Scurvy is a disease caused by deficiency of vitamin C , which is essential for the synthesis of collagen in human beings. The chemical name of vitamin C is ascorbic acid. The name scurvy derived from the Latin word scorbutus, and the disease is known since ancient Greek and Egyptian times. Scurvy is usually the disease of sailors in the 16-th to 18th centuries who navigated long distance without enough vitamin C. In modern era cases of scurvy are very rare.
Vitamin C is not synthesised in the human body which is necessary for production of collagen and iron absorption and so must take from external sources. People must consume citrus fruits and vegetables that contain vitamin C, in order to avoid the vita-min C deficiency, known as scurvy.
The disease often presents itself initially as symptoms of malaise and lethargy, fo-llowed by appearance of spots on the skin, spongy bleeding gums. Spots are more ma-rked on the thighs & legs, and the diseased person looks pale and depressed. The adv-anced stage of scurvy is characterised by open, suppurating wounds, loss of teeth, ne-uropathy, fever, jaundice and death.
Aetiology (Causes) of Scurvy
• The most important primary cause of scurvy is insufficient intake of vitamin C (Ascorbic Acid), which may be due to lack of knowledge, acute insufficiency, anorexia or difficulty in ingesting food orally.
• Scurvy occurs from the prolonged consumption of diet devoid of fresh fruits and vegetables.
• The principal deficiency in such a diet is the lack of ascorbic acid (vitamin C) which is responsible for the characteristic features of the disease. Usually such diets are more likely to be deficient in other nutrients also like iron, vitamin A and sometimes protein.
Risk Factors of Scurvy
In modern era scurvy is very rare disease but still it may occur in:
• Elderly people
• Chronic alcoholic
• Those that live on a diet lack in fresh fruits (Citrus fruits) and vegetables.
• Infants and children on poor or special diets for socio-economic reasons may be prone to scurvy.
Pathology of vitamin C Deficiency :
Vitamin C (Ascorbic Acid) deficiency may lead to:
• Defective formation of collagen in connective tissue
• Defective intercellular cement
• Defective dentine in teeth
• Defective osteoid tissue in bone.
• Capillary haemorrhages, delayed healing of wounds and defective formation of teeth bones occur during growth.
• In adults the teeth may become loose
• Anaemia may be a prominent feature of scurvy
History and Epidemiology of Scurvy
• In the year 1497 Vasco de Gama sailed round the Cape of Good Hope and established a trading centre on the Malabar cost. Scurvy occurred among his crew and 100 out of 160 people died. For the next 300 years scurvy was a major factor determining the success or failure of all sea ventures.
• In the year 1753, a Scottish naval surgeon, published a systematic explanation of the Scurvy, in which he showed that the disease can be cured by fresh lemo-ns and oranges but also be prevented by adequate dietary and hygienic measu-res.
• Although scurvy ceased to be an important disease of sailors, it continued to distress the troops present in the forts and civil population surrounded by host-ile forces and those confined to prisons.
• It also occurs in infants fed on preserved and artificial milks. These provided an adequate substitute for protein, fat and carbohydrates in human milk by ha-ve little or no ascorbic acid; scurvy in infants became an important disease.
• The period of greatest productivity of infantile scurvy was in the last 20 years of the 19th century.
• At a later date, cases of scurvy used to occur in adult patients treated for peptic ulcer by severe and prolonged dietary restrictions.
• When knowledge of vitamin C was established in early 19th century, scurvy soon became a rare in Britain and other countries.
• This satisfactory position occurs partly due to the increased production of citr-us fruits and green vegetables and their distribution in the canned or frozen st-ate; this makes them available throughout the year.
• Scurvy still occurs however as a result of ignorance, poverty and maternal neglect.
• Sporadic scurvy cases continue to arise, at the other extreme age, amongst old males.
• Scurvy appears to be a rare disease in infants and children in most subtropical and tropical countries.
• When the Maternal and Child Health Services are inadequate, especially in in-fantile scurvy may be more common than reports indicate, especially in infants who for one reason or another are weaned from the breast prematurely.
• Scurvy is more likely to occur in arid (lacking in rainfall) regions of the world in time of draught, as in Arabia and parts of India, after a failure of monsoon rains.
Clinical Features of Scurvy
• The best clinical feature of scurvy is that given in 1753 by Lind who had grea-ter experience of the disease than any modern physician and described his obs-ervations with the clarity and elegance characteristic of his time. He said that the specific sign of the scurvy was the appearance of the gums, and certainly the characteristic gingivitis often first suggests the diagnosis.
Symptoms of scurvy may begin with
• Loss of appetite
• Poor gain in weight
• Shortness of breath (Increased respiratory rate)
• Disconmfort and tenderness in legs
• Pain and swelling over weight bearing bone.
• Feelings of paralysis
As the disease advances a scurvy patient may come with
• Bleeding gums
• Loosening of teeth
• Bruising and petetial haemorrhage of mucous membrane and skin
• Hoemorragic eyes
• Poor wound healing
• Bulging of eye balls (Proctosis)
• Follicular keratosis sometimes associated with vitamin A deficiency
• Costochondral beading (Cartilage between joints) leads to enlargement of costochondral junction,
• Curly hairs (Corkscrew hair),
• Sicca syndrome (Autoimmune disease of connective tissue).
• By the time the disease is fully developed the patient is often anaemic.
• Examination of an adult patient with scurvy usually reveals no abnormal phys-ical signs of disease except gingivitis and subcutaneous haemorrhages and so gravity of his condition may not be appreciated.
• Patient may die suddenly from cardiac failure without warning.
• In the late stages of disease, general anasarca (generalised oedema), jaundice, oligurea, neuropathy, fever and convulsions and if continue leads to death.
In infants the main clincal features of scurvy are
• Lassitude (Weakness with lack of energy),
• Painful limbs
• Enlargement of the costochondral junctions.
• Before the teeth eruption, scorbutic infants do not develop gingivitis & when it occurs the gums have typical 'scurvy buds', a feature of considerable diagnos-tic importance.
Diagnosis of Scurvy
The health care providers will perform a thorough physical examination for signs and symptoms of scurvy mentioned above. Exact vitamin C levels can be measured by laboratory tests that analise ascorbic acid levels in the serum (or WBC ascorbic acid concentration). Radiological measures can be performed to diagnose and to see the damage done by the disease.
Treatment of Scurvy
• Because of the danger of sudden death, synthetic ascorbic acid is given soon in adequate quantities. Parenteral treatment has no advantage over oral administr-ation.
• Treatment of scurvy is simply with vitamin C suppliments taken orally. The adult dose is 1000 mg/day for at least one week followed by 500 mg/ day until full recovery. Children require vitamin C 150-300 mg /day for 1 month.
• Aim of treatment is to saturate the body with vitamin C as soon as possible. A fully saturated body contains approsimately 5 g. of the vitamin C, so a dose of 250 mg. orally four times a day should achieve this within a week.
• Scurvy can be prevented easily by taking recommended daily dose of vitamin C. This is between 30-60 mg/day. By following the '5 servings of fruit & veg-etables daily' rule, you will get required daily intake of vitamin C.
Dietary sources of Vitamin C
Ascorbic acid is present in insignificant amounts in foods of animal origin.
Rich sources of vitamin C are:
• Blackcurrants (small black berries)
• Brussels sprouts
• Bell peppers
• Extracts of rose hips
• Pine needdles
• All citrus fruits
• Fresh vegitables
Prognosis of Vitamin C
With adequate treatment no patient dies of scurvy and recovery is usually rapid and complete.