NIV Congres

Introduction: In the acute environment of an Emergency Department, we sometimes forget to focus on thorough history taking and don’t think of outdated diagnoses. Vitamin C deficiency was first described in the Middle Ages and formerly often seen among sailors with insufficient consumption of vitamins during their stay at sea. At the beginning of the 20th century, the pathophysiological mechanism and treatment options were clarified and since that time, scurvy is seen less frequently. Nowadays, patients vulnerable for vitamin C deficiency are often known with eating disorders, psychiatric disorders, alcohol misuse or contain patients who are hospitalized and therefore dependent on institutional meals.

Case description: A 29-year old woman with an unremarkable medical history presented on the Emergency Department with progressive fatigue and skin abnormalities. During the last 2 weeks, she developed edema in her lower legs, with extending hematomas and small red spots. Her gingiva were swollen and bled rapidly when brushing her tooth. There were no other signs of hemorrhagic diathesis and no cardiac or pulmonary complaints. She was a non smoker and consumed no alcohol. On physical examination, she was evidently anemic and had gingival disease with hyperplasia and bleeding gums. Auscultation of the heart revealed a systolic murmur, with no pulmonary or abdominal abnormalities. Her legs showed ecchymoses, petechiae and mild hyperkeratosis. Laboratory results showed a severe microcytic anemia (Hb 4.0 mmol/l, MCV 74 Fl), likely based on an iron deficiency (iron 2.2 µmol/l); leukocytes of 4.3x10⁹/l and thrombocytes of 413x10⁹/l, with normal kidney and liver function. As it turned out that she only ate small pancakes under a self-made sugar-free diet in the last 3 monhs, the combination of the mentioned skin abnormalities, gingival disease and fatigue was suspicious for a vitamin C deficiency. Therefore, our patient was admitted and intravenous ascorbic acid supplementation was started. Laboratory testing finally confirmed the diagnosis of scurvy, showing an immeasurably low serum level of vitamin C (< 2.8 μmol/L).

Discussion: While scurvy is usually viewed upon as an ancient disease, these days it is still prevalent, though very rare and especially among certain groups at risk. It may present as a semi-acute disorder and mimic other diagnoses. Once recognised, vitamin C deficiency is an easily treatable disease. This case report underlines that symptom recognition and thorough history taking even in an emergency setting are crucial in timely detection of vitamin C deficiency.