Vitamin C (ascorbic acid) is a water-soluble vitamin essential in the human diet because the body is unable to synthesise it. It is found in a wide variety of fruit (especially grapefruit, lemons, limes, blackcurrants, oranges and kiwi fruit) and vegetables (eg, broccoli, green and red peppers, tomatoes, cabbage, sprouts and sweet potatoes). It is also found in fresh milk, fish and offal such as liver and kidney.
Vitamin C is essential for collagen formation and helps to maintain the integrity of skin and connective tissue, bone, blood vessel walls and dentine. It is essential for wound healing and facilitates recovery from burns. It also facilitates the absorption of iron.
Very high doses of vitamin C can acidify the urine, may cause diarrhoea, can predispose to urinary calculi and can cause iron overload.
Chronic, severe deficiency of vitamin C results in scurvy, which is characterised by haemorrhages and abnormal bone and dentine formation. The adverse effects of more mild degrees of vitamin C deficiency are not known. The body's pool of vitamin C can be depleted within 1-3 months. People with vitamin C deficiency may also have other vitamin deficiencies and malnutrition.
- Scurvy is generally rare.
- The incidence of scurvy peaks in children aged 6-12 months who are fed a diet deficient in citrus fruits or vegetables.
- Children with abnormal dietary habits, mental illness or physical disabilities are prone to develop scurvy.
- Incidence also peaks in the elderly.
- Infants who are fed only cow's milk during the first year of life.
- Alcoholism and conforming to food fads.
- Being elderly.
- Low-income families, who tend not to buy foods high in vitamin C.
- Scurvy has been diagnosed in those eating fast food with almost no intake of fresh food or vegetables.
- Increased need due to increased utilisation in pregnant and lactating women, thyrotoxicosis, surgery and burns.
- People with type 1 diabetes and those on haemodialysis or peritoneal dialysis, because of increased vitamin C requirements.
- Anorexia nervosa or anorexia from other diseases such as AIDS or cancer.
- Chronic diarrhoea, which increases faecal loss. Risk is increased in those with Crohn's disease and ulcerative colitis, because of reduced vitamin C absorption.
Presentation of scurvy
- Early recognition of scurvy can be difficult because symptoms may appear nonspecific and can mimic more common conditions. In any patient with spontaneous haematoma and purpura, in the context of nutritional disorder, scurvy should be systematically considered.
- The disease spectrum of scurvy is quite varied and includes dermatological, dental, bone and systemic manifestations.
The following symptoms may occur:
- Early symptoms of malaise and lethargy.
- Shortness of breath, arthralgia and myalgia develop after several months.
- Skin changes include easy bruising, petechiae and poor wound healing.
- Gum disease and loosening of teeth are common.
- Emotional changes, including irritability, can be apparent.
- Dry mouth and dry eyes may occur.
- In the later stages, jaundice, generalised oedema and heart failure, haemopericardium, neuropathy, convulsions and sudden death may occur.
The following signs may be present:
- Skin changes can include perifollicular hyperkeratotic papules, perifollicular haemorrhages, purpura and ecchymoses. These are seen most commonly on the legs and buttocks. There may be poor wound healing and breakdown of old scars. Alopecia may occur.
- In the nails, splinter haemorrhages may occur.
- Gums can bleed and become swollen, friable and infected; petechiae can occur on the mucosae.
- Conjunctival haemorrhage, flame-shaped haemorrhages and cotton-wool spots may be seen. Bleeding into the periorbital area, eyelids and retrobulbar space may occur.
- A scorbutic rosary (where the sternum sinks inwards at the costochondral junctions) may occur in children.
- High-output heart failure due to anaemia can be seen and hypotension may occur late in the disease.
- Fractures, dislocations, tenderness of bones and bleeding into muscles and joints are possible.
- Synovitis with joint effusion can occur.
- Oedema may occur late in the disease.
- Loss of weight secondary to anorexia is common.
- The diagnosis of scurvy is usually based on a combination of clinical and radiographic findings.
- Presence of low vitamin C levels may help but often the best way to confirm diagnosis is to watch for resolution of symptoms with vitamin C treatment.
- A positive capillary fragility test may be found.
- Anaemia is common.
- Bleeding, coagulation and prothrombin times are all normal.
- X-rays can assess for fractures and dislocations. They may also show subperiosteal elevation, alveolar bone reabsorption and ground-glass appearance of the bone cortex. The most common radiographic finding is osteopenia.
- Treatment is ascorbic acid replacement therapy.
- Infants and children are usually treated with vitamin C 100-300 mg daily and adults 500-1000 mg daily for one month or until full recovery of clinical signs and symptoms occurs.
- Supplements should be combined with intake of foods high in vitamin C.
- Any other dietary deficiencies should also be treated.
- As scurvy can lead to severe complications, nothing should delay vitamin C supplementation, which is a simple and rapidly effective treatment.
- Analgesics may be necessary for those with symptoms.
Gastrointestinal effects are the most common adverse clinical events associated with acute, high doses of vitamin C given over a short period of time.
- Scurvy can be fatal if untreated.
- Patients respond quickly to oral therapy and complete recovery is usually expected.
- An adequate dietary intake of vitamin C is essential.
- Around 90% of vitamin C in the diet comes from fruit and vegetables. Cooking reduces vitamin C content by 30-40%.
- The recommended daily intake of vitamin C in the diet depends on age and sex.
- Dietary Reference Values for Food Energy and Nutrients for the UK suggest the following recommended nutrient intake:
- For children aged 1-10 - 30 mg/day.
- For children aged 11-14 - 35 mg/day.
- For children aged over 15 and adults - 40 mg/day.
- As a rough guide, one large orange will provide the recommended daily intake of vitamin C for an average adult.
Further reading and references
Hansen SN, Tveden-Nyborg P, Lykkesfeldt J; Does vitamin C deficiency affect cognitive development and function? Nutrients. 2014 Sep 196(9):3818-46. doi: 10.3390/nu6093818.
Allan GM, Arroll B; Prevention and treatment of the common cold: making sense of the evidence. CMAJ. 2014 Feb 18186(3):190-9. doi: 10.1503/cmaj.121442. Epub 2014 Jan 27.
Agarwal A, Shaharyar A, Kumar A, et al; Scurvy in pediatric age group - A disease often forgotten? J Clin Orthop Trauma. 2015 Jun6(2):101-7. doi: 10.1016/j.jcot.2014.12.003. Epub 2015 Jan 5.
Al-Dabagh A, Milliron BJ, Strowd L, et al; A disease of the present: scurvy in "well-nourished" patients. J Am Acad Dermatol. 2013 Nov69(5):e246-7. doi: 10.1016/j.jaad.2013.04.051.
Levavasseur M, Becquart C, Pape E, et al; Severe scurvy: an underestimated disease. Eur J Clin Nutr. 2015 Jun 17. doi: 10.1038/ejcn.2015.99.
Ferrari C, Possemato N, Pipitone N, et al; Rheumatic manifestations of scurvy. Curr Rheumatol Rep. 2015 Apr17(4):26. doi: 10.1007/s11926-015-0503-6.
Dietary Reference Values; British Nutrition Foundation