Scurvy: historical review and current diagnostic approach

High prevalence of adult and nonadult scurvy in an early agricultural transition site from Mainland Southeast Asia was associated with decreased survivorship

OBJECTIVES

The osteological paradox recognizes that the presence of lesions is not always directly related with increased mortality. When combined with the clinical, historical, and epidemiological literature on scurvy, survivorship analysis, a form of statistical analysis to assess the relationship between the presence of diseases in the archeological record and survival, helps determine the overall burden of the disease both in terms of morbidity and mortality. This article explores the relationship between scurvy and survivorship in 26 adults from Man Bac, a Neolithic site from northern Vietnam together with prepublished evidence of scurvy in the nonadult population (n = 44).

METHODS

Diagnosis of scurvy included differential diagnosis combined with the Snoddy, A. M. E., Buckley, H. R., Elliott, G. E., Standen, V. G., Arriaza, B. T., & Halcrow, S. E. (2018). Macroscopic features of scurvy in human skeletal remains: A literature synthesis and diagnostic guide. American Journal of Physical Anthropology, 167(4), 876-895. https://doi.org/10.1002/ajpa.23699 threshold criteria and the Brickley, M. B., & Morgan, B. (2023). Assessing diagnostic certainty for scurvy and rickets in human skeletal remains. American Journal of Biological Anthropology, 181, 637-645 diagnostic certainty approaches. Kaplan-Meier survival curves were produced to assess the relationship between the presence of probable scurvy and age-at-death.

RESULTS

The prevalence of probable scurvy in adults (35%) was considerably lower than reported for the nonadults (80%). Almost all lesions observed in the adults were in a mixed stage of healing. Kaplan-Meier analysis demonstrated no difference in survivorship between infants and children (<15 years) with or without probable scurvy, whereas a meaningful difference was observed for the adults and adolescents (15+ years).

CONCLUSIONS

The findings demonstrate that scurvy considerably decreased survivorship to older age categories. The degree of lesion remodeling, however, indicates that scurvy was not necessarily the direct cause of death but contributed to an overall disease burden that was ultimately fatal.

Scurvy presenting in a homeless 32-year-old male: a case report

Vitamin C deficiency, otherwise known as scurvy, is one the oldest known diseases. Although its prevalence has substantially diminished, certain populations such as smokers, alcoholics, elderly, and those with malabsorptive syndromes remain at risk. Deficiency presents with perifollicular hemorrhage, corkscrew hairs, and petechiae that can evolve into ecchymoses and purpura. Diagnosis starts with clinical suspicion and is confirmed with plasma and leukocyte ascorbic acid levels. Early suspicion is key. Treatment with vitamin C offers an excellent prognosis and avoids unnecessary workup for differential diagnoses. In our case, a 45-year-old male alcoholic with progressively worsening symptoms was found to have scurvy. Treatment was initiated with vitamin C supplementation, and he had remarkable improvement in his symptoms within weeks. This case demonstrates that scurvy is not a disease of history and must be considered in modern medicine, especially as homelessness with concomitant poor nutrition continues to increase.

Optimization of Sirius Red-Based Microplate Assay to Investigate Collagen Production In Vitro

Tissue fibrosis is characterized by chronic fibroblast activation and consequently excessive accumulation of collagen-rich extracellular matrix. In vitro microplate-based assays are essential to investigate the underlying mechanism and the effect of antifibrotic drugs. In this study, in the absence of a gold-standard method, we optimized a simple, cost-effective, Sirius Red-based colorimetric measurement to determine the collagen production of fibroblasts grown on 96-well tissue culture plates. Based on our findings, the use of a serum-free medium is recommended to avoid aspecific signals, while ascorbate supplementation increases the collagen production of fibroblasts. The cell-associated collagens can be quantified by Sirius Red staining in acidic conditions followed by alkaline elution. Immature collagens can be precipitated from the culture medium by acidic Sirius Red solution, and after subsequent centrifugation and washing steps, their amount can be also measured. Increased attention has been paid to optimizing the assay procedure, including incubation time, temperature, and solution concentrations. The resulting assay shows high linearity and sensitivity and could serve as a useful tool in fibrosis-related basic research as well as in preclinical drug screening.

Infantile scurvy as a consequence of agricultural intensification in the 1st millennium BCE Etruria Campana

The 1st millennium BCE in Italy was a time of agricultural intensification of staple cereal production which shaped sociocultural, political, and economic spheres of pre-Roman groups. The lifeways and foodways of the Etruscans, the greatest civilization in western Europe before Roman hegemony, are traditionally inferred from secondary written sources, funerary archaeology, archaeobotany, and zooarchaeology. However, no direct data extrapolated from the study of human skeletal remains are available to evaluate the extent to which agricultural intensification and decreased dietary diversity impacted health and the expression of skeletal indicators of metabolic disease. Macroscopic and radiological analyses were conducted on an archaeological skeletal sample of non-adults (n = 29) recovered from Pontecagnano (southern Italy) dating to the Orientalizing period (730-580 BCE). This allowed us to identify five cases of scorbutic non-adults and to assign diagnostic values to skeletal lesions of scurvy that have not been previously described in the literature. The onset of scurvy in the examined sample is related to the increased reliance of Etruscans on crops lacking vitamin C in this period of agricultural intensification. The skeletal expression of scurvy varied among the non-adults, with differences in location and disease severity; these were interpreted considering the age-at-death of the individuals coupled with feeding behaviors and interindividual variability.

Scurvy: Rediscovering a Forgotten Disease

Scurvy is a nutritional deficiency caused by low vitamin C levels that has been described since ancient times. It leads to a varied presentation, affecting multiple organ systems due to its role in the biochemical reactions of connective tissue synthesis. Common manifestations include gingival bleeding, arthralgias, skin discoloration, impaired wound healing, perifollicular hemorrhage, and ecchymoses. Although there has been a dramatic reduction in the prevalence of scurvy in modern times owing to vitamin C supplementation and intake, sporadic cases still occur. In developed countries, it is mainly diagnosed in the elderly and malnourished individuals and is associated with alcoholism, low socio-economic status, and poor dietary habits. Scurvy has been an unusual cause of gastrointestinal (GI) bleeding among other GI manifestations. It can be adequately treated and prevented via vitamin C supplementation.

Scurvy: A Diagnosis Not to Be Missed

Vitamin C deficiency, one of the oldest-known nutritional disorders, is now uncommon in high-income countries. Recently, however, there has been an increase in cases of vitamin C deficiency, also known as scurvy. We report three adult patients with histories of homelessness, food insecurity, and poor nutrition, making them particularly vulnerable to restrictive diets and at increased risk for scurvy. After proper diagnosis and treatment, favorable outcomes can be rapidly obtained. This case series emphasizes the importance of keeping a broad differential diagnosis and inquiring about nutritional history in patients presenting with purpura, gingival bleeding, and body hair changes.

Construction of a ratiometric fluorescence sensing platform based on DES-CDs/CoOOH/OPD system for ascorbic acid detection

Herein, a ratiometric fluorescence sensing platform based on deep eutectic solvent-carbon dots (DES-CDs) was constructed to efficiently determine ascorbic acid (AA). The CDs were synthesized by hydrothermal method using green...

Cribra orbitalia is correlated with the meningo-orbital foramen and is vascular and developmental in nature

Cribra orbitalia is a phenomenon with interdisciplinary interest. However, the etiology of cribra orbitalia remains unclear. Recently, the appearance of cribra orbitalia was identified as vascular in nature. This study assessed the relationship between anatomical variation of vasculature, as determined by the presence of meningo-orbital foramina, and the presence of cribra orbitalia in 178 orbits. Cribra orbitalia was identified in 27.5% (49:178) of orbits (22.7%, 35:154 adult orbits and 58.3%, 14:24 subadult orbits) and meningo-orbital foramina were identified in 65.8% (100:152) of orbits. Among the 150 total intact adult orbits (i.e., orbital roof and posterior orbits both intact), cribra orbitalia was found in 35 (23.3%). Of these 35 occurrences of cribra orbitalia, 32 (91.4%) had the concurrent finding of a meningo-orbital foramen. However, in the absence of the meningo-orbital foramen, cribra orbitalia was only found in three sides out of the total sample of intact orbits (3:150; 2.0%). Fisher's exact test revealed that the presence of cribra orbitalia and the meningo-orbital foramen were statistically dependent variables (p = .0002). Visual evidence corroborated statistical findings-vascular impressions joined cribra orbitalia to meningo-orbital foramina. This study identifies that individuals who possess a meningo-orbital foramen are anatomically predisposed to developing cribra orbitalia. Conversely, cribra orbitalia is unlikely to occur in an individual who does not possess a meningo-orbital foramen. Thus, the antecedent of cribra orbitalia is both vascular and developmental in nature. This report represents an important advancement in the understanding of cribra orbitalia-there is an anatomical predisposition to the development of cribra orbitalia.

Sustaining Astronauts: Resource Limitations, Technology Needs, and Parallels between Spaceflight Food Systems and those on Earth

Food and nutrition are critical to health and performance and therefore the success of human space exploration. However, the shelf-stable food system currently in use on the International Space Station is not sustainable as missions become longer and further from Earth, even with modification for mass and water efficiencies. Here, we provide a potential approach toward sustainability with the phased addition of bioregenerative foods over the course of NASA’s current mission plans. Significant advances in both knowledge and technology are still needed to inform nutrition, acceptability, safety, reliability, and resource and integration trades between bioregenerative and other food systems. Sustainability goals on Earth are driving similar research into bioregenerative solutions with the potential for infusion across spaceflight and Earth research that benefits both.

Scurvy: A Neglected Cause of Muscle Pain and Weakness in a Child With Picky Eating Behavior

Ascorbic acid (vitamin C) is an essential micronutrient that the human's body cannot synthesize endogenously. Scurvy, a disease of ascorbic acid deficiency, can manifest in a myriad of presentations. Due to its rarity in the modern world, scurvy is considered as a disease of the past. We present a paediatric case of scurvy with musculoskeletal manifestations as a result of picky eating behavior. 

We report a previously healthy nine-year-old boy who presented with unexplained progressive bilateral lower limb generalized weakness and pain for two months. All initial biochemical and radiological investigations were unremarkable. Upon further history taking, he had severe picky eating behavior which raised the suspicion of scurvy. The diagnosis was confirmed with a serum ascorbic acid test. After ascorbic acid supplementation, his symptoms resolved immediately. Further food behavioral modification counselling to his family members helped to change his diet in a lasting way. As a result, he had no recurrence of symptoms.

This case highlights the importance of having a high index of suspicion for an uncommon disease and emphasizes the need for a detailed dietary history upon patient’s presentation.

Scurvy, Starvation, and Flea Infestation - A Case Report From 21st Century Europe

Scurvy is a disease caused by vitamin C deficiency, historically associated with long sea voyages, periods of famine and war. Currently, it is often misdiagnosed and underreported, as physicians tend to consider it a disease of the past.

We present the case of a 79-year-old female who was admitted to the Emergency Department complaining of pruritus. The patient lived alone and in poor hygiene conditions. Diet was scarce. One week before admission she was in contact with flea-ridden stray dogs. Sometime later she noted several fleas and multiple pruritic small papules, crusts, and excoriations on her torso, limbs, palms, soles, and scalp. Physical examination showed the patient to be pale, emaciated, and poorly groomed. Laboratory analysis showed microcytic anemia. Flea bites were treated with oral antihistamines and prednisolone. Follow-up one month later showed weight gain and partial resolution of skin lesions. However, multiple small ecchymosis on both lower and upper limbs, and occasional perifollicular petechias on her lower extremities, were noted. Additional workup showed undetectable serum vitamin C levels. A diagnosis of scurvy was made. The patient was treated with 1000 mg per day of oral vitamin C for one month leading to complete recovery.

We present this case to remind that early recognition of vitamin C deficiency and appropriate supplementation are essential in patients with scurvy. Physicians should be aware of classic signs, symptoms, and social factors associated with this forgotten disease.

Scurvy: A Disease not to be Forgotten

An 18-year-old man presented to our hospital with muscular pain, diffuse petechiae, spontaneous thigh ecchymosis, edema and pain of the right knee, bilateral pretibial subcutaneous nodules, and gingival hypertrophy and hemorrhage. His history was positive for a mixed anxiety-depressive disorder and a restrictive diet caused by self-diagnosed food allergies. Skin lesions appeared like hyperkeratotic papules with coiled hairs and perifollicular hemorrhages. A diagnosis of scurvy was made upon demonstration of low serum levels of ascorbic acid. An allergy evaluation found cross-reactivity between pollens and food, related to the presence of panallergens. Moreover, we found that our patient was also affected by celiac disease. In conclusion, scurvy should be considered in the differential diagnosis of patients with petechiae and ecchymosis, especially when food restriction, malabsorption, or psychiatric disorders are present.

Scurvy presenting as lower limb ecchymoses in the setting of metastatic colorectal cancer

A 58-year-old woman presented with a 1-week history of lower limb bruising. She had a medical history of recurrent metastatic colon cancer with a sigmoid colectomy and complete pelvic exenteration leading to colostomy and urostomy formation. She had malignant sacral mass encroaching on the spinal cord. This caused a left-sided foot drop for which she used an ankle-foot orthosis. She was on cetuximab and had received radiotherapy to the sacral mass 1 month ago. On examination, there were macular ecchymoses with petechiae on the lower limbs. There was sparing of areas that had been compressed by the ankle-foot orthosis. Bloods showed mild thrombocytopaenia and anaemia with markedly raised inflammatory markers. Coagulation studies consistent with inflammation rather than disseminated intravascular coagulation. She was found to have Klebsiella bacteraemia secondary to urinary source. Skin biopsy showed dermal haemorrhage without vessel inflammation. Vitamin C levels were low confirming the diagnosis of scurvy.

End stage scurvy in the developed world: A diagnostic conundrum but not to be mistaken for pyoderma gangrenosum

Scurvy is a clinical syndrome, resulting from ascorbic acid deficiency. Prevalence of the condition is now extremely low in the Western population and its diagnosis can be challenging without a high index of suspicion. When cases do present, they are often misdiagnosed initially. Therefore, a thorough history, physical exam, and laboratory evaluation are key to showing this now rare but extremely well-known disease. We report a case of scurvy manifesting as persistent non-healing lower-extremity ulcerations, initially mistaken for pyoderma gangrenosum. The patient responded to appropriate replacement therapy, but ulcers were slow to heal. As was the case in our patient, symptom reversal may require additional nutritional replacement. We encourage physicians to consider nutritional deficiencies in their differential diagnoses and highlight the incidence of malnutrition in the proper clinical setting to avoid diagnostic delay.

Evidence of infectious disease, trauma, disability and deficiency in skeletons from the 19th/20th century correctional facility and asylum «Realta» in Cazis, Switzerland

As a reaction to widespread poverty, a system of coercive welfare developed in Switzerland during the 19^th century. Poverty was often thought to result from an individual’s misconduct rather than from structural, economic or political circumstances. People whose lifestyle deviated from the desired norm or who were unable to make a living for themselves were subjected to so-called administrative detention at institutions such as workhouses and poorhouses. The excavation of the cemetery of the correctional facility/workhouse and asylum «Realta» in Cazis offered the opportunity to gain insight into the living conditions of a marginalized group of people and to shed light on aspects of coercive welfare that have hardly been addressed in historical studies. A comprehensive study of pathological alterations was used to assess possible physical causes and effects of administrative detention. Skeletal samples from regular contemporaneous cemeteries provided data for the general population and thus allowed us to detect peculiarities in the «Realta» assemblage. Possible cases of Stickler Syndrome, microcephaly, congenital syphilis, endemic hypothyroidism and disabilities secondary to trauma may have been the reason for the affected individuals’ institutionalisation. The high prevalence of tuberculosis was linked to the socioeconomic status and the living conditions at the facility. Several cases of scurvy and osteomalacia may have resulted from various risk factors such as poverty, alcoholism, mental illness or institutionalisation. The fracture rates, especially of ribs, were extremely high. A large proportion of the fractures were incompletely healed and most likely occurred during detention due to interpersonal violence. Underlying diseases further contributed to the high fracture rates. This first study on skeletons from an institution of administrative detention in Switzerland demonstrated how pre-existing health conditions and the socioeconomic background contributed to the chance of being detained, and how detention led to further deterioration of health.

Vitamin C Can Shorten the Length of Stay in the ICU: A Meta-Analysis

A number of controlled trials have previously found that in some contexts, vitamin C can have beneficial effects on blood pressure, infections, bronchoconstriction, atrial fibrillation, and acute kidney injury. However, the practical significance of these effects is not clear. The purpose of this meta-analysis was to evaluate whether vitamin C has an effect on the practical outcomes: length of stay in the intensive care unit (ICU) and duration of mechanical ventilation. We identified 18 relevant controlled trials with a total of 2004 patients, 13 of which investigated patients undergoing elective cardiac surgery. We carried out the meta-analysis using the inverse variance, fixed effect options, using the ratio of means scale. In 12 trials with 1766 patients, vitamin C reduced the length of ICU stay on average by 7.8% (95% CI: 4.2% to 11.2%; p = 0.00003). In six trials, orally administered vitamin C in doses of 1⁻3 g/day (weighted mean 2.0 g/day) reduced the length of ICU stay by 8.6% (p = 0.003). In three trials in which patients needed mechanical ventilation for over 24 hours, vitamin C shortened the duration of mechanical ventilation by 18.2% (95% CI 7.7% to 27%; p = 0.001). Given the insignificant cost of vitamin C, even an 8% reduction in ICU stay is worth exploring. The effects of vitamin C on ICU patients should be investigated in more detail.

Scurvy, an old story in a new time: The hematologist's experience

BACKGROUND

Scurvy is a rare entity in developed countries and the diagnosis may often be delayed resulting in unnecessary investigations and/or potentially severe complications. A recent increase in the number of patients diagnosed with scurvy in our hematology clinics indicated the need to review the literature on the diagnosis and optimal management of similar patients.

METHODS

We conducted a retrospective chart review of patients referred to hematology at our tertiary care centre between 2010 and 2018, who were ultimately diagnosed with scurvy. Data collected from electronic medical records included baseline characteristics, clinical features on presentation, bloodwork results from initial consultation, treatment plan as well as response to treatment.

FINDINGS

Twenty-two adults patient had a diagnosis of scurvy with a mean vitamin C level of 6 μmol/L. Iron deficiency anemia (54%) and gastrointestinal disorders (54%) were the most common comorbidities noted in our cohort. Proton-pump inhibitors use was noted in 54% of patients. Bleeding (45%) and bruising (45%) were the most commonly reported clinical features. Eleven patients received oral supplementation, five had intravenous (IV) vitamin C and six were not treated. Two patients required a transition from oral to IV supplementation. Vitamin C dosing ranged between 250 and 2000 mg and the frequency varied from daily for oral therapy to every few weeks or months for IV.

INTERPRETATION

Awareness of scurvy and its associated risk factors and clinical presentation is important in the evaluation of a patient with bleeding tendency. Treatment plan should be individualized, and a careful review of patients' diet, medial history and medications is warranted.

From in planta Function to Vitamin-Rich Food Crops: The ACE of Biofortification

Humans are highly dependent on plants to reach their dietary requirements, as plant products contribute both to energy and essential nutrients. For many decades, plant breeders have been able to gradually increase yields of several staple crops, thereby alleviating nutritional needs with varying degrees of success. However, many staple crops such as rice, wheat and corn, although delivering sufficient calories, fail to satisfy micronutrient demands, causing the so called 'hidden hunger.' Biofortification, the process of augmenting nutritional quality of food through the use of agricultural methodologies, is a pivotal asset in the fight against micronutrient malnutrition, mainly due to vitamin and mineral deficiencies. Several technical advances have led to recent breakthroughs. Nutritional genomics has come to fruition based on marker-assisted breeding enabling rapid identification of micronutrient related quantitative trait loci (QTL) in the germplasm of interest. As a complement to these breeding techniques, metabolic engineering approaches, relying on a continuously growing fundamental knowledge of plant metabolism, are able to overcome some of the inevitable pitfalls of breeding. Alteration of micronutrient levels does also require fundamental knowledge about their role and influence on plant growth and development. This review focuses on our knowledge about provitamin A (beta-carotene), vitamin C (ascorbate) and the vitamin E group (tocochromanols). We begin by providing an overview of the functions of these vitamins in planta, followed by highlighting some of the achievements in the nutritional enhancement of food crops via conventional breeding and genetic modification, concluding with an evaluation of the need for such biofortification interventions. The review further elaborates on the vast potential of creating nutritionally enhanced crops through multi-pathway engineering and the synergistic potential of conventional breeding in combination with genetic engineering, including the impact of novel genome editing technologies.

Macroscopic features of scurvy in human skeletal remains: A literature synthesis and diagnostic guide

The past two decades have seen a proliferation in bioarchaeological literature on the identification of scurvy, a disease caused by chronic vitamin C deficiency, in ancient human remains. This condition is one of the few nutritional deficiencies that can result in diagnostic osseous lesions. Scurvy is associated with low dietary diversity and its identification in human skeletal remains can provide important contextual information on subsistence strategy, resource allocation, and human-environmental interactions in past populations. A large and robust methodological body of work on the paleopathology of scurvy exists. However, the diagnostic criteria for this disease employed by bioarchaeologists have not always been uniform. Here we draw from previous research on the skeletal manifestations of scurvy in adult and juvenile human skeletal remains and propose a weighted diagnostic system for its identification that takes into account the pathophysiology of the disease, soft tissue anatomy, and clinical research. Using a sample of individuals from the prehistoric Atacama Desert in Northern Chile, we also provide a practical example of how diagnostic value might be assigned to skeletal lesions of the disease that have not been previously described in the literature.

A Very Uncommon Case of Pulmonary Hypertension

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PH can sometimes be a challenging diagnosis.

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Echocardiography can assess RV overload and evaluate sudden changing in PASP.

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Although rare, scurvy should be part of an expanded differential diagnosis of PH.

Juvenile scurvy from Late Medieval Knin, Croatia

In this study, we examine the scurvy associated skeletal lesions among juveniles from the late Medieval site Uzdolje-Grablje in Croatia. The study aims to establish a demographic pattern of scurvy using existing diagnostic criteria. The sample consists of 16 well-preserved and fairly complete juveniles, excavated from a cemetery dating to 1420-1920. Skeletal remains were analyzed macroscopically for signs of porosity and new bone formation. Scurvy is diagnosed using the "Ortner criteria" of cranial and postcranial lesions. Depending on the location of the lesions, individuals were diagnosed with either scurvy or possible scurvy. Half of the individuals in our sample are diagnosed with scurvy, with additional 25% being diagnosed with possible scurvy. Along with porotic lesions, all individuals diagnosed with scurvy/possible scurvy showed new bone formation on at least one skeletal element. The occurrence of lesions associated with scurvy in our sample is unusually high. Instead of focusing solely on diet and insufficient intake of the vitamin C, a more likely explanation lies in the synergy between diet, exposure to infections, and the environment.

Scurvy: Dietary Discretion in a Developed Country

Although the causes have changed, scurvy (vitamin C deficiency) is still diagnosed in developed countries. We report a case of an 18-year-old female who presented to our emergency department with thrombocytopenia, sinus tachycardia, hypotension, fatigue, gingival hyperplasia, knee effusion, petechiae and ecchymosis in lower extremities. The differential diagnosis included hematologic abnormalities, infectious etiologies, vasculitis and vitamin deficiency. A brief dietary history was performed revealing poor fruit and vegetable intake, thus increasing our suspicion for vitamin C deficiency. This experience illustrates the importance of a dietary history and reminds us to keep scurvy in the differential diagnosis.

Carbon ceramic microelectrodes modified with buckyballs for simultaneous determination of redox-active biomolecules

In this report, simultaneous electrochemical determination of ascorbic acid (AA), dopamine (DA), uric acid (UA) and tryptophan (Trp) was achieved using buckyball-modified carbon ceramic microelectrodes (CCMEs). A concentration-dependent increase in anodic peak current signals was observed in comparison with those obtained at bare CCMEs. The optimal pH for simultaneous determination of a quaternary mixture of AA–DA–UA–Trp was determined to be pH 4. The peak separations for the mixture containing AA–DA–UA–Trp were well-defined at the scan rate of 50 mV s⁻¹. The catalytic peak current obtained was linearly dependent on the AA, DA, UA and Trp concentrations in the range of 6.0–600, 6.0–600, 6.0–600 and 4.0–440 μM, respectively. The detection limits for AA, DA, UA and Trp were also determined to be 1.64, 0.82, 0.36 and 1.22 μM, respectively. The analytical performance of this sensor has also been challenged for simultaneous electrochemical detection of AA, DA, UA and Trp in real samples.

In this report, simultaneous electrochemical determination of ascorbic acid (AA), dopamine (DA), uric acid (UA) and tryptophan (Trp) was achieved using buckyball-modified carbon ceramic microelectrodes (CCMEs).

Scurvy at the agricultural transition in the Atacama desert (ca 3600-3200 BP): nutritional stress at the maternal-foetal interface?

Studies of contemporary populations have demonstrated an association between decreased dietary diversity due to resource scarcity or underutilization and an increase in diseases related to poor micronutrient intake. With a reduction of dietary diversity, it is often the women and children in a population who are the first to suffer the effects of poor micronutrient status. Scurvy, a disease of prolonged vitamin C deficiency, is a micronutrient malnutrition disorder associated with resource scarcity, low dietary diversity, and/or dependence on high carbohydrate staple-foods. The aim of this paper is to assess the potential impact of nutritional transition on the prevalence of diseases of nutritional insufficiency in an archaeological sample. Here, we report palaeopathological findings from an Early Formative Period transitional site located in coastal Northern Chile (Quiani-7). The subadult cohort from this site is composed of four perinates who exhibit a number of non-specific skeletal changes suggestive of a systemic pathological condition. One of these is associated with an adult female exhibiting diagnostic skeletal lesions of scurvy. We argue that the lesions exhibited by these perinates may represent maternal transmission of vitamin C deficiency but acknowledge that there are difficulties in applying current diagnostic criteria for scurvy to individuals this young.

The Roles and Mechanisms of Actions of Vitamin C in Bone: New Developments

Vitamin C is an important antioxidant and cofactor that is involved in the regulation of development, function, and maintenance of several cell types in the body. Deficiencies in vitamin C can lead to conditions such as scurvy, which, among other ailments, causes gingivia, bone pain, and impaired wound healing. This review examines the functional importance of vitamin C as it relates to the development and maintenance of bone tissues. Analysis of several epidemiological studies and genetic mouse models regarding the effect of vitamin C shows a positive effect on bone health. Overall, vitamin C exerts a positive effect on trabecular bone formation by influencing expression of bone matrix genes in osteoblasts. Recent studies on the molecular pathway for vitamin C actions that include direct effects of vitamin C on transcriptional regulation of target genes by influencing the activity of transcription factors and by epigenetic modification of key genes involved in skeletal development and maintenance are discussed. With an understanding of mechanisms involved in the uptake and metabolism of vitamin C and knowledge of precise molecular pathways for vitamin C actions in bone cells, it is possible that novel therapeutic strategies can be developed or existing therapies can be modified for the treatment of osteoporotic fractures.

Trepanation and surgical infection in the 18th century

BACKGROUND

It is widely believed that trepanation prior to modern surgical hygiene was dangerous because of surgical infection, especially in the hospital. There has been a wide variability in the success and risks of different historical studies

PURPOSE

To obtain a more accurate assessment of the risks of post-operative infection following 18th-century cranial trauma and to note what factors were of prognostic significance.

MATERIAL AND METHODS

Seven 18th-century texts on head injury are reviewed and analyzed.

RESULTS

Infection was the commonest cause of death (in over 60% of patients) in five series but not in the other two. Hospital admission did not appear to be a major factor influencing mortality from infection. Delayed infection was the indication for patient referral and trepanation in more than two patients in two series. In one series, the patients were helped by the procedure, in the other they were not. The reasons for the difference are discussed. The most striking finding was that patients treated in rural areas had a much better prognosis.

CONCLUSIONS

The risks of suffering a surgical infection following head injury and trepanation are multifactorial. Admission to hospital seems to have been less risky than has been previously thought. It seems that the greatest risk factor for a lethal infection for these patients was living in an urban environment.

2011: the scurvy Odyssey

The authors report the case of a 50-year-old alcoholic man with chronic hepatitis C virus infection, who presented to the emergency department with fever and exuberant ecchymoses and petechiae on both legs. After a careful examination and laboratory assessment, the not-so-obvious hypothesis of scurvy was disclosed. Simply with vitamin C replacement and nutritional advice, a dramatic improvement in his condition was observed. In modern societies, a generalised access to food renders scurvy as a rare disease, often misdiagnosed. A multidisciplinary approach is emphasised as the key to a more simple differential diagnosis, avoiding unnecessary exams and preventing serious complications, or even death, if left untreated.

Induction of phase 2 antioxidant enzymes by broccoli sulforaphane: perspectives in maintaining the antioxidant activity of vitamins a, C, and e

Consumption of fruits and vegetables is recognized as an important part of a healthy diet. Increased consumption of cruciferous vegetables in particular has been associated with a decreased risk of several degenerative and chronic diseases, including cardiovascular disease and certain cancers. Members of the cruciferous vegetable family, which includes broccoli, Brussels sprouts, cauliflower, and cabbage, accumulate significant concentrations of glucosinolates, which are metabolized in vivo to biologically active isothiocyanates (ITCs). The ITC sulforaphane, which is derived from glucoraphanin, has garnered particular interest as an indirect antioxidant due to its extraordinary ability to induce expression of several enzymes via the KEAP1/Nrf2/ARE pathway. Nrf2/ARE gene products are typically characterized as Phase II detoxification enzymes and/or antioxidant (AO) enzymes. Over the last decade, human clinical studies have begun to provide in vivo evidence of both Phase II and AO enzyme induction by SF. Many AO enzymes are redox cycling enzymes that maintain redox homeostasis and activity of free radical scavengers such as vitamins A, C, and E. In this review, we present the existing evidence for induction of PII and AO enzymes by SF, the interactions of SF-induced AO enzymes and proposed maintenance of the essential vitamins A, C, and E, and, finally, the current view of genotypic effects on ITC metabolism and AO enzyme induction and function.

Scurvy hidden behind neuropsychiatric symptoms

Approaching an uncommon disease may result in diagnostic delay even in patients with typical clinical features. In this respect, diseases related to nutritional deficiencies may represent a diagnostic challenge. We describe a 2.5-year-old child with typical features of scurvy, who was referred for autistic-like behavior and severe muscle weakness and pain in lower limbs. Extensive investigations for non-nutrition-related disorders were first performed, including a muscle biopsy showing a selective type II fibers hypotrophy. Scurvy was eventually considered, after recalling the child's peculiar dietary habits.

α-Conotoxin BuIA[T5A;P6O]: a novel ligand that discriminates between α6ß4 and α6ß2 nicotinic acetylcholine receptors and blocks nicotine-stimulated norepinephrine release

α6* (asterisk indicates the presence of additional subunits) nicotinic acetylcholine receptors (nAChRs) are broadly implicated in catecholamine-dependent disorders that involve attention, motor movement, and nicotine self-administration. Different molecular forms of α6 nAChRs mediate catecholamine release, but receptor differentiation is greatly hampered by a paucity of subtype selective ligands. α-Conotoxins are nAChR-targeted peptides used by Conus species to incapacitate prey. We hypothesized that distinct conotoxin-binding kinetics could be exploited to develop a series of selective probes to enable study of native receptor subtypes. Proline6 of α-conotoxin BuIA was found to be critical for nAChR selectivity; substitution of proline6 with 4-hydroyxproline increased the IC(50) by 2800-fold at α6/α3β2β3 but only by 6-fold at α6/α3β4 nAChRs (to 1300 and 12 nM, respectively). We used conotoxin probes together with subunit-null mice to interrogate nAChR subtypes that modulate hippocampal norepinephrine release. Release was abolished in α6-null mutant mice. α-Conotoxin BuIA[T5A;P6O] partially blocked norepinephrine release in wild-type controls but failed to block release in β4(-/-) mice. In contrast, BuIA[T5A;P6O] failed to block dopamine release in the wild-type striatum known to contain α6β2* nAChRs. BuIA[T5A;P6O] is a novel ligand for distinguishing between closely related α6* nAChRs; α6β4* nAChRs modulate norepinephrine release in hippocampus but not dopamine release in striatum.

Scurvy: forgotten but definitely not gone

Scurvy, a disease of vitamin C deficiency, is purportedly rare in the United States yet frequently may be misdiagnosed. Presenting symptoms include bone pain, limping, rashes, or spongy bleeding gingiva. These symptoms mimic many other disorders, which often results in numerous unnecessary, invasive, and expensive procedural investigations. The strongest indication of a scurvy diagnosis is the dramatic response to the administration of vitamin C. This case report demonstrates the complexities involved in determining the cause of one child's symptoms. A thorough nutritional history and a shrewd clinician are essential to the early diagnosis and treatment of scurvy.

Scurvy extinct? Think again!

Scurvy is still seen sporadically in the developed world. Scurvy, a dietary disease due to the deficient intake of vitamin C, is uncommon in the pediatric population. Scurvy occurs as a result of decreased vitamin C consumption or absorption. We present the case of a 6-year-old boy visiting our department with bleeding gums, musculoskeletal pain, and weakness. Four days after starting oral vitamin C supplementation, there was significant improvement in the patient's gingival appearance and general health. The clinical presentation and laboratory investigation (Hemoglobin %, total blood picture) , together with the dramatic therapeutic response to ascorbic acid administration, confirmed the diagnosis of scurvy. Scurvy can be missed unless oral and general physicians maintain a high index of suspicion. Therefore it is time to wonder if scurvy is extinct yet.

Scurvy induced by obsessive-compulsive disorder

Historically, scurvy has been associated with sailors of great navigational epochs. This disease has been known since ancient Egypt, but nowadays it is almost forgotten. Although its prevalence has decreased over the centuries, scurvy is still present in developed countries. A 61-year-old man was referred to hospital with a 30-day history of anorexia, fatigue, gingival bleeding and ecchymosis of the arms and legs. On physical examination he presented gingival hypertrophic lesions, signs of chronic periodontitis and petechial rash, and several bruises on his arms and legs. A food frequency questionnaire revealed a long history of poor diet, with no vegetables or fruit. The patient had ingested only chocolate milk and cookies for the last 10 years due to fear of pesticides being present in foods of vegetable origin. A diagnosis of scurvy induced by obsessive-compulsive disorder was suspected, and after vitamin C supplementation there was a marked improvement of symptoms.

Gingival hypertrophy: a solitary manifestation of scurvy

A 48-year-old woman presented with rapid onset hypertrophy of both the upper and lower gingiva. A detailed history and a diet nearly void of fruits and vegetables raised the suspicion of a possible deficiency of vitamin C. An estimation of the serum ascorbic acid level confirmed our suspicions (<0.12 mg/dL; normal range, 0.4-1.0 mg/dL) and a diagnosis of scurvy was confirmed. A course of 1000 mg/d of ascorbic acid was initiated that caused a dramatic resolution of the gingival lesions. Gingival hypertrophy has a large differential diagnosis; however, it is also known to be an extremely rare manifestation of scurvy. A high index of suspicion for scurvy is relevant given its low prevalence in developed nations and how easily remediable the disease can be, even when it presents in a severe form.

Scurvy is still present in developed countries

INTRODUCTION

Scurvy, while uncommon, still occurs in developed countries despite the widespread availability of vitamins and fortified foods. A vitamin C deficiency prevalence of 10 to 14% in adults was reported in the National Health and Nutrition Examination Survey (NHANES) in 1994.

OBJECTIVE

We report the case of a 57-year-old male who presented with a combined vitamin C deficiency (scurvy) and a Zinc deficiency.

INTERVENTIONS

He came to the emergency department complaining of a painful swollen ecchymotic leg and dyspnea. Prescriptions for narcotics did not relieve his symptoms. When a detailed dietary history was obtained, we added scurvy to the differential diagnosis. An extensive evaluation excluded trauma, coagulopathies, neoplasia, and vasculitides.

MAIN RESULT

The combination of a classic skin biopsy and a low vitamin C level confirmed the diagnosis.

CONCLUSION

This presentation illustrates the necessity of including scurvy in the differential diagnosis of ecchymoses and demonstrates specific populations at risk: single adults and the elderly with deficient diets.