Atypical Presentation of Vitamin C Deficiency Manifesting as Petechial Hemorrhaging

Abstract

A 62-year-old man with history of cigarette smoking presented with fatigue, lightheadedness, exertional dyspnea, lower extremity swelling, ecchymoses, and petechiae. There was no history of trauma, infection, new medications, or abnormal diet. Physical exam revealed red petechial 3-5mm macules and pink-violaceous purpuric indurated patches over the bilateral upper and lower extremities, buttocks, and lower abdomen. Corkscrew hairs were noted on the bilateral lower extremities. Laboratory studies were significant for anemia and elevated acute phase reactants. Thiamine, folate, and vitamin B12 were within normal limits. Workup for thrombocytopenia, platelet dysfunction, coagulopathies, hemolysis, vasculitidies, liver or gastrointestinal disease, rheumatologic disorders, and bone marrow disorders was negative. Skin biopsy and histology revealed dermal extravasated erythrocytes without evidence of vasculitis or thrombi. Ascorbic acid plasma concentration was then tested and below the limit of detection on hospital day six. A diagnosis of scurvy was made, and the patient was discharged on 1000mg Vitamin C daily supplementation. At two-week follow up, constitutional symptoms were resolved, anemia corrected, and cutaneous symptoms improving. The medical, hematology, and dermatology teams did not originally suspect a vitamin C deficiency in this patient. This case emphasizes the importance of the consideration of scurvy on the differential of petechiae, even in patients who do not present with the typical risk factors or features. Medical providers should consider scurvy, particularly in patients at risk for malnutrition due to chronic conditions and/or history of alcohol or tobacco use disorder.