Be vigilant for scurvy in high-risk groups.

Scurvy is caused by prolonged dietary deficiency of vitamin C, the plasma concentration of which appears inversely related to mortality from all causes. Its clinical importance relates principally to its role as a cofactor in a number of enzyme reactions involved in collagen synthesis, dysfunction of which disrupts connective tissue integrity, resulting in impaired wound healing and capillary bleeding. In the UK, overt scurvy is diagnosed only rarely. However, subclinical vitamin C deficiency appears quite common, one study estimated that 25% of men and 16% of women in the low income/materially deprived population had vitamin C deficiency, with smoking a strong predictor. Because many of the early symptoms of vitamin C deficiency (fatigue, malaise, depression and irritability) are non-specific, the diagnostic possibility of scurvy is usually delayed until haemorrhagic manifestations occur. The classical cutaneous features consist of perifollicular purpura, contorted (corkscrew) hairs and follicular hyperkeratosis, particularly affecting the legs. Large areas of purpura or ecchymosis may occur. Swelling and bleeding of the gums is an early mucosal symptom, and progressively severe gum disease causes loss of teeth. Subperiosteal haemorrhage, particularly in the femur and tibia, can present as pain, pseudoparalysis, swelling and discoloration of the legs. Haemorrhage into joints and muscle is very uncomfortable. Diagnosis is generally made on the basis of clinical features, corroborated by a history of dietary inadequacy, and the subsequent rapid resolution of symptoms with the restoration of an adequate vitamin C intake.