Researchers say this ancient disease should be suspected in patients who present with symptoms of vasculitis.
Are Australia’s cost of living and obesity crises and a rise in weight loss surgery creating a perfect storm for the resurgence of scurvy?
West Australian researchers think so and have detailed the case of a man aged in his early 50s who presented to Sir Charles Gairdner Hospital with a painful rash and bruising. After other causes were ruled out, he was diagnosed with the disease caused by vitamin C deficiency.
Their case has been published in the journal BMJ Case Reports, the authors highlighting Australia’s economic conditions and the rise in bariatric surgery as potential reasons for scurvy’s re-emergence.
“In Australia, the rising cost of food [up 5.9% in the last 12 months] is making it harder for families to afford meals,” they wrote.
“The increasing cost of living means that people are more reliant on lower-cost foods, which tend to be poor in nutritional value. Patients who have undergone bariatric surgery are also at risk of developing micronutrient deficiency.
“Although they are particularly susceptible to fat-soluble vitamin deficiencies [vitamins A, D, E and K], if combined with a poor diet, they can also be deficient in vitamin C.
“There are multiple case reports of patients developing scurvy as a complication post-bariatric surgery, often presenting with spontaneous petechiae or ecchymoses of the skin.”
Scurvy is thought to have killed millions during the Renaissance era of long-distance sea exploration, when sailors spent months on ships with a very limited diet.
This patient had multiple risk factors, including poor dietary habits, obesity, previous bariatric surgery, use of proton pump inhibitors and low-income status.
He presented to hospital with tiny painful red-brown pinpoints on his legs resembling a rash. Blood was present in his urine and he was anaemic. He tested negative for inflammatory, autoimmune and blood disorders, and scans revealed no evidence of internal bleeding. A skin biopsy returned no diagnostic clues.
His rash continued to spread while he was in hospital. Further questioning revealed that he was short of money and had neglected his diet, eating little in the way of fruit and vegetables. He reported that he sometimes skipped meals altogether.
The patient had also stopped taking the nutritional supplements prescribed for him after previous weight loss surgery, because he said he couldn’t afford them, the authors wrote.
A nutritional panel revealed a very low vitamin D level and vitamin C was undetectable. He was diagnosed with scurvy and treated with daily vitamin C (1000 mg), vitamin D3, folic acid and multivitamin supplements, after which his painful rash and other symptoms resolved.
A dietitian review was organised, and a meal plan was created. He also started eating a lemon daily.
“Scurvy is a re-emerging disease with the rising cost of living,” the authors wrote. “It can present as early as a month after a vitamin C-deficient diet. Petechial skin lesions often occur especially in the lower extremities and may be mistaken for systemic vasculitis.
“The diagnosis is often made after an extensive diagnostic workup including imaging and biopsies, thus delaying treatment. Risk factors for scurvy include poor nutrition, gastric bypass surgery, dialysis, alcoholism, psychiatric history and eating disorders.
“This disease is easily reversible with supplementation, with a dramatic response seen within 24 hours. Failure to treat may lead to catastrophic haemorrhage, hence, early recognition and prompt treatment are vital.”
A study in June this year found vitamin C deficiency was common among children at an Australian paediatric hospital.
Another study in June found that with the rise in obesity, a growing proportion of the population was not covered by the recommended daily intake of vitamin C, as plasma concentrations vary inversely with body weight.
Dr Jayne Barbour, an accredited practising dietitian from Flinders University, said the rise in scurvy needed attention.
“In the UK and now in Western Australia, we are seeing a drop in diet quality resulting in the re-emergence of scurvy. These cases are still rare but concerning,” she said.
“The re-emergence of scurvy is a reflection of the ‘perfect storm’ given the rise in food insecurity and the increasing cost of living pressures, as well as the limited availability of fresh produce in remote areas.”
Dr Barbour said the situation was further compounded by the rise in the number of Australians using weight-loss medications such as semaglutide – in addition to those who had undergone bariatric surgery.
“It will be interesting to see if this disease from the past becomes more frequently diagnosed against the backdrop of the growing use of weight-loss medications,” she said.
“Data from the Australian Bureau of Statistics reveal that Australian intakes of fruit and vegetables have dropped to a further low with less than 10% of the population meeting the recommended servings of fruit and vegetables.”
Food sources strong in vitamin C include dark green vegetables, citrus fruits, strawberries, tomatoes, kiwi fruit, capsicum, with potatoes being one of the cheapest sources.
“Those following a restricted diet may require supplementation with a vitamin and mineral supplement and should seek professional nutritional advice from a dietitian,” said Dr Barbour.
