ScurvyMANAGEMENT

ENDOCRINE AND METABOLIC PRESENTATIONS · 12 SECTIONS

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677 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

Acute Porphyria Adrenal crisis Adrenal Insufficiency (Addisonian Crisis)Dehydration Diabetes Insipidus Diabetic Ketoacidosis (DKA)Euglycemic DKA (SGLT2 inhibitor)Galactosemia GLP-1 receptor agonist complications (retained gastric contents, aspiration risk)Homocystinuria Hypercalcemia Hyperkalemia Hypermagnesemia Hypernatremia Hyperosmolar Hyperglycemic State (HHS)Hypertensive emergency Hypertensive urgency Hypocalcemia Hypoglycemia Hypogonadism (Acute Presentation)Hypokalemia Hypomagnesemia Hyponatremia Hypoparathyroidism (Tetany)Insulin pump failure Maple Syrup Urine Disease (Crisis)Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCAD)Metabolic Acidosis Metabolic Alkalosis Myasthenia gravis crisis Myxedema coma Pellagra Pheochromocytoma (Crisis)Pituitary Apoplexy Pompe Disease (GSD II)Respiratory Acidosis Respiratory Alkalosis Scurvy SIADH Starvation Ketosis Tarui Disease (GSD VII)Thyroid storm Tyrosinemia Vitamin D Deficiency (Severe-Rickets)Von Gierke Disease (GSD I)

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp47

Alarm features and stabilization

›Hemodynamic threats

›Syncope or presyncope suggesting hemodynamic compromise

›Orthostatic vital signs

›Active hemorrhage from large hematomas

›High-output cardiac failure from severe anemia

›Tachycardia with signs of heart failure

›Hemoglobin < 70 g/L as transfusion threshold trigger

›Massive spontaneous hemorrhage

›Hemarthrosis with joint compartment concern

›Large subperiosteal hematoma in children

›Immediate resuscitation priorities

›IV access and fluid resuscitation for hemodynamic instability

›Two large-bore peripheral IVs

›Crystalloid bolus 500 ml over 15 minutes for hypotension

›Type and screen for suspected significant hemorrhage

›Packed red cell transfusion if Hgb < 70 g/L with symptoms

›Avoid delay in vitamin C therapy pending workup

›Vitamin C administration must not be delayed in confirmed or highly suspected cases

›IV ascorbic acid if unable to tolerate oral intake

›Oral route preferred once stable

Key decision points

›Diagnosis confirmation pathway

›Serum ascorbic acid level < 11 mmol/L (< 0.2 mg/dL) diagnostic

›Clinical diagnosis acceptable when labs unavailable and presentation classic

›Empiric treatment warranted if strong clinical suspicion

›Classic triad: perifollicular hemorrhage, corkscrew hairs, bleeding gums

›Highly specific combination when all three present

02History/hx75

Dietary history

›Dietary intake pattern

›Duration of inadequate fruit and vegetable intake

›Onset of deficiency typically after 1 to 3 months of deficient intake

›Fatigue is earliest symptom

›Type of restricted diet

›Tea-and-toast diet in elderly

›Processed food-only or ketogenic diet

›Heated or boiled milk diet in infants

›RDA benchmarks

›90 mg/day for men

›75 mg/day for women

›Additional 35 mg/day for smokers

Symptom timeline

›Symptom progression sequence

›Early: fatigue, irritability, malaise

›Weeks 1 to 4 of deficiency

›Often attributed to depression or functional illness

›Intermediate: skin and gum changes

›Perifollicular hemorrhage

›Hyperkeratosis, corkscrew hairs

›Bleeding and swollen gums in dentate patients

›Advanced: musculoskeletal and hemorrhagic complications

›Joint and bone pain

›Spontaneous hematomas

›Hemarthrosis

›Severe: hemodynamic instability

›Syncope

03Physical Exam/exam60

Skin and hair findings

›Pathognomonic skin signs

›Perifollicular hemorrhage

›Highly specific for scurvy

›Lower extremities most common distribution

›Corkscrew or swan-neck hairs

›Coiled kinked hair shafts

›Seen around follicular hemorrhage

›Hyperkeratotic follicular papules

›Keratosis pilaris-like

›Trunk and limbs

›Ecchymoses and purpura

›Large confluent areas

›Disproportionate to minor trauma

›Poor wound healing

›Reopening of previously healed wounds

›Surgical site dehiscence

Oral and gingival exam

›Gingival findings

›Swollen, spongy, purple gums

›Bleeds on light touch

›Absent in edentulous patients

›Interdental papilla hemorrhage

›Early gum sign

›Progresses to frank bleeding with minimal provocation

›Tooth mobility in advanced cases

›Due to alveolar bone hemorrhage

›Rare in mild-moderate cases

04Differential Diagnosis/ddx49

Life-threatening mimics

›Hemorrhagic emergencies

›Coagulopathy from DIC

›ICD-10 D65

›PT/PTT prolonged, fibrinogen low

›Thrombocytopenic purpura (ITP)

›ICD-10 D69.3

›Platelet count markedly low, coagulation normal

›Hemophilia A or B

›ICD-10 D66, D67

›PTT prolonged, factor VIII or IX level low

›Leukemia with marrow failure

›ICD-10 C91-C95

›Peripheral smear and bone marrow biopsy distinguish

Vasculitis and inflammatory mimics

›Inflammatory skin and vessel disease

›IgA vasculitis (Henoch-Schonlein purpura)

›ICD-10 D69.0

›Palpable purpura, systemic inflammation elevated

›Skin biopsy IgA deposits distinguishing

›Leukocytoclastic vasculitis

›Palpable purpura with elevated inflammatory markers

›Biopsy required for definitive diagnosis

›Rheumatoid arthritis or reactive arthritis

›ICD-10 M05, M02

›Joint pain and elevated ESR/CRP overlap

›RF, anti-CCP, uric acid help differentiate

05Laboratory Tests/lt57

Vitamin C and nutritional markers

›Serum ascorbic acid

›Gold standard diagnostic test

›Level < 11 mmol/L (< 0.2 mg/dL) confirms deficiency

›Sensitivity and specificity high when stored and processed correctly

›Leukocyte ascorbic acid level

›Better reflection of tissue stores than serum

›Not routinely available at most centers

›Clinical diagnosis acceptable if labs unavailable

›Classic triad plus dietary history sufficient for empiric treatment

›Nutritional co-deficiency screen

›Serum iron, ferritin, TIBC

›Iron deficiency anemia commonly coexists

›Ferritin may be falsely elevated by inflammation

›B12 and folate levels

›Megaloblastic anemia coexistence

›Particularly in alcohol-related malnutrition

›Vitamin D (25-OH)

›Often co-deficient especially in children

›Rickets coexistence in pediatric scurvy

›Albumin and prealbumin

›General malnutrition marker

›Low albumin correlates with severity of malnutrition

Hematologic evaluation

›Complete blood count

›Anemia pattern

›Normocytic or macrocytic anemia common

›Hemolytic anemia if G6PD deficiency coexisting

06Diagnostic Tests/dt63

Scoring Systems

›No validated scurvy-specific clinical scoring system exists

›Diagnosis based on clinical criteria and confirmatory laboratory testing

›Serum ascorbic acid level < 11 mmol/L diagnostic

›Classic triad criteria: perifollicular hemorrhage, corkscrew hairs, gingival hemorrhage

›Brighton Collaboration criteria for clinical diagnosis

›Used primarily in research settings

›Definite, probable, and possible case definitions

›Nutritional screening tools as adjuncts

›MUST (Malnutrition Universal Screening Tool) identifies at-risk patients

›MNA (Mini Nutritional Assessment) for geriatric patients

›Neither specific for scurvy

MRI

›MRI indications in scurvy

›Subperiosteal hematoma characterization

›High signal on T2 consistent with subperiosteal hemorrhage

›Distinguishes hematoma from tumor or infection

›Joint hemorrhage (hemarthrosis) assessment

›Fluid-sensitive sequences detect joint effusion and synovial thickening

›Signal characteristics help stage chronicity

›Spinal epidural hematoma in severe cases

›Rare but reported

›Cord compression requires urgent MRI spine

›MRI not required for straightforward clinical diagnosis

›Reserve for diagnostic uncertainty or surgical planning

›Avoid routine MRI when clinical and lab diagnosis clear

›CT indications in scurvy

07Disposition/dispo46

Admission criteria

›Indications for inpatient management

›Hemodynamic instability

›Syncope or presyncope with orthostatic hypotension

›Active hemorrhage requiring transfusion

›Severe anemia

›Hemoglobin < 70 g/L with cardiac symptoms

›High-output cardiac failure

›Large hemorrhagic complications

›Compartment syndrome risk from hemarthrosis or large hematoma

›Intracranial hemorrhage

›Intra-abdominal bleeding

›Inability to tolerate oral intake

›Requires IV vitamin C supplementation

›Serious alternative diagnosis not yet excluded

›Malignancy, bleeding disorder, vasculitis requiring inpatient workup

Discharge criteria

›Requirements for safe outpatient management

›Hemodynamically stable

›No orthostatic hypotension

›Heart rate and blood pressure within normal limits

›Mild-to-moderate presentation

›No significant anemia (Hgb > 80 g/L with no symptoms)

›No large hematomas or joint hemorrhage

›Able to tolerate oral vitamin C supplementation

›Adequate plan for dietary modification in place

›Reliable follow-up secured

›1 to 2 week follow-up appointment arranged

08Treatment/t68

Vitamin C supplementation

›Oral vitamin C therapy (preferred route)

›Standard adult regimen

›100 mg orally three times daily

›Alternative: 500 mg orally once daily

›Duration: approximately 1 month until resolution

›Maintenance after acute repletion

›Continue at RDA doses: 90 mg/day men, 75 mg/day women

›Dietary modification to sustain intake long-term

›IV vitamin C (Ascor) for inability to tolerate oral

›Adult dosing (age 11 years and older)

›200 mg IV once daily

›Maximum duration 7 days

›Pediatric dosing

›Age 1 to 10 years: 100 mg IV once daily

›Infants 5 to 11 months: 50 mg IV once daily

›Maximum duration 7 days

›Transition to oral as soon as tolerated

›IV to oral switch once enteral route available

›High-dose vitamin C considerations

›Doses above 1 g/day associated with hyperoxaluria risk

›Avoid in renal insufficiency or history of calcium oxalate stones

›Monitor renal function during high-dose IV therapy

›G6PD deficiency precaution

›IV vitamin C can precipitate hemolysis

›Screen or reduce dose in known or suspected G6PD deficiency

Supportive care

›Anemia management

09Special Populations/sp70

Pregnancy

›Scurvy in pregnancy

›Increased vitamin C requirements during pregnancy

›RDA 85 mg/day in pregnancy

›RDA 120 mg/day while breastfeeding

›Risk factors in pregnancy

›Hyperemesis gravidarum reducing dietary intake

›Poverty and food insecurity

›Eating disorders exacerbated in pregnancy

›Fetal and neonatal considerations

›Maternal vitamin C deficiency linked to suboptimal fetal collagen development

›Neonatal scurvy rare but reported with severely deficient mothers

›Treatment in pregnancy

›Oral vitamin C safe at therapeutic doses

›High-dose supplementation above 2 g/day theoretical concern for fetal oxalate metabolism

›Standard 100 mg TID regimen appropriate for most pregnant patients

›Prenatal care coordination

›Dietitian referral for nutritional optimization

›Monitor iron and folate as coexisting deficiencies common

Geriatric

›Scurvy in older adults

›High-risk population characteristics

›Social isolation with limited food preparation capacity

›Cognitive decline affecting dietary choices

›Institutionalized patients with limited dietary variety

›Polypharmacy including PPI use

›Atypical presentation in elderly

›Fatigue and weakness attributed to deconditioning

›Bruising attributed to skin fragility or anticoagulation

›High index of suspicion required

›Gingival findings may be absent

›Edentulous patients lack classic gingival signs

›Skin and hair findings become primary diagnostic clues

›Comorbidity considerations

›Renal insufficiency limits high-dose IV vitamin C

›Cardiac failure from severe anemia may decompensate underlying heart disease

›Drug-nutrient interactions more frequent with polypharmacy

›Fall risk with bone and joint involvement

›Hemarthrosis and bone pain increase fall risk

›Delirium risk with severe anemia

›Discharge planning

›Meals-on-wheels or community nutritional support

›Occupational therapy for meal preparation capacity assessment

Pediatrics

›Scurvy in children

›Age distribution

›Most cases in children aged 6 months to 2 years (weaning period)

›Older children with autism spectrum disorder or selective eating

›Classic pediatric presentation

›Refusal to walk or frog-leg position at rest

›Pseudoparalysis from subperiosteal hemorrhage

›Extreme irritability on handling (pain from bone tenderness)

›Radiographic findings unique to pediatric bone

›Wimberger ring sign on X-ray

›Trummerfeld zone and Pelkan spurs at metaphysis

›Frankel's line at zone of provisional calcification

›Periosteal elevation from subperiosteal hematoma

›Safeguarding and non-accidental injury exclusion

›Bone changes and unexplained bruising mandate safeguarding assessment

›Collaborative evaluation with pediatrics, social work, and child protection team

›Serum vitamin C level and dietary history essential before labeling abuse

›Feeding history in infants

›Exclusive boiled or evaporated cow milk feeding destroys vitamin C

›Lack of fruit and vegetable introduction after 6 months

›Caregivers may not recognize dietary inadequacy

›Pediatric dosing for vitamin C

›Children 1 to 10 years: 100 mg IV daily if oral route unavailable

›Infants 5 to 11 months: 50 mg IV daily

›Oral preferred: age-appropriate dose once tolerating feeds

›Recovery and follow-up

›Pain resolves within days of supplementation

›Radiographic healing over weeks to months

›Growth reassessment at follow-up well-child visits

10Background/b68

Epidemiology

›Prevalence and distribution

›Developed world prevalence

›Underestimated due to underdiagnosis

›Population prevalence approximately 7 to 13% in low-income populations in some studies

›Frequently misdiagnosed as autoimmune or rheumatologic disease

›At-risk demographic groups

›Elderly living alone

›Homeless individuals

›Individuals with alcohol use disorder

›Children with autism spectrum disorder and food selectivity

›Post-bariatric surgery patients

›Geographic clustering

›Higher rates in areas with food insecurity

›Not limited to developing countries

›Diagnostic delay

›Mean diagnostic delay of several months to years in adults

›Frequently triggers unnecessary invasive workup for malignancy or vasculitis

›Mortality

›Rare in treated cases

›Sudden death reported in severe untreated historical cases

›Cardiac failure from severe anemia potentially fatal

Pathophysiology

›Mechanism of vitamin C deficiency disease

›Role of ascorbic acid in collagen synthesis

›Essential cofactor for prolyl and lysyl hydroxylase enzymes

›Without hydroxylation, procollagen triple helix is unstable

›Defective collagen results in fragile blood vessels and connective tissue

›Vascular fragility consequences

›Perivascular bleeding: perifollicular hemorrhage, purpura, hematomas

›Gingival bleeding from capillary fragility

›Subperiosteal hemorrhage from periosteal vessel fragility

›Role in iron metabolism

›Enhances non-heme iron absorption in the gut

›Facilitates ferritin iron mobilization

›Deficiency contributes to iron deficiency anemia

›Antioxidant depletion effects

›Ascorbic acid is major aqueous-phase antioxidant

›Deficiency increases oxidative stress

›Contributes to impaired immune function and wound healing

›Neurotransmitter synthesis effects

›Cofactor for dopamine beta-hydroxylase (norepinephrine synthesis)

›Contributes to autonomic dysfunction and mood changes

›Fatigue and depression partly neurochemical in etiology

›Body storage and depletion timeline

›Total body ascorbic acid pool approximately 1500 mg

›Symptomatic deficiency after 1 to 3 months of zero intake

›Clinical scurvy after 3 to 6 months of severe deficiency

Therapeutic Considerations

›Treatment response characteristics

›Clinical recovery timeline

›Fatigue and pain: improve within days

›Skin and gum findings: resolve within 1 to 2 weeks

›Radiographic bone changes: months for full healing

›Route of administration considerations

›Oral preferred for most presentations

›IV required only when oral absorption impaired or intake impossible

›Bioavailability of oral ascorbic acid approximately 70 to 90% at low doses

›Recurrence prevention

›Scurvy recurs if underlying dietary inadequacy not corrected

›Maintenance supplementation required in high-risk patients

›Addressing social determinants essential for sustained recovery

›Evidence base for treatment

›No large randomized controlled trials for optimal dosing regimen

›Standard 100 mg TID or 500 mg daily widely used and effective

›Expert consensus supports empiric treatment when clinical diagnosis strong

›Safety of supplementation

›Ascorbic acid well tolerated at therapeutic doses

›GI upset (diarrhea) with high oral doses

›Hyperoxaluria risk above 1 g/day especially with renal impairment

›G6PD deficiency: IV vitamin C risk of hemolysis requires dose reduction

11Patient Discharge Instructions/pdi45

copy discharge instructions

›Diagnosis and cause

›Diagnosis of scurvy (vitamin C deficiency)

›Caused by not getting enough vitamin C in your diet

›Can develop after 1 to 3 months of eating very few fruits and vegetables

›Treatment prescribed

›Vitamin C supplements as prescribed (typically 100 mg three times daily for 1 month)

›Take with or without food

›Do not stop early even if you feel better

›Diet instructions

›Foods high in vitamin C

›Citrus fruits: oranges, grapefruits, lemons

›Bell peppers, strawberries, broccoli, tomatoes, kiwi

›Eat these daily to maintain vitamin C levels

›Food preparation guidance

›Avoid boiling vegetables which destroys vitamin C

›Lightly steam or eat raw when possible

›Activity and wound care

›Limit activity if joint pain or bone pain present

›No heavy lifting or running until symptoms resolve

›Use crutches or assistive devices if walking is painful

›Wound care

›Keep any skin wounds clean and covered

›Wounds may heal slowly until vitamin C is replenished

›Expected recovery

›Timeline

›Fatigue and pain improve within a few days

›Bruising and skin changes improve within 1 to 2 weeks

12References/r29

Guidelines and key sources

›Riviere E, Mathe A, Blaison F, et al. Scurvy, an Enduring Mimicker and Diagnostic Dilemma in Adults: A Review of the 280 Relevant Published Cases in the Twenty-First Century. Clinical Nutrition. 2026.

›PMID 41759242

›Systematic review of adult scurvy epidemiology and clinical features

›Hirschmann JV, Raugi GJ. Adult Scurvy. Journal of the American Academy of Dermatology. 1999.

›PMID 10570371

›Foundational review of adult scurvy clinical presentation

›Pichan C, Dhaliwal G, Cusick A, Saint S, Houchens N. Inadequate Support. New England Journal of Medicine. 2021.

›NEJM case-based review of scurvy diagnosis

›Highlights modern diagnostic pitfalls

›FDA Drug Label. Ascor (ascorbic acid injection). Updated 2025-11-19.

›DailyMed setid 388aad52-fc01-4784-9791-1dbc80c69306

›IV dosing guidance for adults and pediatrics

›Levine M, Rumsey SC, Daruwala R, Park JB, Wang Y. Criteria and Recommendations for Vitamin C Intake. JAMA. 1999.

›PMID (JAMA 1999 vol 281)

›RDA recommendations and pharmacokinetic basis

›Nastro A, Rosenwasser N, Daniels SP, et al. Scurvy Due to Selective Diet in a Seemingly Healthy 4-Year-Old Boy. Pediatrics. 2019.

›PMID 31413181

›Pediatric presentation and safeguarding considerations

›Amos LE, Carpenter SL, Hoeltzel MF. Lost at Sea in Search of a Diagnosis. Pediatric Blood and Cancer. 2016.

›Diagnostic workup and differential of unexplained bleeding in children

›Gandhi M, Elfeky O, Ertugrul H, Chela HK, Daglilar E. Scurvy: Rediscovering a Forgotten Disease. Diseases. 2023.

›PMID 37366866

›Epidemiology, pathophysiology, and modern management review

›Khalife R, Grieco A, Khamisa K, et al. Scurvy, an Old Story in a New Time: The Hematologist's Experience. Blood Cells Molecules and Diseases. 2019.

›PMID 30704850

›Hematologic manifestations and PPI association

›Miyaguchi K, Urushidani S. Recurrent Subcutaneous Hemorrhage and Leg Weakness: A Case of Scurvy Presenting as Simple Purpura. American Journal of Emergency Medicine. 2026.

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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