Unrecognised scurvy

Publisher Website
Google Scholar
Abstract
Case reportA 30 year old white law clerk presented to the orthopaedic team with a two week history of non-traumatic left leg swelling and bruising. It had started with pain and swelling on the medial aspect of the left knee, which progressed to extensive bruising and swelling on the posteromedial aspect of the left thigh and calf. He was a non-smoker with no relevant medical history and was not on any medication. He looked well, and examination was unremarkable. His haemoglobin level was 105 g/l, mean cell volume 78 fl, mean cell haemoglobin 26 pg, with no thrombocytopaenia. A colour-flow Duplex-Doppler ultrasound excluded deep vein thrombosis but detected tissue oedema. He was discharged with ruptured left gastrocnemius muscle as a provisional diagnosis.A fortnight later he presented to the medical assessment unit after a follow-up blood test arranged by his general practitioner showed a haemoglobin level of 37 g/l. He reported breathlessness, with no history of haematemesis, haemoptysis, or melaena, but he mentioned frequent episodes of epistaxis that resolved spontaneously after his first admission. On examination, he had generalised swelling and bruising of his left leg with a full complement of palpable pulses. No other bruises or petechiae were found on the rest of the body. His laboratory investigations showed that platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen concentration, and renal function were all normal, but that his D-dimer concentration was raised at 2559 ng/ml.On this admission, a repeat venous Duplex-Doppler ultrasound of the left leg showed a haematoma in the left distal thigh and deep vein thrombosis in the superficial femoral vein extending down to the ankle. Another repeat ultrasound by a consultant radiologist excluded evidence of deep vein thrombosis, and therefore anticoagulation was not started. Despite multiple blood transfusions, the patient’s haemoglobin level stayed low. A gastroscopy revealed multiple duodenal ulcers, which were injected with adrenaline, and triple therapy with amoxicillin, clarithromycin, and omeprazole was started for Helicobacter pylori infection. Since the patient’s haemoglobin level remained low, between 65 g/l and 75 g/l, and a new onset of gum bleeding was noted, he was referred to gastroenterology and haematology. Meanwhile, an immune mediated haemolytic anaemia was excluded by vasculitic screen and Coombs test. Meckel’s scan for ectopic gastric mucosa was negative. A bone marrow biopsy was normal apart from showing mild erythroid hyperplasia consistent with his recent history of blood loss. Scurvy was then considered as a differential diagnosis, as further questioning revealed that the patient’s diet was deficient in fruits or vegetables. Given the symptom presentation of epistaxis, gum bleeding, and haemorrhage in the lower limbs, oral supplementation with vitamin C was started. Subsequently, his haemoglobin level improved to 85 g/l, and he had no further symptoms on follow-up. This was a diagnosis of exclusion, as no confirmatory investigation such as serum ascorbic levels was available.

This publication has 0 references indexed in Scilit: