Persistent scurvy after vitamin C supplementation in a high-risk patient: a case report

Background: Scurvy is a multi-organ syndrome caused by a deficiency of vitamin C. Although historically significant, scurvy is being increasingly diagnosed in the modern era due to the growing prevalence of risk factors including socioeconomic barriers to quality nutrition, smoking, alcohol consumption, chronic illness, and dialysis. Scurvy can present with a variety of signs and symptoms including fatigue, neuropsychiatric disturbances, arthralgia, gingivitis, and hemorrhagic skin lesions. It is rarely reported in adults without significant alcohol use or a self-restricted diet. We present a unique case of a middle-aged man on hemodialysis with food insecurity in whom scurvy was suspected following a careful dermatologic examination. This report aims to highlight the diversity of risk factors for vitamin C deficiency and the challenges of treating patients facing barriers to adequate nutrition and healthcare access. Case Description: A 51-year-old male with chronic kidney disease on hemodialysis, untreated hepatitis C, tobacco use disorder, and housing instability presented to the hospital with sub-acute changes in cognition and unexplained bleeding from his dialysis catheter. Physical examination revealed significant weight loss, lower extremity alopecia, and perifollicular petechiae with corkscrew and swan-neck hairs. A diagnosis of scurvy was confirmed with undetectable serum vitamin C (<0.1 mg/dL; reference range, 0.4-2.0 mg/dL), and a subsequent dietary history revealed recent food insecurity. Vitamin C 500 mg was supplemented twice daily for 14 days. Nutrition counseling and a multivitamin prescription were provided prior to patient-directed discharge. A repeat hospitalization 120 days later revealed incomplete resolution of vitamin C deficiency. Conclusions: Nutritional deficiencies, including vitamin C deficiency, are important to consider in patients with complex medical and social histories. High-risk groups deserving particular consideration are those demonstrating socio-economic barriers to healthcare and nutrition, patients with severe chronic illness, and patients on dialysis. Manifestations of scurvy are variable and may include less specific signs such as anemia, neuropsychiatric disturbance, and bleeding, as well as more specific dermatologic phenomena. Treatment includes high-dose vitamin C supplementation, but careful patient education and interdisciplinary support may be necessary to prevent recurrence in high-risk populations.