Presentation

A 63-year-old male with dementia was referred to dermatology with a rash concerning for vasculitis. He denied itch or pain from the rash but noted pain at his right calf. On examination, there were peri-follicular purpuric macules and hyperkeratotic papules with corkscrew hairs. Conjunctival hemorrhage, hemorrhagic gingivitis, splinter hemorrhages, and a large ecchymosis with ultrasound-confirmed hematoma of the right calf were noted (Fig. 1a, b). On review, his wife shared that his diet had been limited since he developed dementia, consisting exclusively of grains and dairy. Given the physical findings and history of restricted diet, a presumptive diagnosis of scurvy was made. An undetectable serum ascorbic acid level, < 0.1 mg/dL confirmed the diagnosis. The patient was started on ascorbic acid 1000 mg daily; his rash improved after 2 weeks of supplementation and resolved after 6 weeks.

Fig. 1
figure 1

Cutaneous manifestations of vitamin C deficiency. a Peri-follicular purpuric macules and hyperkeratotic papules with corkscrew hairs. Splinter hemorrhages. b Gingival hemorrhage

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Discussion

Vitamin C is an essential water-soluble vitamin exclusively obtained through diet, it is essential for collagen synthesis, and its deficiency leads to impaired collagen synthesis and capillary fragility [1]. Vitamin C deficiency is rare in the developed world and is typically seen in patients with alcohol use disorder, restrictive dieting, psychiatric disease, dementia, and malabsorptive diseases. The first manifestation of vitamin C deficiency is typically fatigue. Corkscrew hairs with peri-follicular petechiae are pathognomonic for scurvy [2]. Musculoskeletal manifestations including arthralgias, particularly in the knees, ankles, and wrists, as well as myalgias, are seen in up to 80% of patients. Hemarthroses are also commonly seen and may be the initial chief complaint of the patient [3]. Hemarthroses have been found to occur mainly in the hips, knees, and ankles and are believed to be the result of damage to synovial blood vessels and microfractures [4]. More rare musculoskeletal manifestations include regional transient osteoporosis [5]. Early recognition of key physical findings is important to ensure prompt treatment.