An HIV-Infected Man with Odynophagia and Rash

Abstract

Diagnosis: Scurvy. The patient's serum ascorbic acid level was 0.1 mg/dL (normal range, 0.4-1.5 mg/dL). The punch biopsy of the skin of the right lower leg (figures 1 and 2) revealed minimal hyperkeratosis and thin epidermis (figure 3). There was extravasated blood in superficial dermis, admixed with karyorrhectic debris. Some of the dermal capillaries showed mild leukocytoclastic changes. There was no hair follicle in the specimen. Scurvy was diagnosed, and the patient was treated with high doses of ascorbic acid for 1 week. The leg edema and purpura quickly resolved during treatment (figure 4). Endoscopy of the upper gastrointestinal tract disclosed esophagitis with strictures, which were dilated. The pancytopenia was secondary to alcohol abuse, liver disease, and HIV infection. Scurvy is an uncommon disorder in developed countries. It is typically associated with malnutrition, alcoholism, severe gastroesophageal reflux, or/and advanced age [1-4]. Ascorbic acid deficiency leads to defective collagen formation. Histopathologic examination reveals RBC extravasation into the dermis, with a perivascular and perifollicular distribution; there may be sparse superficial perivascular infiltrate of inflammatory cells. Follicular hyperkeratosis with coiled, fragmented, cork-