A 72-year-old woman presented to the emergency department with a 3-month history of a rash on both legs and an additional 6 months of gingival bleeding. The patient’s medical history was notable for esophageal strictures leading to poor oral intake for at least 2 years.
She had not visited her dentist for the gingival bleeding. When she developed the rash on her legs her nurse practitioner thought of insect bites (chigger bites) as she had done some gardening without protective measures and had used organic fertilizer in the flower beds which she tended.
Chigger bites are uncomfortable, itchy, annoying, and can make it difficult to sleep. In most cases, chigger bites don’t cause any harm to health. Chiggers feed on skin cells, but not on blood. They don’t carry or transmit disease. However, chigger bites can become infected from too much scratching. If a patient develops swelling, fever, or other signs of infection then local or even systemic antibiotics may be needed. In case of severe itching which interferes with the patients lifestyle s short course of steroids may be needed.
Her doctor saw her and did not think these were chiggers specially keeping in mind the long history of her poor dietary intake with almost complete absence of fresh fruits and vegetables and also the gingival bleeding. She lived on cereals (dalia) and milk and chapati soaked in curry or thin lentils. The hemorrhages appeared to be perifollicular and hair tweezed out of a follicle appeared corkscrew in appearance. A skin biopsy also confirmed corkscrew hair. Scurvy was suspected, and the diagnosis was subsequently confirmed by a measure of ascorbic acid in plasma of less than 5 μmol per liter (0.1 mg per deciliter; reference range, 23 to 114 μmol per liter [0.4 to 2.0 mg per deciliter]). Oral replacement of ascorbic acid was initiated at 500 mg daily for 3 months. The patient subsequently underwent serial esophageal dilations for management of the esophageal strictures and resumed a normal diet thereafter. At the 4-month follow-up, the skin and gingival findings had both resolved.
She developed the mucocutaneous manifestations of scurvy from a poor dietary intake of fresh fruits and vegetables. What could she have taken to prevent this condition? Fresh lime juice made into lemonade is a refreshing and delicious source of vitamin C. Fruit juices from fresh fruit like oranges, grapefruit,
watermelon, melon, apricots and peaches will provide the vitamin. Tomatoes juice will also do the same.
Many of the vitamin deficiency diseases, such as scurvy (vitamin C), beriberi (thiamine), and pellagra (niacin), have been almost completely eliminated in resource-rich countries, except in occasional patients with underlying medical disorders or highly restricted diets. In resource poor countries they can still be seen specially in high mountainous areas where roads may be closed in the severe winters and food supply is limited to what can be stored in the summer. Where maize is a major source of calories niacin deficiency manifests itself as pellagra specially in young children.
Dietary reference intakes (DRIs) were developed by the Food and Nutrition Board of the Institute of Medicine to guide nutrient intake in a variety of settings . DRIs are comprised of:
●Recommended dietary allowance (RDA) – The dietary intake that is sufficient to meet the daily nutrient requirements of 98 percent of the individuals in a specific life stage group and with specific physiologic conditions, such as pregnancy.
●Adequate intake (AI) – An estimate of the nutrient intake necessary to maintain a healthy state. The AI is used when there are insufficient data to determine the RDA.
●Upper tolerable level (UL) – The maximum level of intake that is likely to pose no risk of adverse health effects.
Sources — Important food sources of vitamin C are citrus fruits like oranges, grapefruit, lemon and lime, tomatoes, potatoes, brussels sprouts, cauliflower, broccoli, strawberries, cabbage, and spinach and the leaves of turnips and radishes, bell peppers, green chilies, and mangoes have 36.6 mg of vitamin C per 100 gm. The provision of dietary vitamin C is highly dependent on food preparation because oxidative conditions can destroy active vitamin C in foods. In children, breast milk provides an adequate source of ascorbic acid for newborns and infants hence scurvy is not seen in breast fed infants. Ascorbic acid is the enolic form of an alpha-ketolactone and is closely akin to the glucose structure. A number of compounds that exhibit the biologic activities of ascorbic acid are generally referred to as vitamin C. Most mammals can synthesize vitamin C from glucose, with the exception of primates.
It takes a few months for clinical symptoms to develop after there is a dietary deficiency of vitamin C. Ascorbic acid deficiency is responsible for scurvy, which is characterized by prominent cutaneous signs (petechiae, perifollicular hemorrhage, and bruising), gingivitis, arthralgias, and impaired wound healing. Other symptoms may be Sjogren’s syndrome, arthralgias, edema, anemia. The hemorrhagic skin lesions are initially flat but may coalesce and become palpable, especially on the lower extremities. This finding may resemble a systemic vasculitis. Musculoskeletal pain, which may be severe, may be caused by hemorrhage into the muscles or periosteum. A limp may be the presenting symptom, particularly in nonverbal children. Generalized systemic symptoms are weakness, malaise, joint swelling, arthralgias, anorexia, ecchymoses, xerosis, leg edema, depression, neuropathy, and vasomotor instability. Cardiorespiratory symptoms, including dyspnea, hypotension, and sudden death have been reported and are thought to be caused by impaired vasomotor response.
Who is going to get scurvy in the modern era? Ascorbic acid deficiency occurs mostly in severely malnourished individuals, drug abusers, patients with psychiatric disorders, alcoholism, or social isolation or those living in extreme poverty or on diets devoid of fruits and vegetables because of being unable to eat because of lack of teeth or having severe reflux disease or esophageal strictures. In the elderly, institutionalized, or chronically ill patients, scurvy can be seen due to their poor dietary intake. Scurvy has also been described in children with autism spectrum disorder who habitually eat a highly selective diet that is devoid of fruits and vegetables (often associated with autism spectrum disorder). Scurvy will also occur in children with iron overload due to medical conditions such as sickle cell disease or thalassemia, or a history of bone marrow transplantation. Iron overload can precipitate scurvy because ferric deposits accelerate the catabolism of ascorbic acid.
Blood concentrations of ascorbic acid are regulated by renal excretion. Excess amounts are filtered by renal glomeruli and reabsorbed via the tubules to a predetermined threshold .
Symptoms of scurvy generally occur when the plasma concentration of ascorbic acid is less than 0.2 mg/dL (11 micromol/L). Measurement of ascorbic acid in leukocytes is a better measure of body stores but this test is not widely available.
The treatment for scurvy is vitamin C supplementation and reversal of the conditions that led to the deficiency. A wide range of replacement doses have been used successfully. For children, recommended doses are 100 mg ascorbic acid given three times daily (orally, intramuscularly or intravenously) for one week, then once daily for several weeks until the patient is fully recovered . Adults are usually treated with 300 to 1000 mg daily for one month. Dietary deficiencies need to be corrected. Many of the constitutional symptoms will start subsiding within 24 hours. Bruising and gingival bleeding stop in a few weeks.
Should we take vitamin C for the prophylaxis of other diseases? Several therapeutic and prophylactic roles have been described for vitamin C, including prevention of cardiovascular disease and cancer. Evidence does not support the use of vitamin C supplementation for disease prevention. Vitamin C has little or no role in preventing the common cold.
Can you eat too much vitamin C and can it be toxic?
Toxicity — A number of side effects of ascorbic acid have been reported in the literature. Large doses of vitamin C (in gram quantities) can give false negative stool guaiac results and have been associated with diarrhea and abdominal bloating. Epidemiologic data have shown a correlation between dietary and supplemental vitamin C intake and oxalate kidney stones in men, especially at very high doses
How much vitamin C do we need? We need very small amounts: 15 to 45 mg daily in children, 75 mg per day for most women and 90 mg per day for men; pregnant or lactating women and the elderly have requirements up to 120 mg/day. This is the minimum requirement to prevent scurvy.