eMedicine Specialties > Dermatology > Metabolic Diseases

Scurvy: Differential Diagnoses & Workup

Author: Anne Laumann, MB, ChB, MRCP(UK), FAAD, Associate Professor, Department of Dermatology, Feinberg School of Medicine, Northwestern University
Coauthor(s): Julia Sanger Minocha, MD, Resident Physician, Department of Medicine, Feinberg School of Medicine, Northwestern University; Janet J Wong, MD, Consulting Dermatologist, Department of Dermatology, University of Connecticut
Contributor Information and Disclosures

Updated: Jan 21, 2009

Differential Diagnoses

Hypersensitivity Vasculitis (Leukocytoclastic Vasculitis)
Thrombophlebitis

Other Problems to Be Considered

Acute ulcerative gingivitis
Coagulation abnormalities
Collagen-vascular diseases
Deep vein thrombosis
Infection
Adverse medication effects
Platelet disorders
Septic arthritis
Systemic bleeding disorders
Trauma to legs and joints

Workup

Laboratory Studies

  • The diagnosis is mainly made on the basis of the historical features and the physical findings. Plasma ascorbic acid level may help in establishing the diagnosis, but this level tends to reflect the recent dietary intake rather than the actual tissue levels of vitamin C. Signs of scurvy can occur with low-normal serum levels of vitamin C.
  • The level of vitamin C in leukocytes more accurately correlates to tissue stores compared with serum levels because these cells are not affected acutely by circadian rhythm or dietary changes. A specific and reproducible reverse-phase, high-pressure liquid chromatographic method has been found reliably to measure vitamin C in lymphocytes.6 This test is currently not clinically available but it might be useful for screening. A more commonly used method is the ascorbic acid tolerance test, which quantitates urinary ascorbic acid over the 6 hours following an oral load of 1 g of ascorbic acid in water. The best confirmation of the diagnosis of scurvy is still its resolution following vitamin C administration.

Imaging Studies

  • The earliest radiologic manifestation of infantile scurvy is generally seen at the distal ends of the radii where fuzziness of the lateral aspects of the cortices is present with slight rarefaction of the neighboring cancellous bone.
  • As the disease progresses, radiographs demonstrate characteristic changes at the cartilage-shaft junctions of the long bones, especially at the distal ends of the femurs. Key imaging features show osteoporosis; increased density and widening of the zone of provisional calcification between the epiphysis and metaphysis (white line of Frankel); metaphyseal spurs or marginal fractures (Pelkan spur), a transverse band of radiolucency in the metaphysis (scurvy line or Trümmerfeld zone), which is subjacent to the zone of provisional calcification; ring of increased density surrounding the epiphysis (Wimberger ring); and periosteal elevation.

Histologic Findings

Noninflammatory perivascular extravasation of red cells and deposition of hemosiderin near hair follicles with intrafollicular keratotic plugs and coiled hair may be seen in a skin biopsy specimen.

More on Scurvy

Overview: Scurvy
Differential Diagnoses & Workup: Scurvy
Treatment & Medication: Scurvy
Follow-up: Scurvy
References
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References

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  2. Noble JM, Mandel A, Patterson MC. Scurvy and rickets masked by chronic neurologic illness: revisiting "psychologic malnutrition". Pediatrics. Mar 2007;119(3):e783-90. [Medline].

  3. Duggan CP, Westra SJ, Rosenberg AE. Case records of the Massachusetts General Hospital. Case 23-2007. A 9-year-old boy with bone pain, rash, and gingival hypertrophy. N Engl J Med. Jul 26 2007;357(4):392-400. [Medline].

  4. Arron ST, Liao W, Maurer T. Scurvy: a presenting sign of psychosis. J Am Acad Dermatol. Aug 2007;57(2 Suppl):S8-10. [Medline].

  5. Delanghe JR, Langlois MR, De Buyzere ML, Torck MA. Vitamin C deficiency and scurvy are not only a dietary problem but are codetermined by the haptoglobin polymorphism. Clin Chem. Aug 2007;53(8):1397-400. [Medline].

  6. Emadi-Konjin P, Verjee Z, Levin AV, Adeli K. Measurement of intracellular vitamin C levels in human lymphocytes by reverse phase high performance liquid chromatography (HPLC). Clin Biochem. May 2005;38(5):450-6. [Medline].

  7. Abernethy DR, Arnold GJ, Azarnoff D. Mosby Drug Consult. St. Louis, Mo: Mosby; 2005.

  8. Carinci F, Pezzetti F, Spina AM, et al. Effect of Vitamin C on pre-osteoblast gene expression. Arch Oral Biol. May 2005;50(5):481-96. [Medline].

  9. Fain O. Musculoskeletal manifestations of scurvy. Joint Bone Spine. Mar 2005;72(2):124-8. [Medline].

  10. Formon J. Nutrition of Normal Infants. Chicago, Ill: Mosby-Year Book; 1993:22, 360-5.

  11. Garg K, Draganescu JM, Albornoz MA. Puzzles in practice. A rash imposition from a lifestyle omission. Vitamin C deficiency. Postgrad Med. Nov 1998;104(5):183-4. [Medline].

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  15. Hatuel H, Buffet M, Mateus C, Calmus Y, Carlotti A, Dupin N. Scurvy in liver transplant patients. J Am Acad Dermatol. Jul 2006;55(1):154-6. [Medline].

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  17. McKenna KE, Dawson JF. Scurvy occurring in a teenager. Clin Exp Dermatol. Jan 1993;18(1):75-7. [Medline].

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  21. Sarkany RPE, Breathnach SM, Seymour CA. Vitamin C deficiency. In: Burns T, Breathnach SM, Cox N, Griffiths CE, eds. Rook's Textbook of Dermatology. Vol. 57. 7th ed. Oxford, England: Blackwell; 2004:94-95.

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  23. Yalcin A, Ural AU, Beyan C, Tastan B, Demiriz M, Cetin T. Scurvy presenting with cutaneous and articular signs and decrease in red and white blood cells. Int J Dermatol. Dec 1996;35(12):879-81. [Medline].

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Further Reading

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Keywords

infantile scurvy, Barlow disease, Barlow's disease, vitamin C deficiency, ascorbic acid, widower scurvy, chronic malnutrition

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Contributor Information and Disclosures

Author

Anne Laumann, MB, ChB, MRCP(UK), FAAD, Associate Professor, Department of Dermatology, Feinberg School of Medicine, Northwestern University
Anne Laumann, MB, ChB, MRCP(UK), FAAD is a member of the following medical societies: American Academy of Dermatology, Association of Professors of Dermatology, Chicago Dermatological Society, Chicago Medical Society, Illinois Dermatological Society, Illinois State Medical Society, Illinois State Medical Society, Medical Dermatology Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Julia Sanger Minocha, MD, Resident Physician, Department of Medicine, Feinberg School of Medicine, Northwestern University
Julia Sanger Minocha, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Janet J Wong, MD, Consulting Dermatologist, Department of Dermatology, University of Connecticut
Janet J Wong, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Kathryn Schwarzenberger, MD, Associate Professor of Medicine, Division of Dermatology, University of Vermont College of Medicine; Consulting Staff, Division of Dermatology, Fletcher Allen Health Care
Kathryn Schwarzenberger, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, American Dermatological Association, Dermatology Foundation, Medical Dermatology Society, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Van Perry, MD, Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas Health Science Center
Van Perry, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Laser Medicine and Surgery
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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