Extensive bruising secondary to vitamin C deficiency

Abstract

An otherwise fit and well 56-year-old man presented with extensive ecchymosis and soft-tissue haematomas affecting his legs. Coagulation studies were normal. Further questioning revealed a severely restricted diet. The bruising improved rapidly after commencing oral vitamin C supplementation. Serum vitamin C level was low, supporting the clinical diagnosis of scurvy.

BACKGROUND

Scurvy is commonly thought of as an historical disease. Its symptoms were recorded as early as 1550 BC and it was prevalent amongst seafarers during the 16th to 18th centuries. The discovery of the link between scurvy and deficiency of dietary vitamin C (ascorbic acid) has markedly reduced its incidence over the last century. However, cases do still occasionally occur and the diagnosis should not be forgotten, especially in a society increasingly obsessed by pre-prepared food and fad diets.

CASE PRESENTATION

A 56-year-old Caucasian man presented to the emergency department with a 2-week history of increasing bruising of both thighs. He denied any trauma or previous history of bleeding tendency. He was previously fit and well and was not taking any regular medications. He lived alone, had a longstanding history of alcohol excess and a smoking history of 60 pack years (20 cigarettes/day). On further questioning he admitted to a poor diet over the preceding 3 months consisting mainly of tinned soup and dried noodles. This had been exacerbated by a painful ulcer under his tongue, which had further limited his oral intake.

Examination revealed extensive confluent bruising affecting the posterior of both legs with underlying tense haematoma (fig 1). Both limbs were neurovascularly intact and there were no other areas of ecchymosis or petechiae. There was no lymphadenopathy, splenomegaly or stigmata of chronic liver disease. Oral examination revealed an ulcerated lesion of the floor of the mouth, suspicious of a squamous cell carcinoma (SCC).

Figure 1.

Bruising affecting the patient’s thigh and pelvic area.

Figure 2.

Extensive confluent bruising of the patient's posterior legs.

INVESTIGATIONS

Initial laboratory test results (normal range in parentheses) were as follows: haemoglobin 88 g/L (normal range 130–165 g/L), leucocyte count 9.2×10⁹/l (4–11×10⁹/l), platelet count 421×10⁹/l (140–450×10⁹/l), mean corpuscular volume 110.0 fl (80–100 fl), international normalised ratio (INR) 1.0 (1.0–1.3), and activated partial thromboplastin time 23 seconds (25–35 seconds). Urea, electrolytes, creatinine and liver function tests were unremarkable, except for a raised bilirubin level of 32 umol/L (3–18 umol/L). Haemoglobin level had been 136 g/L just 5 days earlier when checked by the patient’s general practitioner. Ultrasonography of the thighs confirmed deep soft-tissue haematomas without other abnormalities.

Further investigations included normal iron studies, vitamin B12 and red cell folate levels, and lactate dehydrogenase level of 265 IU/L (0–248 IU/L), haptoglobin <0.07 g/L (0.3–2.0 g/L), reticulocyte count 364 ×10⁹/L (50–100 ×10⁹/L), and negative results for urinary haemosiderin. Platelet function assays revealed mild impairment that could be attributable to the patient’s reduced haematocrit of 0.26 (0.37–0.55). Individual clotting factor assays for factors II, V, VII, VIII, IX, X, XI and XII were all within the normal range.

Based on the clinical history and normal clotting studies a presumptive diagnosis of vitamin C deficiency was made. Serum vitamin C level was later reported as <5 umol/L (40–100 umol/L), consistent with this diagnosis.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis for this presentation of extensive bruising should include:

• 1 Trauma

• 2 Vasculitis

• 3 Disorders of coagulation such as thrombocytopenia, clotting factor deficiencies, abnormal platelet function

• 4 Warfarin therapy

• 5 Causes of vascular fragility such as amyloidosis, Ehlers–Danlos disease and scurvy.

TREATMENT

The patient received a transfusion of packed red blood cells and was started on oral vitamin C, thiamine and a multivitamin tablet. He was referred to an ear, nose and throat specialist for investigation of the lesion on the floor of his mouth.

OUTCOME AND FOLLOW-UP

Within 2 days of starting oral vitamin supplementation, the patient’s bruising had begun to show significant improvement. The patient reported complete resolution within 3 weeks. The fall in haemoglobin level was attributed to the extensive thigh haematomas as no other clinical evidence of blood loss was identified. Haemoglobin level remained stable after the transfusion. The patient has since undergone surgical resection of the lesion on the floor of the mouth, which was confirmed as an SCC.

DISCUSSION

Humans cannot synthesise vitamin C and therefore rely on exogenous dietary sources to meet the body’s needs. A diet containing fresh fruit and vegetables or vitamin C supplementation is essential to prevent vitamin C deficiency. Symptoms may develop in as little as 4 weeks on a vitamin C-free diet.¹ Although scurvy is uncommon in modern medicine, it can still occur in patients with restrictive diets. Alcoholics and the elderly are particularly vulnerable.

Initial symptoms are non-specific, and include anorexia, lethargy, weakness and depression. Vitamin C deficiency results in defective collagen synthesis, which leads to the other clinical features of scurvy. Abnormal keratin formation leads to broken and “corkscrew” hairs. Increased bleeding tendency is thought to be due to the breakdown of capillary wall connective tissue rather than a platelet or clotting defect.² Bleeding is generally a late feature of the disease and can affect gums, skin, muscles and joints. Perifollicular haemorrhages and purpura affecting the posterior legs are characteristic.³ Left untreated, scurvy will progress, leading to potentially fatal complications such as cerebral haemorrhage and haemopericardium.

LEARNING POINTS

• 1 Scurvy may present with lethargy, anorexia, “corkscrew” hairs and bleeding affecting the gums, skin, muscles and joints

• 2 Familiarity with the symptoms and signs of scurvy may prevent costly and unnecessary investigation

• 3 If the diagnosis is scurvy, bleeding and bruising will resolve rapidly following commencement of oral vitamin C supplementation

• 4 Scurvy may present in anyone with a severely restricted diet and is easily treated.