To the Editor: The Medical Mystery in the December 1 issue1involved a 71-year-old man with lower-extremity ecchymosis (Figure 1)and gingivitis (Figure 2, arrows). He was a retired Armyman living alone with a modest income. He had poor nutritionalintake, had a history of 150 pack-years of smoking cigarettes,and consumed two glasses of red wine each day.
Scurvy was suspected and confirmed by a low level of ascorbicacid (3.6 µmol per liter; normal range, 30 to 40). Othernutritional deficiencies that were identified included thoseof folic acid (1.37 ng per milliliter [3.1 nmol per liter];normal range, 3 to 17 ng per milliliter [6.8 to 38.5 nmol perliter]); calcium (1.96 mmol per liter; normal range, 2.22 to2.61); and 25-hydroxyvitamin D (7 mmol per liter; normal range,27 to 175). Ascorbic acid was given orally at a dose of 500mg per day. Eight days later, the patient was able to walk alone,the ecchymosis gradually disappeared, and the congestive periodontitiswas notably improved.
Denis Mulleman, M.D. Philippe Goupille, M.D. François Rabelais University 37032 Tours CEDEX 1, France
Editor's note: We received 2001 responses to this Medical Mystery,including 58 percent from physicians in practice, 23 percentfrom physicians in training, and 11 percent from medical students.Responses were received from 81 countries. Of those, 69 percentcorrectly identified this case as due to a deficiency of vitaminC, or scurvy. Other proposed diagnoses were leukemia (especiallymonocytic variants), suggested by 14 percent of respondents;a variety of other nutritional deficiencies, by 8 percent; andmany other conditions (such as autoimmune diseases, an overdoseof medication, amyloid, and sepsis), by the remaining 9 percent.
Scurvy is a disease of great historical interest, especiallyin mariners participating in long voyages. Ascorbic acid (vitaminC) has many biologic functions; the best understood is its rolein collagen synthesis — the failure of which leads tomany of the clinical manifestations of scurvy. A moderate consumptionof fruits and vegetables is adequate to prevent this disease.
References
Mulleman D, Goupille P. A medical mystery -- extensive ecchymosis. N Engl J Med 2005;353:2384-2384. [Free Full Text]
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