Diagnosis: Scurvy
Upon further questioning, the patient revealed that his diet consisted solely of alcohol and meat. A serum vitamin C was ordered and returned at 0.1 mg/dL (normal, 0.4-2.0 mg/dL).
Alcoholism is a big tip-off. The diagnosis of scurvy is usually clinical, based on risk factors that suggest a diet deficient in vitamin C. The most common risk factor is alcoholism.1 Other risk factors include adults living alone (notably men), poverty, poor access to groceries, reclusiveness, dementia, nutritional ignorance, avoidance of “acid” foods because of purported allergy, gastrointestinal disorders (eg, colitis, inflammatory disease), poor dentition, food fads or food avoidances, cancer, schizophrenia, and depression.1
Men more than women. Men between the ages of 20 and 39 and those older than 60 years have a higher prevalence of vitamin C deficiency than similarly aged women, according to a National Health and Nutrition Examination Survey of 7277 children and adults.2 Overall, 8.2% of the men and 6% of the women surveyed were deficient in vitamin C.2
Henoch-Schönlein purpura, leukemia included in differential Dx
The differential diagnosis of scurvy includes autoimmune diseases, coagulopathies, hematologic malignancies, adverse effects of medications, meningococcemia, necrotizing gingivitis, senile purpura, thrombophlebitis, other vitamin deficiencies (vitamins K, D, B12, folate, and zinc), and physical abuse or trauma.
Autoimmune diseases such as systemic lupus erythematosus, Henoch-Schönlein purpura, Sjögren syndrome, and rheumatoid arthritis often involve cutaneous manifestations of purpuric and petechial rash. These diseases tend to have systemic involvement that can include the airways, kidneys, and nervous system—as well as rheumatologic findings of joint involvement.3 Making the diagnosis hinges on autoantibody serologies and inflammatory markers.
Coagulopathies such as clotting factor deficiencies, platelet dysfunction, and disseminated intravascular coagulation can also present with skin rash and anemia. Laboratory analysis shows abnormalities of blood cell counts (anemia, throm-bocytopenia), prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen and clotting factor deficiencies.
Hematologic malignancies such as leukemia or lymphoma can cause petechial and purpuric rashes. Fever, fatigue, weight loss, bone pain, easy bleeding or bruising, lymphadenopathy, and hepatosplenomegaly highlight the systemic manifestations of these malignancies. Positive findings on complete blood count (CBC), coagulation profile, erythrocyte sedimentation rate, and bone marrow biopsy help confirm this diagnosis.
Petechial or purpuric rash can be an adverse effect of anticoagulants, antiplatelet agents, and nonsteroidal anti-inflammatory drugs. Symptoms range in severity and generally resolve with the discontinuation of the offending agent.
Meningococcemia involves a maculopapular rash with petechia and ecchymosis resulting from the spread of bacterial infection from cerebral spinal fluid (CSF) to the systemic circulation. Infection-related effects on clotting factors can be identified with a CBC, PT/aPTT times, and testing for fibrinogen and fibrin degradation products. CSF analysis and culture along with a history and exam findings of fever, malaise, hypotension, and meningeal signs point to meningitis.