Approach Considerations
Because sudden death may occur in patients with scurvy, ensuring adequate vitamin C replenishment in patients with vitamin C deficiency is the hallmark of therapy. Restoration of body stores of vitamin C is essential to achieve complete resolution of symptoms. In most adult patients, provision of 250 mg of vitamin C 4 times a day for 1 week aids in achieving this goal.
Identifying and treating comorbid nutritional deficiencies (eg, iron deficiency anemia, folate deficiency, other vitamin deficiencies) are integral parts of management. Provision of a balanced and liberal diet to meet the nutritional needs of the patient aids in recovery.
Ascorbic Acid
Orange juice is an effective dietary remedy for curing infantile scurvy and was the standard treatment before the discovery of vitamin C. Upon instituting dietary or pharmacologic treatment, the clinical recovery is impressive. The appetite of the infant is recovered within 24-48 hours. The symptoms of irritability, fever, tenderness upon palpation, and hemorrhage generally resolve within 7 days.
Patients should take oral ascorbic acid at 100 mg 3-5 times a day until a total of 4 g is reached, and then they should decrease intake to 100 mg daily. Alternatively, ascorbic acid may be taken at 1 g/day for the first 3-5 days, followed by 300-500 mg/day for 1 week. Then, the recommended daily allowance is resumed.
Divided doses are given, because intestinal absorption is limited to 100 mg at one time. Parenteral doses are necessary in those with gastrointestinal malabsorption.
In October 2017, the Food and Drug Administration (FDA) approved Ascor (ascorbic acid) for the short-term (<1 wk) treatment of scurvy in adults and children aged 5 months or older for whom oral administration is not possible, is insufficient, or is contraindicated. The exact mechanism of action of ascorbic acid for the treatment of scurvy is unknown. It is believed that the administration restores the body pool of ascorbic acid.
The recommended adult dose is 200 mg IV daily, and treatment should not exceed 7 days. If there is no improvement in scorbutic symptoms, re-treat until resolution of scorbutic symptoms is observed. [39]
Diet
A diet adequate in vitamin C can prevent the development of scurvy. Foods high in vitamin C include citrus fruits, especially grapefruits and lemons; berries and cantaloupe; and vegetables, including broccoli, spinach, green peppers, tomatoes, potatoes, cauliflower, and cabbage.
The recommended daily allowance for vitamin C varies with the age of the individual. The current recommendation for adults is 120 mg daily, although a dose of 60 mg daily is all that is required to prevent scurvy. Some experts think the level should be as high as 200 mg daily to match the level present in 5 servings of fruits and vegetables daily, a diet shown to decrease cancer risk.
The Food and Nutrition Board of the National Academy of Sciences and the National Research Council have provided minimum recommended daily dietary allowances of vitamin C (see the table below) [6] :
Table. (Open Table in a new window)
| Age | Recommended Amount |
|---|---|
| Birth to 6 mo | 40 mg |
| Infants 7-12 mo | 50 mg |
| Children 1-3 yr | 15 mg |
| Children 4-8 yr | 25 mg |
| Children 9-13 yr | 45 mg |
| Boys 14-18 yr | 75 mg |
| Girls 14-18 yr | 65 mg |
| Men | 90 mg |
| Women | 75 mg |
| Pregnant females <18 yr | 80 mg |
| Pregnant women 19-50 yr | 85 mg |
| Breastfeeding females <18 yr | 115 mg |
| Breastfeeding women 19-50 yr | 120 mg |
Megadoses of vitamin C have not been shown in clinical trials to reduce viral illnesses such as colds. Large doses of vitamin C (ie, more than 1 g/day) may increase the risk of certain illnesses such as kidney stones, particularly oxalate stones.
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Anteroposterior radiograph of the lower extremities shows ground-glass osteopenia, a characteristic of scurvy.
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Perifollicular hemorrhage.
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Periodontal images of the patient taken before periodontal treatment. Extensive gingival overgrowth with severe periodontal inflammation was observed in the maxillary and mandibular arches at the first visit (July, 2008). Image from open access article Omori K, Hanayama Y, Naruishi K, Akiyama K, Maeda H, Otsuka F, Takashiba S. Gingival overgrowth caused by vitamin C deficiency associated with metabolic syndrome and severe periodontal infection: a case report. Clin Case Rep. 2014 Dec; 2(6):286-95.
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Treatment protocol for above patient with extensive gingival overgrowth with severe periodontal inflammation in the maxillary and mandibular arches. Image from open access article Omori K, Hanayama Y, Naruishi K, Akiyama K, Maeda H, Otsuka F, Takashiba S. Gingival overgrowth caused by vitamin C deficiency associated with metabolic syndrome and severe periodontal infection: a case report. Clin Case Rep. 2014 Dec; 2(6):286-95.
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Periodontal images taken before and after ascorbic acid supplementation. (A) Recurrent gingival overgrowth observed after the second gingivectomy and before ascorbic acid supplementation (September, 2011), (B) images taken after 9 months of ascorbic acid supplementation (June, 2012). The white arrows indicate typical sites of recurrent gingival overgrowth. Image from open access article Omori K, Hanayama Y, Naruishi K, Akiyama K, Maeda H, Otsuka F, Takashiba S. Gingival overgrowth caused by vitamin C deficiency associated with metabolic syndrome and severe periodontal infection: a case report. Clin Case Rep. 2014 Dec; 2(6):286-95.
Tables
| Age | Recommended Amount |
|---|---|
| Birth to 6 mo | 40 mg |
| Infants 7-12 mo | 50 mg |
| Children 1-3 yr | 15 mg |
| Children 4-8 yr | 25 mg |
| Children 9-13 yr | 45 mg |
| Boys 14-18 yr | 75 mg |
| Girls 14-18 yr | 65 mg |
| Men | 90 mg |
| Women | 75 mg |
| Pregnant females <18 yr | 80 mg |
| Pregnant women 19-50 yr | 85 mg |
| Breastfeeding females <18 yr | 115 mg |
| Breastfeeding women 19-50 yr | 120 mg |
