulated that a diet lacking in vitamin C or the steroid treatment he received after kidney transplantation may have induced the scurvy.

James Lind's Treatise of the Scurvy (1753)

Lind is revered as the first doctor to conduct systematic clinical trials of potential cures for scurvy-trials in which oranges and lemons came out as decisive winners. The following paper argues that our modern understanding of scurvy and vitamin C has hindered our understanding of Lind's own conception of his work and of the place within it of his clinical trials. Lind conceived of scurvy not as a disease of dietary deficiency, but of faulty digestion. In the full context of his Treatise of the Scurvy, and of his own medical practice, the seeming decisiveness of the trials fades, to be replaced by a sense of Lind's bafflement at the nature of the disease to which he had devoted his career.

Early scurvy complicating anorexia nervosa

Scurvy is an extremely rare complication of anorexia nervosa. Despite the poor intake of nutrients, anorexia nervosa is not commonly associated with vitamin deficiencies. We report a case of early scurvy complicating long-standing anorexia nervosa. Anorexia nervosa appears to be increasing in incidence. Although scurvy is unusual, this case shows the importance of its recognition as a nutritional consequence of anorexia nervosa.

Barlow's disease

The classical form of Barlow's disease or infantile scurvy, with bruises, broken bones and sores that will not heal, is rarely seen today, but it seems to be reappearing under a different guise, when infants with borderline vitamin C depletion are assaulted with too many inoculations at one time.Moreover, it is now sometimes mistakenly diagnosed as child abuse.

[Axel Holst and Theodor Frolich--pioneers in the combat of scurvy]

Axel Holst (1860-1931), professor of hygiene and bacteriology at the University of Oslo and paediatrician Theodor Frølich (1870-1947) became interested in a disease termed "ship beriberi" which afflicted the crews of sailing ships, and which showed an uncanny likeness to scurvy. They suspected a nutritional deficiency, and established an animal model that allowed systematic study of factors that led to disease as well as the preventive value of different substances. The choice of the guinea pig as the experimental animal for these studies was one indeed fortuitous, as that species has been shown to be among the very few mammals incapable of endogenous synthesis of ascorbic acid. They found that the guinea pigs developed distinctly scurvy-like symptoms when fed a diet consisting of various types of grain either whole or baked into bread, and that these symptoms were prevented when the diet was supplemented with known antiscorbutics like fresh cabbage or lemon juice. Their findings were published in 1907 in the Journal of Hygiene, but caused scientific uproar since the concept of nutritional deficiencies was a novelty at the time. The crucial factor, Vitamin C, was discovered in 1930 by Albert Szent-Györgyi, for which he was rewarded the Nobel Prize. No prizes or proper recognition were awarded Holst and Frølich at the time. It took some 60 years before they due acclaim was given to them; the 1907 paper by Holst and Frølich is now considered the most important single contribution to elucidating the aetiology of scurvy.

Scurvy mimicking systemic vasculitis

An 91 years old woman was hospitalized because of lethargy, shortness of breath and diffuse subcutaneous hemorrhage of legs. Clinical features were consistent with the diagnosis of vasculitis with systemic involvement. However dermatologic characteristics of the legs, in association with malnutrition, suggested vitamin C deficiency which was confirmed by laboratory test. Ascorbic acid supplement dramatically improved her clinical symptoms. This case remarks how scurvy may mimmick a systemic vasculitis.

An orange a day keeps the doctor away: scurvy in the year 2000

Scurvy has been known since ancient times, but the discovery of the link between the dietary deficiency of ascorbic acid and scurvy has dramatically reduced its incidence over the past half-century. Sporadic reports of scurvy still occur, primarily in elderly, isolated individuals with alcoholism. The incidence of scurvy in the pediatric population is very uncommon, and it is usually seen in children with severely restricted diets attributable to psychiatric or developmental problems. The condition is characterized by perifollicular petechiae and bruising, gingival inflammation and bleeding, and, in children, bone disease. We describe a case of scurvy in a 9-year-old developmentally delayed girl who had a diet markedly deficient in vitamin C resulting from extremely limited food preferences. She presented with debilitating bone pain, inflammatory gingival disease, perifollicular hyperkeratosis, and purpura. Severe hypertension without another apparent secondary cause was also present, which has been previously undescribed. The signs of scurvy and hypertension resolved after treatment with vitamin C. The diagnosis of scurvy is made on clinical and radiographic grounds, and may be supported by finding reduced levels of vitamin C in serum or buffy-coat leukocytes. The response to vitamin C is dramatic. Clinicians should be aware of this potentially fatal but easily curable condition that is still occasionally encountered among children.

[Diagnostic image (40). Scurvy]

In a 17-year-old woman with anorexia nervosa, scurvy was diagnosed as the cause of fatigue, abdominal pain, vaginal bleeding and several distinctive skin lesions.

Scurvy in capybaras bred in captivity in Argentine

In order to determine if the absence of vitamin C in the diet of capybaras (Hydrochoerus hydrochaeris) causes scurvy, a group of seven young individuals were fed food pellets without ascorbic acid, while another group of eight individuals received the same food with 1 g of ascorbic acid per animal per day. Animals in the first group developed signs of scurvy-like gingivitis, breaking of the incisors and death of one animal. Clinical signs appeared between 25 and 104 days from the beginning of the trial in all individuals. Growth rates of individuals deprived of vitamin C was considerably less than those observed in the control group. Deficiency of ascorbic acid had a severe effect on reproduction of another population of captive capybaras. We found that the decrease in ascorbic acid content in the diet affected pregnancy, especially during the first stages. The results obtained suggest that it is necessary to supply a suitable quantity of vitamin C in the diet of this species in captivity.

Vitamin C deficiency in guinea pigs differentially affects the expression of type IV collagen, laminin, and elastin in blood vessels

Vitamin C deficiency causes morphologic changes in the endothelial and smooth muscle compartments of guinea pig blood vessels. Endothelial cells synthesize the basement membrane components, type IV collagen and laminin, and smooth muscle cells synthesize elastin in blood vessels. Therefore, we examined the possibility that vitamin C deficiency affects the expression of these proteins. Decreased expression of types I and II collagens in other tissues of vitamin C-deficient guinea pigs is associated with weight loss and the consequent induction of insulin-like growth factor binding proteins; thus we also used food deprivation to induce weight loss. Female guinea pigs received a vitamin C-free diet, supplemented orally with ascorbate. Vitamin C-deficient guinea pigs received the same diet but no ascorbate, and the food-deprived group received no food, but were supplemented with vitamin C. Concentrations of mRNAs for basement membrane components and elastin in blood vessels were measured by Northern blotting; overall basement membrane metabolism was assessed by measuring immunoreactive laminin and type IV 7S collagen in serum. Laminin mRNA in blood vessels and serum laminin concentrations were unaffected by vitamin C deficiency. Concentrations of type IV collagen and elastin mRNAs in blood vessels were not significantly affected in moderately scorbutic guinea pigs (0-7% weight loss), but with increased weight loss, type IV collagen mRNA was 57% (P < 0.05) and elastin mRNA was 3% (P < 0. 01) of normal values. In food-deprived guinea pigs, type IV collagen mRNA was 51% (P < 0.05) and elastin mRNA was 35% (P < 0.05) of normal. Serum type IV 7S collagen concentrations were 25% of normal in scorbutic guinea pigs with extensive weight loss. The lower expression of type IV collagen and elastin mRNAs in blood vessels may contribute to defects observed in blood vessels during scurvy.

Expression of rat gene for L-gulono-gamma-lactone oxidase, the key enzyme of L-ascorbic acid biosynthesis, in guinea pig cells and in teleost fish rainbow trout (Oncorhynchus mykiss)

The ability of rainbow trout liver and kidney preparations to produce L-ascorbic acid with an added source of L-gulono-gamma-lactone oxidase (GLO) and the absence of their own GLO activity suggested that the reason for the absence of L-ascorbic acid biosynthesis in fish and in guinea pig, a scurvy-prone mammal, can be similar. Nevertheless, results of rat GLO cDNA expression in guinea pig cells and in rainbow trout proved different. In guinea pig cells, rat GLO was expressed in a functional form. Regardless of recombinant GLO transcripts detected in rainbow trout embryos, alevins and in juvenile fish, neither GLO protein nor GLO activity were found. Furthermore, production of L-ascorbic acid in transgenic rainbow trout was not revealed in feeding tests with vitamin C-free diets or after direct administration of L-gulono-gamma-lactone. These results indicate that conditions required for translation or stability of rat GLO are absent in rainbow trout tissues.

[The "Limophōros": Polybius III, 87, 2]

The word "limophōros", a hapax legomenon appearing in Polybius' Histories, does not mean scurvy, but rather scabies. Polybius created the word to describe an illness he believed was derived from a nutritional deficit, but can really only be seen as an attempt to describe an illness the etiology of which he was wholly unfamiliar.

Hyperglycemia-induced latent scurvy and atherosclerosis: the scorbutic-metaplasia hypothesis

Latent scurvy is characterized by a reversible atherosclerosis that closely resembles the clinical form of this disease. Acute scurvy is characterized by microvascular complications such as widespread capillary hemorrhaging. Vitamin C (ascorbate) is required for the synthesis of collagen, the protein most critical in the maintenance of vascular integrity. We suggest that in latent scurvy, large blood vessels use modified LDL--in particular lipoprotein(a)--in addition to collagen to maintain macrovascular integrity. By this mechanism, collagen is spared for the maintenance of capillaries, the sites of gas and nutrient exchange. The foam-cell phenotype of atherosclerosis is identified as a mesenchymal genetic program, regulated by the availability of ascorbate. When vitamin C is limited, foam cells develop and induce oxidative modification of LDL, thereby stabilizing large blood vessels via the deposition of LDL. The structural similarity between vitamin C and glucose suggests that hyperglycemia will inhibit cellular uptake of ascorbate, inducing local vitamin C deficiency.

[Scurvy, a serious and rare form of avitaminosis, easily diagnosed and treated. Presentation of a case]

We report a 66 years-old man case that was admitted with abdominal wall hemorrhagic swelling ecchymosis on inferior extremities and perifollicular purpura with hyperkeratosis of the follicles, which gives it an appearance of palpable purpura, together with gingival hemorrhage and moderate anemia. He was a well-nourished sick man but who made a peculiar diet, practically free from fruit and vegetables which developed a pure and serious form of scurvy. We report this case because we consider that the features which appear are illustrative to provide the immediate clinical diagnosis of this uncommon disease, potentially mortal, but easy to diagnose, if we think about it in the adequate clinical contexts, and which it is quickly curable with the administration of ascorbic acid.

[Scurvy with simultaneous wet beriberi in 2 patients]

Two patients developed the clinical picture of scorbut and simultaneous wet beriberi. The diagnosis was confirmed by low concentrations of ascorbic acid and thiamin and thiaminfosfate-ester in serum and in whole blood. Treatment with ascorbic acid led to a rapid reversal of scorbutic changes, but the changes due to the wet beri-beri persisted. Thiamine supplementation was given only perorally in the first patient, and a severe catabolic state in the other delayed the improvement in the beriberi. Direct determination of ascorbic acid and thiamin and thiaminfosfate-esters in serum and in whole blood may confirm the diagnosis of vitamin deficiencies.

[Scurvy--a mistakenly forgotten disease]

Four cases of scurvy diagnosed within a period of two years are reported. They comprised 2 male patients with heavy nicotine and alcohol abuse, a 35-year-old woman with malnutrition due to food supplements phobia, and a 69-year-old woman with malnutrition due to dementia and social isolation. All four patients were adynamic and anemic. Three patients showed typical dermatologic signs with hemorrhagic hyperceratosis, suffusions or cork-screw hair. Two patients complained of parodontol disorders. Other symptoms were gastrointestinal bleeding, sicca syndrome, retinal bleeding, subdural hematoma, edema and arthralgia. Associated disorders were folic acid and vitamin B12 depletion in two cases, and nephropathy and pneumonia with pneumothorax in one case each. In all cases the serum asorbic acid concentration was below the scorbutic level of 11 mumol/l. Historical data, pathogenesis, incidence, clinical presentation, diagnosis and therapy of scurvy are discussed. We conclude that scurvy can be observed even in a developed country such as Switzerland at the end of the 20th century. The real incidence may be underestimated because symptoms are not well known and disappear rapidly after admission because of sufficient vitamin C content in normal diet. Patients at risk are socially isolated alcoholics, old people, psychiatric patients and diet enthusiasts. Usually scurvy occurs in conjunction with other deficiencies. Smoking and acute illness enhance ascorbic acid depletion. With a knowledge of the symptomatology of scurvy, it is easy to diagnose and treatment is simple and effective.

[Scurvy after a suicide attempt by starvation]

A 29-year-old man was admitted to hospital, unconscious and with extensive bleedings in skin and muscles. For many weeks he had been practically starving himself with suicidal intent. Physical examination revealed signs of anaemia and gingivitis with hypertrophy of the tooth borders and bleeding gums, as well as bright blood on rectal examination. There were extensive ecchymoses and petechiae, especially in the legs. Some of the body hair was corkscrew-curly. Haemoglobin level was 7.2 g/dl, mean corpuscular volume 93 fl, reticulocyte count 29/1000. The Rumpel-Leede test was abnormal (60 petechiae/4 cm2), as were the vitamin C level (0.026 mg/dl whole blood) and the ascorbic acid tolerance test. As these findings indicated scurvy, vitamin C was administered, 1 g daily intravenously for 5 days, followed by 500 mg daily by mouth. Remarkable improvement was apparent as early as 72 hours after onset of treatment. The endogenous depression, the underlying cause of the suicide attempt, was treated with clomipramine. When the patient was discharged after 13 days his physical and mental state was much improved.

A case of scurvy presenting with cutaneous and articular signs

This report is on a patient, who presented purpura and hemarthrosis in a context of vitamin C deficiency. This case gives us the opportunity to discuss the differential diagnosis, the clinical features, the pathogenicity and the treatment of this rare condition.

Scurvy in a nonalcoholic person in the United States

Scurvy is rarely diagnosed in our society today. The authors describe the case of a 31-year-old man with weakness, gingival pain, and a rash over the lower extremities. He had a history of poor nutritional intake, no alcohol consumption, and a 13 pack-year history of cigarette smoking. Laboratory studies revealed an extremely deficient serum ascorbic acid level. Treatment was begun with oral ascorbic acid tablets and, within 3 days after discharge, all clinical symptoms of scurvy had resolved. Scurvy is an easily treated disease and should be considered when there is an appropriate history and classic clinical findings. Because vitamin C deficiency can be seen in many chronic disease states, it is important to recognize some of the early features and clinical manifestations of such nutritional deficiencies.

[Scurvy from self-imposed diet]

Scurvy, a rare disease, is still found today in malnourished patients. We recently diagnosed a case of scurvy in a 64-year-old woman resulting from a self-imposed diet. She had severe anemia and the characteristic gingival and skin lesions, which responded dramatically to ascorbic acid therapy. We report this case to make physicians aware of the possibility of scurvy and of its clinical symptoms.

[Rickets- and/or scurvy-like bone lesions in beta-thalassemia major]

Recently, a new type of skeletal lesions has been described in Cooley's anemia as a possible complication secondary to therapy. In 12 children affected with thalassemia major, who received an intensive transfusional regimen combined with continuous iron chelation therapy (desferoxamine-B: 50-80 mg/kg/day), some radiological abnormalities of the long bones were observed similar to those described in rickets and scurvy. These rickets and/or scurvy-like lesions had never been reported before the introduction of high-dose desferoxamine therapy. The pathogenesis of these lesions is uncertain, but the toxic effect of desferoxamine probably plays an important role in their development. The association of growth retardation and rickets and/or scurvy-like skeletal lesions in Cooley's anemia patients may be used as a valuable clinical criterion in long-term chelation management.