What is Scurvy?
Scurvy is a nutritional disease caused by a diet that lacks vitamin C [Ascorbic acid]. It is a condition characterized by general weakness, anemia, gum disease, and skin hemorrhages caused by a prolonged deficiency of vitamin C or ascorbic acid in the diet. The human body is unable to synthesize vitamin C; hence it has to be obtained from the diet or supplements.
Scurvy was first reported as far back as 1550 B.C. when it was discovered in sailors, who after long voyages developed bleeding gums, teeth problems, swelling in body, skin rash, joint pain and anemia. This was later attributed to the lack of intake of fresh fruits and vegetables which are rich sources of vitamin C.
- Vitamin C is required for the formation of collagen. Collagen is a type of protein found in many different types of tissue such as skin, blood vessels, bones and cartilage. If the body does not produce enough collagen, tissues will start to break down. Today, vitamin C is a popular vitamin being added to skin care products. Topical vitamin C preparations are being widely used to improve skin appearance by reducing fine lines and wrinkles, promote wound healing and protect against sunburns.
- It is also required for iron regulation within the body. Low levels of Vitamin C in the body may lead to anemia, increasing fatigue and lethargy.
- It helps in the proper functioning of the immune system.
- Vitamin C is essential for the production and metabolizing of dopamine, serotonin and other neurotransmitters which are required for energy production.
- Some studies have shown that vitamin C helps in the prevention and treatment of heart disease, stroke and may help prevent cancer.
- Scurvy is a serious problem in underdeveloped countries, in international refugee camps and in populations that subsist mainly on cereal grains.
- There are rising numbers of scurvy cases in people from developed countries who are overweight and appear to be well fed.
- Scurvy is uncommon in the neonatal period.
- The incidence of scurvy peaks in children aged 6-12 months who are fed a diet deficient in citrus fruits or vegetables as well as in elderly people.
- In India, the incidence of vitamin C deficient people over 60 years of age is extremely high, with 74 percent in the northern and 46 percent in the southern part of India.
- According to new studies up to three quarters of elderly in India have vitamin C deficiency due to poor dietary habits, smoking and consumption of tobacco.
- Vitamin C has been shown to hasten recovery after illnesses and also strengthen immunity against allergies, repeated colds.
- Since vitamin C is water soluble, any excess is passed out of the body in urine and feces.
- Vitamin C is completely destroyed by cooking and prolonged storage.
The main cause is an insufficient intake of vitamin C. This can be due to:
- Low income families or famine conditions where the diet may be lacking in fresh fruits and vegetables
- Excessive consumption of alcohol associated with an improper diet
- Abnormal eating patterns as in anorexia nervosa, or bulimia (serious eating disorders)
- Elderly or widowers who may be careless about their eating habits
- People who follow diet fads or peculiar diets to lose weight
- Difficulty in ingesting foods or those who follow restrictive diets due to allergies and other health problems
- Crohn’s disease – a chronic inflammatory bowel disease that affects the lining of the digestive tract
- Ulcerative colitis – a condition that results in inflammation and ulcers of the colon and rectum where the body’s ability to absorb nutrients is impaired
- Populations that subsist mainly on cereal grains
- Late weaning of infants
- Eating only cooked or frozen food
The symptoms of scurvy begin, after about 2-3 months of dietary deficiency and can be classified into 4 stages:
- First stage- people begin to feel abnormally lethargic and are prone to sudden fatigue. There is pain in leg muscles and a feeling of being very tired and weak all the time.
- Second stage- gums begin to swell and bleed with slight pressure. Teeth become loose at the roots. There is severe pain in the joints and muscles due to bleeding in the joints which causes areas of swelling over the bones of the arms and legs. Perifollicular hemorrhages and easy bruising due to capillary fragility are seen. These appear as reddish or bluish spots surrounding the hair follicles. The hairs are very dry and are twisted like corkscrews and break off close to the skin.
- Third stage- the gums bleed profusely, become putrid and begin to smell like rotting flesh. The skin will spontaneously hemorrhage. The skin, especially in the legs and feet, develop ulcers that turn gangrenous. There is excruciating pain throughout muscles, joints, and bones. Anemia develops in 75% of patients as a result of blood loss into tissue, gastrointestinal bleeding and intravascular hemolysis.
- Fourth stage-is final stage of scurvy with high fever, black spots on the skin, trembling and fainting leading to death which is usually caused by hemorrhaging in the brain and heart. However, even in stage four, treatment by high levels of vitamin C will reverse the effects of scurvy and the patient can return to good health.
In infants, the symptoms may also include poor weight gain, loss of appetite, diarrhea, fever, proptosis [bulging of eyes] and pain in the legs which makes them adopt a frog leg posture.
Scurvy is diagnosed by a physical examination and taking medical history along with detailed questions about dietary habits into account, in which an inadequate or low intake of fresh fruit and vegetables is identified. Radiological appearances are characteristic and described below:
- Blood tests- to check vitamin C and iron levels. Scurvy is confirmed by a blood test for ascorbic acid showing levels < 11 µmol/L and response of symptoms to treatment with vitamin C supplements and fresh fruit and vegetables.
- X rays- Generalized osteopenia [low bone density], cortical thinning or “pencil-point” cortex, intra articular hemorrhage, scorbutic rosary due to expansion of the costochondral junctions, Wimberger’s ring sign [circular, opaque radiologic shadow surrounding epiphyseal centres of ossification, which may result from bleeding] are common findings in children. Other findings include well calcified cartilage seen as white line of Fraenkel. Subperiosteal bleeding into joint may become calcified making the joint assume a club or dumbbell shape.
In adults, osteopenia and pathologic fractures are commonly seen.
The underlying cause for scurvy should be determined first.
- If it is due to a deficient intake of vitamin C then eating food that is high in vitamin C is advised. Vitamin C supplements by mouth or injections are also advised in cases of severe deficiency.
- If it due to a mental illness such as anorexia nervosa, bulimia, or depression, then a mental healthcare professional, dietician or social worker may be required to treat and prevent further episodes of scurvy.
The recommended dosage is:
- 1 to 2 grams per day for 2 to 3 days
- 500 milligrams for the next 7 days
- 100 mg for 1 to 3 months
- Children should be given 150-300 mg/day for one month
Within 24 hours, patients can expect to see an improvement in fatigue, lethargy, pain, anorexia, and confusion. Bruising, bleeding, and weakness start to resolve within 1 to 2 weeks. Complete recovery may be expected in about 3 months except in the case of severe dental damage.
Prevention of scurvy is easily achieved by taking 30-60 mg of Vitamin C daily.
Scurvy can be prevented by a diet that includes vitamin C-rich foods such as:
- Fruits- citrus fruits such as oranges and [one medium orange contains 70 mg of vitamin C], lemons, strawberries, blackberries, guava, kiwi fruit, papaya, pineapple, and mango
- Vegetables- such as tomatoes, parsley, carrots, red and green bell peppers [one green bell pepper contains 60 mg], broccoli, potatoes, cabbage, spinach, cauliflower, and kale
- Liver and oysters
It is advised to consume 5 servings of fruit and vegetables daily.
A serving of fruit is equivalent to one medium piece of fruit or 1/2 cup of chopped fruit.
One cup of green leafy vegetables such as spinach or kale makes up a single serving. For raw or cooked root vegetables, beans and other non-leafy variants 1/2 cup is a serving.
Recommended daily dietary allowance
- What is scurvy? - (https://www.dermnetnz.org/topics/scurvy/)
- Scurvy - (https://rarediseases.info.nih.gov/diseases/10406/scurvy)
- Scurvy-Reemergence of nutritional deficiencies - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2567249/)
- SCURVY and its prevention and control in major emergencies - (http://www.unhcr.org/4cbef0599.pdf)
- Scurvy - Role of Vitamin C - (https://www.betterhealth.vic.gov.au/health/healthyliving/scurvy)
- Hypovitaminosis C (scurvy) - (https://radiopaedia.org/articles/hypovitaminosis-c-scurvy-1)
Latest Publications and Research on Scurvy[Bloody tears: About a case and a review of the literature]. - Published by PubMed
Scurvy: A Rare Cause of Bone Marrow Edema. - Published by PubMed
Hematopoietic findings in a patient with scurvy. - Published by PubMed
Eighteenth Century Complications With 21st Century General Anesthesia: A Case Report of Scurvy. - Published by PubMed
[Bloody tears: About a case and a review of the literature]. - Published by PubMed