[A case of scurvy occurring during prolonged hospitalization]

A case of scurvy during prolonged stay in hospital is presented. Symptoms and treatment of manifest scurvy and prophylactic therapy are discussed.

Epidemiological patterns of scurvy among Ethiopian refugees

In the Horn of Africa, scurvy is a serious public health problem for refugees who are dependent on standard relief food (cereals, legumes, and oil). To assess the risk factors and to quantify the potential magnitude of scurvy among these displaced communities, we reviewed data collected from 1985 to 1987 by relief programmes in five refugee camps in Somalia and one in the Sudan. Outbreaks of clinical scurvy occurred among refugees in all the camps from 3 to 4 months after their arrival. The incidence of scurvy in two camps was, respectively, 14% over a period of 4 months and 19.8% over a period of 18 months. Prevalences of scurvy estimated from random population samples in the six study camps ranged from 13.6% to 44%. The risk of developing scurvy increased significantly with the length of time that refugees had been in the camps and was also significantly higher among those who were older and among females, particularly those of childbearing age. The prevalence of scurvy among refugees was similar, irrespective of whether or not they had attended supplementary feeding programmes. The control measures that were implemented had a moderate and slow impact on the disease. In both Somalia and the Sudan the relief food distributed to the refugees was almost completely deficient in vitamin C, while the environment where the camps were located precluded an adequate supply of fresh food. To avoid scurvy among refugee communities in this area of Africa it is therefore recommended that vitamin C supplements be added to the relief food at an early stage of a crisis.

Severe hypovitaminosis C occurring as the result of adoptive immunotherapy with high-dose interleukin 2 and lymphokine-activated killer cells

Adoptive immunotherapy of human cancer was investigated in our institution as part of a National Cancer Institute extramural group study. This treatment, for patients with metastatic malignant melanoma, hypernephroma, and colon carcinoma, consisted of three phases: (a) 5 days of i.v. high-dose (10(5) units/kg every 8 h) interleukin 2, (b) 6 1/2 days of rest plus leukapheresis; and (c) 4 days of high-dose interleukin 2 plus three infusions of autologous lymphokine-activated killer cells. Toxicities included fever, chills, tachycardia, hypotension, vomiting, diarrhea, and fluid retention. Ascorbic acid is known to be important to cell-mediated immunity, and it has been reported to be depleted during physiologically stressful events. Therefore, we determined plasma ascorbic acid levels in patients (n = 11) before adoptive immunotherapy and before and after Phases 1, 2, and 3 of treatment. Patients entering the trial were not malnourished. Mean plasma ascorbic acid levels were normal (0.64 +/- 0.25 mg/dl) before therapy. Mean levels dropped by 80% after the first phase of treatment with high-dose interleukin 2 alone (0.13 +/- 0.08 mg/dl). Mean plasma ascorbic acid levels remained severely depleted (0.08 to 0.13 mg/dl) throughout the remainder of the treatment, becoming undetectable (less than 0.05 mg/dl) in eight of 11 patients during this time. Values obtained from 24-h urine collections on two of two patients indicated that ascorbate was not excreted in the urine. Plasma ascorbic acid normalized in three of three patients tested 1 mo after the completion of treatment. Unlike the results for ascorbic acid, blood pantothenate and plasma vitamin E remained within normal limits in all 11 patients throughout the phases of therapy. Responders (n = 3) differed from nonresponders (n = 8) in that plasma ascorbate levels in the former recovered to at least 0.1 mg/dl (frank clinical scurvy) during Phases 2 and 3, whereas levels in the latter fell below this level.

Diabetic renal disease: differences between Asian and white patients

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Vitamin C: the nontoxic, nonrate-limited, antioxidant free radical scavenger

The amount of oral ascorbic acid that a patient can tolerate without diarrhea, increases somewhat proportionately to the "toxicity" of his disease. Clinically, in a disease ameliorated by ascorbate, there is a suppression of symptoms only with very high doses and approximately to that extent which a nonrate-limited, antioxidant free radical scavenger, might be expected to affect that disease process if all harmful free radicals and highly reactive oxidizing substances were quenched. In most pathologic processes, the rate at which free radicals and highly reactive oxidants are produced, exceeds the rate at which the ordinary rate-limited antioxidant free radical scavenging mechanisms can quench those free radicals and oxidants. When ascorbate acts as a scavenger, dehydroascorbate is formed; but if the ascorbate/dehydroascorbate (AA/DHA) ratio is kept high (the redox potential kept reducing) until the unstable dehydroascorbate undergoes hydrolysis or can be reduced back to ascorbate, the dehydroascorbate will do no harm. Since even at very high doses, ascorbate is virtually nontoxic, it may be given in the enormous doses necessary to quench almost all unwanted free radicals and oxidants. The wide spectrum of infectious diseases ameliorated by massive doses of ascorbate indicates some common pathologic processes in these diseases.

Scurvy. A case caused by peculiar dietary habits

A 9-year-old girl had the insidious development of lethargy, gingival erosions, and follicular hyperkeratosis with perifollicular hemorrhage. A dietary history disclosed that she consumed only one kind of sandwich and beverage and took no other foods. A skin biopsy specimen was consistent with the diagnosis of scurvy, and marked improvement occurred with ascorbic acid therapy. Although it is an uncommon disorder in the United States, scurvy may occur in persons with prolonged and peculiar dietary habits.

Vitamin C, oral scurvy and periodontal disease

Scurvy and periodontitis both manifest gingival bleeding but constitute separate entities. Defective collagen in scurvy reflects many symptoms emanating from deficient vitamin C physiology. The various periodontal diseases are caused by oral plaque micro-organisms, the body's reaction to which is strongly influenced by inadequate functioning of leucocytes and monocytes. Although certain infections and systemic diseases cause gingival bleeding, avitaminosis C does not cause commonly encountered periodontal disease, but will aggravate established periodontitis. Vitamin C should not be used for prophylaxis or cure of periodontitis in healthy well-nourished individuals. A patient with bleeding gingivae warrants referral to oral medicine and periodontics specialists for examination and treatment.

Cancer: a simple metabolic disease?

Recent studies on the effects of the essential fatty acid metabolic intermediate, gamma-linolenic acid, on the growth of cancer cells in culture and on induced mammary cancer tumours in rats, strongly suggest that the metabolic defect in the cancer cells studied is simply a metabolic block involving the enzyme delta-6-desaturase. The latter enzyme is responsible for the conversion of linoleic acid to gamma-linolenic acid. These observations would suggest that cancer in the cell lines studied could be a relatively simple metabolic disease.

Scurvy: old disease--new insight

Scurvy was once the number one killer of seafarers on long voyages. One early theory with widespread acceptance was that rancid fat caused scurvy. I propose to show that rancid fat did, indeed, predispose seafarers to scurvy. I propose to show that Captain Cook's successful voyages in the latter half of the eighteenth century were in part due to removal of rancid fat from the diet of his crew and in part due to dietary anti-scorbutic factors.

Vitamin C: from scurvy to the common cold

Vitamin C (ascorbic acid) has been known to prevent scurvy for many years. Recent research has shown its importance in lipid and iron metabolism. Vitamin C may also have some effect on the immune system. There is not as yet conclusive evidence that ascorbic acid may cure or prevent colds or cancer. The vitamin has few side effects even when ingested in large quantities. Several methods for analysis of ascorbic acid have been developed. These include titration and fluorometric methods, a ferrozine technique automated for centrifugal analyzers, a high performance liquid chromatography method, and a dip-stick for urine ascorbic acid.

Bachelor scurvy

Scurvy occurred in an elderly man with fatigue, dyspnea on exertion, and extensive ecchymoses and brawny edema of the legs. Platelet count, prothrombin time, and partial thromboplastin time were normal, but serum ascorbic acid level was very low. Other signs considered to be classic and almost pathognomonic for were absent: bleeding gums, hyperkeratotic follicles, coiled hairs, and perifollicular hemorrhages. Reliance on these well-known features of scurvy may obscure or delay diagnosis of an easily cured disorder Severe scurvy is most commonly suggested by tenderness, extensive ecchymoses, and brawny edema of the lower extremities.

Thomas Crawford, regimental medical officer in the Crimea, 1855

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Adult scurvy

Scurvy was diagnosed in two elderly alcoholic men in our emergency department. Both were ambulatory and had perifollicular petechiae and ecchymoses of the lower extremities and hypertrophic erythematous gingival lesions. There diets were deficient in fresh fruits and vegetables. Treatment with oral ascorbic acid resulted in dramatic resolution of the signs and symptoms. The first patient was admitted to the hospital, where extensive diagnostic studies failed to reveal other etiological explanations for the cutaneous lesions. The second patient was successfully treated as an outpatient.

The formation of collagen and its relation to ophthalmic diseases (second of two parts)

In this second part of the review the chemical abnormalities that have resulted in the formation of detective collagen and consequent disease of the eye are indicated. The cardinal findings for each disease are noted. Certain changes, such as ageing, that relate to collagen are also discussed.

Scurvy resulting from a self-imposed diet

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Scurvy and vitamin C deficiency in Crohn's disease

A case of scurvy presenting in a patient with Crohn's disease is reported. A normal response to replacement therapy is seen. Vitamin C (ascorbic acid) deficiency was found in 7 out of 10 patients with clinically quiescent Crohn's disease, 4 of whom had an adequate oral intake of vitamin C. There was no significant difference in oral intake between patients with Crohn's disease and matched controls but there was a significant difference (P less than 0.001) in leucocyte ascorbic acid levels. It is recommended that patients with Crohn's disease be screened for vitamin C deficiency and receive prophylactic vitamin C supplements daily.

[Scurvy in an adult]

The case is reported of a 29-year-old previously healthy female patient who developed the typical clinical picture of scurvy eight months after changing to a diet exclusively containing cooked cereals. Serum levels of B12, folic acid, and calcium were lowered and the alkaline phosphatase was slightly raised due to the dietary lack of vitamins A, D, B12 and folic acid. No clinical signs of these deficiencies could be observed. Addition of vitamin C to this diet resulted in complete cure in a matter of days. Signs and symptoms of scurvy are discussed in the light of the recent literature. This rare disease is particularly worth considering if one of the following situations is encountered: hemorrhages in the skin, muscles, joints or mucous membranes without apparent cause; therapy-resistant ulcers of mucous membranes in elderly patients; Sicca syndrome and/or wounds exhibiting poor healing.

Gastroesophageal reflux and ascorbic acid insufficiency

The incidental discovery of scurvy in a patient with a symptomatic hiatal hernia has led to the identification of 9 other individuals with chemically proved vitamin C deficiency secondary to an expressed aversion to "acid" food in any form. These patients were screened with capillary fragility tests and serum ascorbic acid determinations from approximately 200 hiatal hernia and reflux patients. With resumption of a normal vitamin C intake, scattered deficiency symptoms disappeared and both capillary fragility tests and serum ascorbic acid levels returned toward normal. There were no wound healing problems.

Nonscorbutic effects of vitamin C: biochemical aspects

There is a certain presumptive evidence for believing than AA has functions other than the simple prevention of classical scurvy; whether these extra-antiscorbutic functions are attributable to AA itself, or to one or more of its metabolites, is not known. Tissue saturation with AA would appear to provide a good insurance against defects in these extra-antiscorbutic areas. ttissue saturation is attainable by a daily intake of 100-150 mg in man; there are no compelling reasons for using megadoses of AA and the emphasis should be on the avoidance of chronic hypovitaminosis C. There is suggestive evidence that megadoses of AA could be physiologically disadvantageous--particularly with regard to in-utero exposure and in persons exposed to high environmental levels of toxic metals.

Influence of ascorbic acid on selenium nutrition in the chick

Experiments were conducted to determine the nature of the effect of dietary ascorbic acid on selenium nutrition in the chick. Results showed that ascorbic acid resulted in increased activities of the selenium-containing enzyme glutathione peroxidase in plasma, accompanied by an apparent reduction in the dietary selenium requirement of the vitamin E-deficient chick. The ascorbic acid contents of plasma, liver, kidney and adrenals were not affected by selenium or vitamin E deficiencies, indicating that selenium-vitamin E deficient chicks are not rendered scrobutic. Absorption experiments using ligated duodenal loops or oral doses indicated that dietary ascorbic acid promoted the enteric absorption of selenium but did not affect the absorption of vitamin E. These results support the hypothesis previously reported that factors which inhibit the oxidation of dietary selenium promote its absorption and, perhaps, its post-absorptive utilization in metabolically active components of the cell.

Immunologic evidence that the gene for L-gulono-gamma-lactone oxidase is not expressed in animals subject to scurvy

L-Gulono-gamma-lactone oxidase (L-gulono-gamma-lactone:oxygen 2-oxidoreductase, EC 1.1.3.8) is the enzyme that catalyzes the terminal step of L-ascorbic acid biosynthesis in mammalian liver. The absence of the oxidase activity in primates and guinea pigs is the reason why these animals are subject to scurvy, which must be considered an inborn error of metabolism. Attempts were made to determine if a protein immunologically crossreactive with L-gulono-gamma-lactone oxidase is present in these animals. Detergent-solubilized microsomal preparations from guinea pig and African green monkey liver did not precipitate the antisera directed to either rat or goat enzyme, nor did any of the other cell fractions obtained from guinea pig liver react with either antiserum. No crossreactive protein was detectable in guinea pig microsomes even with the sensitive procedure or micro-complement fixation. On the other hand, extracts of all 10 other mammalian (4 orders) liver microsomes tested were shown to contain L-gulono-gamma-lactone oxidase activity that did crossreact with antibodies to the rat and goat enzymes. One explanation of these findings is that, in the guinea pig, and perhaps in primates too, the structural gene for L-gulono-gamma-lactone oxidase is not expressed.

Metabolism of ascorbic acid and ascorbic-2-sulfate in man and the subhuman primate

Man does not catabolize ascorbate to CO2, whereas the monkey does catabolize ascorbate and ascorbate sulfate to CO2 when these compounds are given orally. However, it takes the same length of time to produce frank scurvy in both man and the monkey, thus indicating that the comparative storage, rate of use, and mode of metabolism of ascorbate is similar in both species. Preliminary feeding and isotope studies conducted on monkeys are in agreement with the fact that only a small amount of labeled ascorbate or ascorbate sulfate equilibrated with body stores. These results are in agreement with published ascorbic acid requirements of 10 mg/kg body weight. In our experiments, 250 mg/day had to be fed to a 10-kg monkey to completely clear all signs of scurvy and return blood ascorbate levels to normal. Ascorbic acid administered intravenously to monkeys appears to equilibrate completely with the ascorbate pool(s). Ascorbate sulfate was found to be a urinary metabolite of both ascorbic-1-14C acid and ascorbic-6-14C acid fed orally to monkeys.