Perifollicular Hemorrhage Research Articles

Scurvy presenting in a homeless 32-year-old male: a case report.

Vitamin C deficiency, otherwise known as scurvy, is one the oldest known diseases. Although its prevalence has substantially diminished, certain populations such as smokers, alcoholics, elderly, and those with malabsorptive syndromes remain at risk. Deficiency presents with perifollicular hemorrhage, corkscrew hairs, and petechiae that can evolve into ecchymoses and purpura. Diagnosis starts with clinical suspicion and is confirmed with plasma and leukocyte ascorbic acid levels. Early suspicion is key. Treatment with vitamin C offers an excellent prognosis and avoids unnecessary workup for differential diagnoses. In our case, a 45-year-old male alcoholic with progressively worsening symptoms was found to have scurvy. Treatment was initiated with vitamin C supplementation, and he had remarkable improvement in his symptoms within weeks. This case demonstrates that scurvy is not a disease of history and must be considered in modern medicine, especially as homelessness with concomitant poor nutrition continues to increase.

Scurvy: Rediscovering a Forgotten Disease.

Scurvy is a nutritional deficiency caused by low vitamin C levels that has been described since ancient times. It leads to a varied presentation, affecting multiple organ systems due to its role in the biochemical reactions of connective tissue synthesis. Common manifestations include gingival bleeding, arthralgias, skin discoloration, impaired wound healing, perifollicular hemorrhage, and ecchymoses. Although there has been a dramatic reduction in the prevalence of scurvy in modern times owing to vitamin C supplementation and intake, sporadic cases still occur. In developed countries, it is mainly diagnosed in the elderly and malnourished individuals and is associated with alcoholism, low socio-economic status, and poor dietary habits. Scurvy has been an unusual cause of gastrointestinal (GI) bleeding among other GI manifestations. It can be adequately treated and prevented via vitamin C supplementation.

"Perifollicular rim sign" in an enlarged ovary-an additional non-contrast CT finding in ovarian torsion.

To look for the presence of "perifollicular rim sign" on non-contrast CT in surgically proven cases of ovarian or adnexal torsion. A retrospective analysis of abdominopelvic non-contrast CT examinations in surgically proven cases of ovarian or adnexal torsion was conducted seeking the presence of "perifollicular rim sign" in torsed ovaries. "Perifollicular rim sign" was defined as a complete ring of perifollicular hyperdensity around ovarian follicles with an attenuation value of > 50 HU and thickness > 1-2mm. A positive sign was equated to the presence of perifollicular hemorrhage. Pre-operative non-contrast CT was available in 7 out of the 39 ovarian or adnexal torsions included in our study. "Perifollicular rim sign" was present in 5 out of the 7 ovarian torsions on pre-operative non-contrast CT. MRI correlation was available in one patient. Ovarian enlargement (>4cm) was present in all 7 cases. In an appropriate clinical setting, presence of "perifollicular rim sign" in an enlarged ovary on non-contrast CT examination can be considered a useful additional sign for ovarian torsion.

Clinico-Dermoscopic Pattern of Beard Alopecia Areata: A Cross-Sectional Study.

Background:Alopecia areata (AA) is an autoimmune condition affecting hair-bearing regions of the body. Few studies worldwide have focused exclusively on beard alopecia areata (BAA).Aims:To describe the clinical associations, comorbidities, and dermoscopy of BAA.Materials and Methods:Forty-six patients with BAA were recruited for this hospital-based cross-sectional study. Patients with disease onset of less than 1 month, patches showing extension, and appearance of new patches within the past 1 month were grouped under active disease. Dermoscopy was performed using handheld polarized dermoscope. Chi-square test was applied to know the various associations. P value <0.05 was considered statistically significant. STATA 11.2 was used for analysis of data.Results:The mean age was 31.07 ± 8.72 years. The majority (50%) belonged to 20–29 age group. Twenty-two (48%) patients had active disease. Fourteen (30.43%) patients had extra-beard manifestation of AA. Statistically significant association was noted between active disease and extra-beard manifestation (P = 0.034). Diabetes mellitus and hypertension were noted in one and three patients, respectively. Alcohol abuse was noted in six patients and smoking in five patients. Dermoscopic findings such as black dots, short vellus hair, tapering hair, nonfollicular white dots, regrowing hair, yellow dots, and black dots were similar to findings noted in AA. Uncommon findings such as peripilar sign, i-hair, perifollicular hemorrhage, and tulip hair were observed in BAA.Limitations:Small sample size, lack of follow-up.Conclusion:Trichoscopy of BAA may reveal newer nonfollicular findings, in addition to the follicular findings already described in literature for AA.

MRI of ovarian torsion: Correlation of imaging features with the presence of perifollicular hemorrhage and ovarian viability

PurposeThe purpose of our study is to test for: (a) correlation between the presence of a perifollicular T2-hypointense rim on MRI with the presence of perifollicular hemorrhage on histology; and (b) correlation between this finding and diminished ovarian viability after intra-operative detorsion. Methods and materialsOur IRB-approved, retrospective study evaluated 780 patients between August 2012 and February 2016 with ovarian torsion as a diagnostic consideration on the emergency department note. Patients were included if they had preoperative MRI and intraoperatively confirmed case of ovarian torsion. MRIs were retrospectively reviewed for presence of perifollicular T2 hypointense rim in the torsed ovary. Two arms of analysis were performed: (a) assessment of perifollicular hemorrhage on histological exam; and (b) assessment of ovarian viability after intra-operative detorsion. Sensitivity, specificity, positive predictive value, and negative predictive value of MRI for predicting ovarian viability in the setting of torsion was performed. κ test assessed level of agreement between readers. Results24 patients included in one of the two arms; 20 in viability analysis and 12 in perifollicular hemorrhage analysis (8 in both). The presence of T2-hypointense rim on MRI demonstrated 88.9% sensitivity and 66.7% specificity for the diagnosis of perifollicular hemorrhage on histology, and 91.7% sensitivity and 100% specificity for predicting intraoperative viability. ConclusionThe presence of a perifollicular T2 hypointense rim on MRI in the setting of ovarian torsion correlates with perifollicular hemorrhage on histopathologic exam, and may also be a useful predictor of ovarian viability in patients presenting with ovarian torsion.

Gingival Bleeding and Bloody Dialysate: A Case Report of Scurvy in a Child With End-Stage Renal Disease Receiving Peritoneal Dialysis

Patients with chronic kidney disease (CKD) or end-stage renal disease are at risk for vitamin C deficiency and scurvy due to diet restriction, increased urinary loss of the water-soluble vitamin C with diuretics, and in case of patients who are on dialysis, through dialysates. The condition may be overlooked as the clinical manifestation of scurvy may be subtle, and some presentations may mimic clinical signs in CKD. We reported a case of scurvy presenting with gingival bleeding and blood dialysate in a 6-year-old girl with end-stage renal disease who was on continuous ambulatory peritoneal dialysis. Physical examination showed gingival hyperplasia and bleeding, and the pathognomonic bleeding of perifollicular hemorrhage. The typical radiographic changes were present. The clinical signs and symptoms resolved after ascorbic acid treatment. This case underscores the importance of awareness of the increased risk for vitamin C deficiency in patients with CKD and receiving dialysis.

Scurvy in the present times: vitamin c allergy leading to strict fast food diet

Scurvy results from a deficiency of vitamin C, a nutrient otherwise known as ascorbic acid. Today, scurvy is rare yet emerges in select patients. The patient reported herein developed scurvy secondary to deliberate avoidance of vitamin C-rich foods. Classic cutaneous manifestations of scurvy include follicular hyperkeratosis and perifollicular hemorrhage encompassing coiled "corkscrew" hairs and hairs bent into "swan-neck" deformities. Ecchymoses, purpura, and petechiae are also characteristically prominent. Classic oral abnormalities include erythematous, swollen gingivae that hemorrhage from subtle microtrauma.Subungual linear splinter hemorrhages may also manifest as a sign of the disease. To establish the diagnosis requirements include characteristic physical exam findings, evidence of inadequate dietary intake, and rapid reversal of symptoms upon supplementation. Although unnecessary for diagnosis, histological findings demonstrate perifollicular inflammation and hemorrhage, fibrosis, and hyperkeratosis, amongst dilated hair follicles and keratin plugging. Although citrus fruit allergies have been historically documented, ascorbic acid has not been previously reported as an allergen. Although lacking absolute certainty, this report suggests a presumed case of ascorbic acid allergy based on patient history and favorable response to ascorbic acid desensitization therapy.

Scurvy aboard Ferdinand Magellan's voyage of circumnavigation.

One of the greatest feats of explorationwas FerdinandMagellan’s voyage of circumnavigation (1519-1522). The story of this Spanish expedition was chronicled by Antonio Pigafetta, who traveled with Magellan and kept a diary. Pigafetta’smostharrowingaccountconcerns their crossingof thePacific Ocean, duringwhichMagellan’s crew endured a deadly encounter withscurvy.Scurvy isadiseasecausedbyvitaminCdeficiencythatwould plague sailors for thenext3 centuries. This nightmarebeganonNovember 28, 1520, afterMagellan (1480-1521) andhis crewsuccessfully completed their crossingof the treacherous Straits ofMagellan andentered thePacificOcean. This accomplishment fulfilledMagellan’s dream, first envisioned 500 years ago, of finding a westward maritime route from Europe that would lead to the Spice Islands of Indonesia. Concerning thePacific crossing,Pigafettawrites: “Wehadbeenthree monthsandtwentydayswithout takingrefreshmentofanykind.”Magellan’s crewhadexhausted their food stores andwere forced to subsist on rottenbiscuitsandyellow,putrefiedwater. Indesperationthemenateanything: cowhides, sawdust, and even rats. Amidst starvation conditions, manyofMagellan’smenbecameill,asPigafettagraphicallydescribes: “But aboveall othercalamities thiswas theworst: in somementhegumsgrew over the teeth, both lowers anduppers, so that they couldnot eat in any way and thus they died of this sickness. Nineteenmendied....” Pigafetta’s most striking clinical observation was gingival hypertrophy, a featureof scurvy inwhichdefectivecollagensynthesis leads to the lossof support forbloodvesselwalls. Thegums, thereforebecomered, swollen, friable, andhemorrhagic. Thegingival abnormalities occur only in the presence of teeth. Other dermatologic features of scurvy include follicular hyperkeratosis associated with corkscrew hairs, perifollicular hemorrhage, petechiae, ecchymosis, and poor wound healing. On March 6, 1521, Magellan’s expedition reached Guam and procured fresh foods thatenabled thecrewto recover fromtheir illness.Unfortunately,Magellanwas laterkilled inabattle in thePhilippines.OnSeptember8, 1522, the lastshipofMagellan’soriginal fleetof5vesselsdocked inSpain, completing thevoyagearoundtheworld.Onboardwere 18survivorsof theexpedition’soriginal 266men.Mosthadperished in thePacific travels. With the adoption of James Lind’s 1753 landmark dietary recommendations for the prevention and treatment of scurvy, epidemics of thediseaseon thehigh seas subsided. Scurvy, however, can still be clinically seen in populations at risk for malnutrition, such as elderly individuals, indigentpersons,andalcoholics.Thevitaminpropertiesofascorbic acid (vitamin C) were codiscovered by Albert Szent-Gyorgyi and Charles Glen King between 1928 and 1932. Szent-Gyorgyi was later awarded the 1937 Nobel Prize in Physiology or Medicine. Magellan’s voyage of circumnavigationwas amonumental achievementand testofhumanendurance. It also illustratedour frailty andhow fatal it could be for anyone to lack even a single vitamin. Today, mankind looks toward theheavens for further spaceexploration.At thesame timewe realize that our lives are so inextricably boundwith theEarth, a planet whose surface was first circumnavigated nearly 500 years ago.

Classic Skin Findings of Scurvy

Department of Medical Education, Gundersen Medical Foundation (D.D.F.), and Infectious Disease Section, Department of Internal Medicine, Gundersen Health System (T.J.K.), La Crosse, WI. A 43-year-old man with a long history of alcohol abuse presented with altered mental status, confabulation, and rash. He had perifollicular, hyperkeratotic papules and corkscrew hairs over his forearms, thighs, and upper abdomen (Figures 1 and 2), as well as gingival bleeding. A skin biopsy specimen revealed perifollicular fibrosis associated with perifollicular hemorrhage (Figure 3) consistent with a diagnosis of scurvy. The patient was treated with 500 mg of ascorbic acid daily, and the rash resolved after 1 week of treatment. His neurologic symptoms were subsequently determined to stem from Wernicke encephalopathy, which was caused by a coexistent thiamine deficiency.

A Case Of Vitamin C Deficiency Manifesting With Easy Bruising: Suggestion For a Supplementation Protocol

Contrary to most animals which are capable of obtaining ascorbic acid (vitamin C) by metabolizing glucose, humans require an exogenous source of vitamin C. It is a water-soluble vitamin found in various foods, including citrus fruits (oranges, lemons, grapefruit), green vegetables (peppers, broccoli, cabbage), tomatoes, and potatoes. It is essential for growth and repair of tissues, particularly blood vessels. Deficiency of vitamin C is relatively rare; the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) found approximately 13% of the US population to be vitamin C deficient. Smoking cigarettes lowers the amount of vitamin C in the body, so smokers are at a higher risk of deficiency. Additionally, alcoholics, the elderly, patients with psychiatric disorders and individuals who experience social isolation are also at risk. Symptoms can manifest after 3 months of deficient intake of vitamin C -containing foods. Since ascorbic acid is required for collagen synthesis, deficiency usually manifests with bleeding gums, ecchymoses, petechiae, coiled hairs and hyperkeratosis. Diagnosis can be established when plasma levels of vitamin C fall below 0.2mg/dl. There are currently no evidence based guidelines for supplementation once low levels are detected. We describe a case of a 33 year old Caucasian female seen in our clinic for easy bruising of 10 years duration. She would wake up in the morning with bruised arms and legs without any inciting trauma. She denied prolonged bleeding after dental extractions, frequent nose bleeds, menorrhagia any genitounrinary or gastrointestinal blood loss. Her exam revealed ecchymoses on her arms and legs with no evidence of perifollicular hemorrhage or gingival hyperplasia. Workup including CBC, Coagulation profile and Von Willibrand factor levels were all within normal limits. She had a vitamin C level of 0.1mg/dl. She was subsequently advised to increase vitamin C intake through fruits and vegetable and was started on vitamin C supplementation with 500mg twice a day for four weeks. Her repeat vitamin C level on her one month follow up was noted to be 1.9mg/dl. She noticed complete resolution of her symptoms. This case illustrates the fact that vitamin C deficiency should be excluded in adults presenting with bruising. It also offers a supplementation regimen that resulted in improvement of clinical symptoms as well as laboratory value normalization. Disclosures: No relevant conflicts of interest to declare.

Infantile Scurvy

Ascorbic acid (vitamin C) is necessary for the formation of collagen, reducing free radicals, and aiding in iron absorption. Scurvy, a disease of dietary ascorbic acid deficiency, is uncommon today. Indeed, implementation of dietary recommendations largely eradicated infantile scurvy in the US in the early 1900s. We present a case of an otherwise healthy 2-year-old Caucasian girl who presented with refusal to walk secondary to pain in her lower extremities, generalized irritability, sleep disturbance, and malaise. The girl's parents described feeding the patient an organic diet recommended by the Church of Scientology that included a boiled mixture of organic whole milk, barley, and corn syrup devoid of fruits and vegetables. Physical examination revealed pale, bloated skin with edematous, violaceous gums and loosening of a few of her teeth. Dermatologic findings included xerosis, multiple scattered ecchymoses of the extremities, and perifollicular hemorrhage. Laboratory and radiographic evaluation confirmed the diagnosis of scurvy. The patient showed dramatic improvement after only 3 days of treatment with oral ascorbic acid and significant dietary modification. In this case report, we revisit the old diagnosis of scurvy with a modern dietary twist secondary to religious practices. This case highlights the importance of taking a detailed dietary history when evaluating diseases involving the skin.

Scurvy

• A 9-year-old girl had the insidious development of lethargy, gingival erosions, and follicular hyperkeratosis with perifollicular hemorrhage. A dietary history disclosed that she consumed only one kind of sandwich and beverage and took no other foods. A skin biopsy specimen was consistent with the diagnosis of scurvy, and marked improvement occurred with ascorbic acid therapy. Although it is an uncommon disorder in the United States, scurvy may occur in persons with prolonged and peculiar dietary habits. (<i>Arch Dermatol</i>1984;120:1212-1214)