Laurenda Guilford

Case Study
NUTR 6106
03/21/2016
Old World Meets New: A Case Report of Scurvy
In the 1400s to the 1500s it was recognized that men who were on long journeys, such
as sailors, explorers and monks in monasteries, were falling victim to an unknown disease,
finally the lack of fruits in the diet were associated as the cause of many peoples symptoms.
Ascorbic Acid was identified and it became known how crucial it was to include ascorbic acid
(or vitamin C) into the diet. The name for the disease became scurvy. In todays society,
scurvy is a rarely seen disease-but when it is diagnosed, it is more likely to be seen in alcoholics,
children and elderly. Vitamin C has an important role in many functions of the body, both
directly and indirectly, which can lead to a number of inefficient systems and therefore reveal the
outward symptoms seen in scurvy(1). Vitamin C deficiency can even be deadly, or have
irreversible side effects such as fragility of bone or lack of bone formation in the crucial years of
childhood development.
Due to Vitamin Cs Water Solubility, regular intake is needed to properly keep up
adequate collagen production levels, keep Iron in its active form (ferrous iron Fe++), work as the
rate limiting step in bile acid synthesis, work to synthesize hormones (dopamine>norepinephrine->epinephrine), work as a strong antioxidant-while sparring other vitamins
oxidation rate, and more less common effects such as cataracts and high serum cholesterol levels.
One of the most important functions in the body that is affected by low iron levels
is collagen synthesis. Collagen is a matrix of proteins, crosslinked together, highly found in the
foundation of many body parts such as skin, blood vessels, teeth and bones, eyes, heart and

joints(2). In the making of collagen, the body uses two proteins in particular to produce
collagen, they are lysine and proline. But before they can be actively used, Lysine and Proline
must undergo hydroxylation by enzymes that first need to be activated to allow Hydroxylation of
Lysine and Proline for collagen synthesis. These crucial steps allow crosslinking of the newly
formed 4-hydroxyproline and 4-hydroxylysine to form a helical structure with more strength than
steel at the same weight. Failure to crosslink 4-hydroxyproline and 4-hydroxylysine leads to an
inadequate structure (3). Not only is the structure strength compromised, but no structure is
formed at all in long term cases of the disease.
Besides collagen formation, Vitamin C functions as a cofactor in iron, keeping it
in its active ferrous form. Without vitamin C accomplishing this, the body cannot release the
stored form of iron that it contains, causing a patient to become anemic due to lower amounts of
heme iron loaded erythrocytes. Also, vitamin C is a rate limiting step in the production of
catacholamines. If ascorbic acid is not present to push forward the reaction of dopamine to
epinephrines enzyme reaction (w/ dopamine B oxidase) then there is limited rate of dopamine
to epinephrine and therefore a limit of production of norepinephrine. These two hormones are
extremely important to many functions in the body, including but not limited to increasing
cardiac activity, blood pressure, glycogen breakdown, blood glucose levels. The rate limiting
step vitamin C plays in the formation of bile acids is another function in the body that heavily
relies on vitamin C. For the body to create bile acids, 7 cholesterol must be converted to 7-
hydroxyl cholesterol. Ascorbic acid works to oxidize NADPH+H+ to NADP, providing the
needed hydrogens for the formation of 7- hydroxyl cholesterol. Effects of this system
malfunctioning are high serum cholesterol and low bile production. Science is still determining
just how important each antioxidant is to the immune system, and vitamin C is no exception.

Vitamin C alleviates the effects of ROS (reactive oxygen species) to enhance the immune
system, as well as sparring the other vitamins that would be susceptible to damage from the
effects of ROS to the system. There are many other functions in the body that are less crucial
that could be explained here, but the overall takeaway message is that vitamin C is an important
vitamin that needs to be regularly consumed.
Vitamin C is a water soluble vitamin, so it is not stored in high amounts in the
body. Daily intake is necessary to fulfill the bodies need for functioning properly. The RDA for
vitamin C is 65 mg/day for women and 90 mg/day for men. The adequate intake (AI) is 40
mg/day (for infants in particular) and the upper limit (UL) is between 1,200 and 2,000 mg/day
depending on the age and gender of the person(3). The repercussion of exceeding the
recommended UL of vitamin C are few, due to the water solubility of vitamin C. The most
widely seen effects of extreme over consumption are kidney and gall bladder stones, canker
sores, and high amounts of vitamin found in the urine. The under consumption of vitamin C will
cause deficiency, leading to the physiological effects mentioned above, as well as clinical
presentation symptoms that will be mentioned in the following case study.
The following case study is a good representation of what vitamin C deficiency scurvy
is and how it may present in an adult patient population. The studied patient was a 65 year old
male, with heavy alcohol abuse (10-15 drinks/day), and a diet of only cheese pizza. The patient
had been living in foul living conditions and had no medical attention for 20+ years. He had
stable vitals and was found to be alert and oriented. The clinical findings were recent fatigue,
loss of appetite, weight loss, swelling and bruising, spontaneous ecchymosis, poor dentition,
corkscrew hairs on abdomen, chest, legs and arms, perifollicular petechial, erythrocyte
extravasion. Patients serum ascorbic acid levels were found to be <0.12mg/dL and his HgB @

6.3 g/L & MCV 95.6, he had a high prothrombin time, a BUN of 49 mg/dL and Cr 1.9. His labs
for AST were 98 U/L and ALT were 38 U/L. These labs combined indicated a diagnosis of
vitamin C deficiency, normocytic anemia secondary to bone marrow suppression and high
alcohol consumption, vitamin K deficiency, dysfunctional kidneys and liver failure from high
alcohol consumption.
The treatment interventions that took place were 1g/day vitamin C for 5 days, and then
500 mg/day beginning day six. Patient counselling was done and recommendations for alcohol
rehabilitation were made. At patients one month post discharge follow up appointment, the
patient had complete resolution of all skin lesions (4). An oral vitamin C challenge could have
been done, but were unnecessary due to low serum vitamin C. This challenge consists of low
urine levels of vitamin C after high dose vitamin C)
In conclusion, scurvy is rarely seen, but more prominent in elderly, children, alcoholic
and economically challenged populations. In practice, medical care providers and their team
should pay particular attention to these populations for vitamin C deficiency. The reversal of this
deficiency is rather simple and can be accomplished with supplemental vitamin C or by eat lots
of vitamin C foods (5 per day) and the problem should resolve itself over a 1 month time frame.
Extreme cases of vitamin C deficiency can be deadly or irreversible effects can be seen, such as:
long term effects causing loss of bone formation in children, stunting of growth, fragility of
bones. As Registered Dietitians, we should look out for this deficiency in either inpatient or
outpatient settings as well as while working in community settings with the elderly, alcoholic,
low-income, inner city, or child population groups. Diagnosing the deficiency of vitamin C early
and preventing the deficiency with target population education are necessary to prevent any
increase in the diagnosis in our communities.

References
1. Vitamin C (ascorbic acid) Background - Mayo Clinic [Internet]. [cited 2015 Oct 30].
Available from: http://www.mayoclinic.org/drugs-supplements/vitaminc/background/HRB-20060322
2. Vitamin C and Collagen [Internet]. [cited 2016 Mar 20]. Available from:
http://www.vitamincfoundation.org/collagen.html
3. Lipcot, Williams, & Wilkins. Modern Nurtrition in Health and Disease. Modern Nurtrition in
Health and Disease. New York, New York : Walters Kluwer Health, 2013, pp. 100-101.
4.

ULs for Vitamins and Elements.doc - ULs for Vitamins and Elements.pdf [Internet].
[cited 2015 Sep 26]. Available from:
http://iom.nationalacademies.org/Activities/Nutrition/SummaryDRIs/~/media/Files/Activit
y%20Files/Nutrition/DRIs/ULs%20for%20Vitamins%20and%20Elements.pdf

5. Wang AH, Still C. Old World Meets Modern: A Case Report of Scurvy. Nutr Clin Pract.
2007;22:4458.