Vitamin C Deficiency

1. See Also
   1. Vitamin C
2. Pathophysiology: Vitamin C Deficiency
   1. Increased fragility of capillaries
   2. Poor Wound Healing
3. Risk factors
   1. Elderly edentulous patients who cook for themselves
   2. Alcoholism
   3. Mental illness
   4. Infant on processed milk without supplementation
   5. Unusual dietary habits
4. Symptoms
   1. Fatigue
   2. Children
      1. Irritability
      2. Tachypnea
      3. Decreased Appetite
      4. Leg tenderness
   3. External bleeding
      1. Hematuria
      2. Melena
5. Signs: Children and Adults
   1. Purpura (saddle distribution)
      1. Perifollicular Petechiae
      2. Onset on back of lower extremities
      3. Coalesce into Ecchymoses
   2. Hemorrhages
      1. Hemorrhages into muscles of extremities
      2. Hemorrhages into joints
      3. Splinter Hemorrhages into nail beds
      4. Gingival hemorrhages
      5. Visceral hemorrhages
      6. Intracranial Hemorrhage (especially children)
         1. Subdural hemorrhage
         2. Retrobulbar hemorrhage
         3. Subarachnoid Hemorrhage
   3. Gingivitis (only in patients with teeth)
      1. Bluish purple spongy swellings
      2. Most prominent near incisors
   4. Other changes
      1. Poorly healing wounds
      2. Xerosis
   5. Late stage changes
      1. Jaundice
      2. Peripheral Edema
      3. Fever
6. Signs: Children (Bone changes)
   1. Changes in addition to those above
   2. Long bone periosteal changes
      1. Epiphyseal separation with painful swellings
      2. Bowing of long bones
   3. Sunken Sternum
      1. Forms scorbutic rosary at costochondral margin
7. Differential Diagnosis
   1. Oral changes (Xerostomia)
      1. Sjogren's Syndrome
   2. Chest changes with sunken Sternum
      1. Rickets (Rachitic Rosary)
   3. Arthralgias
      1. Rheumatic Fever
      2. Septic Joint
      3. Osteomyelitis
   4. Purpura
      1. Henoch-Schonlein Purpura
      2. Thrombocytopenic Purpura
8. Radiology
   1. Epiphyseal separation
   2. Distal long bone changes (especially at knee)
      1. Ground-glass appearance of bone
      2. Cortex decreased to pencil point width
9. Labs
   1. Ascorbic acid concentration in buffy layer
   2. Urine Aminoaciduria
   3. Complete Blood Count
      1. Normocytic Normochromic Anemia
   4. Prothrombin Time increased
10. Management
    1. Vitamin C (Ascorbic acid) Replacement (preferred)
       1. Adults: 200 mg qd
       2. Children: 100 to 200 mg qd
    2. Dietary Vitamin C
       1. Orange Juice or Tomato Juice >4 ounces per day
11. Complications
    1. Risk of sudden death in late disease
12. Prevention
    1. See Vitamin C for recommended daily needs
13. References
    1. Behrman (2000) Nelson Pediatrics, p. 182-4
    2. Cotran (1999) Robbins Pathologic Basis, p. 449-50
    3. Rees in Lee (1999) Wintrobe's Hematology, p. 1638
    4. Wilson (1991) Harrison's Internal Medicine 438-9
    5. Hirschmann (1999) J Am Acad Dermatol 41(6):895-906
    6. Rajakumar (2001) Pediatrics 108(4):E76