A 47-year-old male presented to the emergency department with a progressive onset of confusion, lethargy, anorexia, fatigue, weakness, and a diffuse nonpruritic perifollicular rash. Over the previous 6 months, the patient had lost 5 to 6 kg. He had multiple spontaneous hematomas on his lower extremities (Figure 1).
After initial supportive treatment, results of primary investigations revealed a normocytic normochromic anemia with a hemoglobin level of 64 g/L. Two units of packed red blood cells were transfused. Electrolytes, platelets, kidney function, liver enzymes, liver function, calcium, magnesium, ammonia levels, and blood glucose were all within normal limits. Results of a fecal occult blood test were negative. Ferritin, folate, and vitamin B12 levels were normal. Results of the toxicology screen were negative.
After the patient was admitted, urine cultures and blood cultures were found to be negative for bacteria. An abdominal ultrasound scan revealed a mild fatty liver with fibrotic changes; however, there was no evidence of cirrhosis or portal hypertension. Bilateral Doppler ultrasound scans of the legs were negative. A computed tomography head scan revealed moderate cerebral and cerebellar atrophy but no evidence of any acute events or intracranial masses. A skin punch biopsy of the perifollicular rash was sent for assessment.
During the patient’s admission, a nutritionist was consulted in order to evaluate his anorexia and weight loss. The report revealed a fairly consistent, regular, and habitual diet of coffee for breakfast, a sandwich for lunch (egg salad, ham and cheese, or peanut butter and banana) along with 2% milk. For dinner, the patient would normally eat either frozen dinners (mostly lasagna) or, on occasion, a small portion of steak, which he would cook himself. Snacks consisted mostly of crackers. He acknowledged drinking 8 to 10 beers per day. The patient was not taking any supplements or vitamins. His diet was very limited in fresh fruits and vegetables. He did not like eating seafood or fish. Consequently, he was started on a daily multivitamin as well as 100 mg of thiamine daily.
Results of the skin biopsy demonstrated evidence of follicular hyperkeratosis, focal perifollicular hemorrhages (Figure 2), and mild chronic inflammation. Corkscrew hairs were also noted. Pathologic features were consistent with vitamin C deficiency. Consequently, a vitamin C serum assay was performed, which showed levels of < 10 μmol/L (normal being 45 to 90 μmol/L). The diagnosis of scurvy was made.