Patient: A 37-year-old woman from Philadelphia
Symptoms: The patient went to the emergency department after 4 days of pain, swelling and bruises in the upper left knee. She reported that these symptoms appeared after using a massage gun on her legs.
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The doctor saw bruises on his thighs, knees and calves, and he had swelling, but there were no joint damage or blood clots on the scan. They encouraged patients to stop using massage guns, continue with medication therapy and follow up later.
A few weeks later she returned with shortness of breath and short lightheads, but she still had a bruise to her leg. MRI of the legs showed tissue swelling and small muscle bruises that are usually caused by blunt trauma to the tissue. Blood tests revealed that her red blood cells and hemoglobin (the part of the blood carrying oxygen) had dropped to dangerously low levels.
Suspicion of the patient’s possible anemia due to iron deficiency, the medical team also checked iron levels and found them to be low. To search for potential causes of blood loss, the doctors performed stool tests and performed stomach and colonic ranges, all of which were normal.
Patients were excreted with daily iron tablets and weekly intravenous iron prescriptions, which were unable to raise hemoglobin levels. She then received several transfusions, each of which temporarily lifted the numbers, but they only fell again within a week. Concerns about her low hemoglobin levels led doctors to pause blood thinner and place intrauterine devices to stop menstrual bleeding.
Approximately six weeks after this decline, she returned to the emergency department with worsening chest pain, night sweats, weight loss and shortness of breath. Her lungs sounded clear, but the scan showed that the right side of her heart was enlarged and weak, with the pressure in her lungs being very high, a condition called pulmonary hypertension. Her oxygen levels worsened overnight, so doctors transferred her to intensive care. At that point, the doctor noticed that she had small red spots around the hair follicles on her legs, and her hair was twisted into the cork skin. She also had swollen purple gums.
Diagnosis: Red spots, cork skin hair and swollen gums are classic signs of vitamin C deficiency, and testing has resulted in no detection of her vitamin C levels. Upon further questions, she reported that she had avoided them for years as citrus food gave her nest box. (Additional fruits and vegetables are also a great source of vitamin C. Female doctors were not sure if they had consumed any of the other foods.)
Without vitamin C, the body cannot build strong collagen. This is a scaffold that supports blood vessels and tissues. The fragile container leaks, leaves bruising, and the wounds are no longer inferior, and in rare cases strain can affect heart and lung function.
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Treatment: The doctor started the patient with a high-dose oral vitamin C supplement, and the turnaround was dramatic. Within 48 hours she was stable enough to quit intensive care. She was then excreted with a prescription for vitamin C supplements, iron-containing multivitamins, and pulmonary hypertension drugs.
The following week, her blood count rose without more transfusions, the bruises and swelling of her gums faded, and her breathing improved. Her blood was safely rebooted. Within six months of discharge, she no longer needed medication due to pulmonary hypertension, her heart functioning and scans returned to normal, and she returned to exercise before she had a bruise.
What makes the case unique: Scurvy is usually remembered as a historic sailor’s disease, but this form of malnutrition can still affect modern people.
Most cases of scurvy cause fatigue, simple bruises, or mild anemia, but this patient developed transfusion-dependent anemia. This means that they needed regular blood transfusions to be counted. Her condition was very serious and she had no response to iron therapy. This is a rare event that is only sometimes described in the medical literature.
She also developed high pulmonary pressure with strain on the right side of the heart. This is an unusual complication of scurvy, which only improves when vitamin C is replaced, rather than a standard drug for the treatment of pulmonary hypertension.
“The current case reminds us that scurvy continues to occur in the United States and highlights its potential severity and clinical characteristics,” the doctor wrote in his case report. “It also emphasizes the importance of dietary history reviews, especially when the diagnosis is elusive.”
For more interesting medical cases, see the Diagnosis Dilemma Archive.
This article is for informational purposes only and is not intended to provide medical advice.
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