Mucocutaneous Manifestations of Scurvy
A 72-year-old woman presented to the emergency department with a 3-month history of a rash on both legs and an additional 6 months of gingival bleeding. The patient’s medical history was notable for esophageal strictures leading to poor oral intake for at least 2 years. Physical examination of the legs showed perifollicular petechiae, follicular hyperkeratosis, and corkscrew hairs in addition to red and blue ecchymoses on both ankles (Panels A and B). Examination of the oral mucosa showed gingival bleeding (Panel C). A skin-biopsy sample obtained from a lesion on one leg showed a corkscrew hair (Panel D, arrow) with perifollicular hemorrhage. Scurvy was suspected, and the diagnosis was subsequently confirmed by a measure of ascorbic acid in plasma of less than 5 μmol per liter (0.1 mg per deciliter; reference range, 23 to 114 μmol per liter [0.4 to 2.0 mg per deciliter]). Oral replacement of ascorbic acid was initiated at 500 mg daily for 3 months. The patient subsequently underwent serial esophageal dilations for management of the esophageal strictures and resumed a normal diet thereafter. At the 4-month follow-up, the skin and gingival findings had both resolved.
