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The prognosis is excellent&#44; with clinical response in the first days of vitamin replacement <a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The authors report the case of a male patient&#44; 63 years&#44; hypertensive&#44; diabetic&#44; with chronic renal failure on hemodialysis for five years&#46; He complained of asymptomatic lesions with progressive increase in the last two months&#44; mainly in the lower limbs&#46; In addition&#44; he reported weakness&#44; episodes of epistaxis&#44; and reported food intake limited to sandwiches and other carbohydrates&#44; denying consumption of fruits and vegetables&#46; On physical examination&#44; he had purpuric areas&#44; plaques and isolated&#44; mostly punctiform with perifollicular location&#44; affecting the lower limbs &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#44; upper limbs&#44; and back&#46; Upon inspection of the oral cavity&#44; no alterations were observed&#46; Corkscrew hairs were observed at dermoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Extremely low plasma levels of ascorbic acid corroborated the diagnosis &#40;0&#46;08&#8239;mg&#47;dL&#59; reference value&#58; 0&#46;5&#8211;1&#46;5&#8239;mg&#47;dL&#41;&#46; The anatomopathological exam showed folliculitis&#44; perifolliculitis&#44; and infundibular keratosis&#44; common findings in scurvy&#46; Days after oral supplementation of vitamin C&#44; at a dose of 300&#8239;mg&#47;day&#44; resolution of the skin lesions was observed&#44; in addition to improvement in asthenia and nasal bleeding&#46; Gingival bleeding&#44; historically the most classic manifestation of scurvy&#44; was not observed in the present case&#44; emphasizing that its absence does not exclude the diagnosis of the disease&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Scurvy is caused by ascorbic acid &#40;vitamin C&#41; deficiency&#59; vitamin C is found in fresh fruits and vegetables&#46; <a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Throughout history&#44; scurvy was mostly diagnosed during the great Irish potato famine between 1845 and 1849&#44; when the population of that country was reduced by 20&#37; to 25&#37;&#44; the American civil war&#44; and more recently the Afghanistan war in 2002&#46; Although uncommon and remembered for its historical significance&#44; scurvy is not a non-existent disease&#44; especially in individuals with unusual diets&#44; the elderly&#44; alcoholics&#44; patients with neoplasms or intestinal absorption disorders&#44; and patients on hemodialysis&#46; The kidneys reabsorb vitamin C and excrete it in the urine only when it exceeds the serum level&#59; however&#44; in dialysis this clearance is indiscriminate&#44; increasing the risk of deficiency&#46; <a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Ascorbic acid plays an important role in the formation of collagen and extracellular matrix&#44; leukocyte function&#44; iron absorption&#44; folic acid metabolism&#44; and other enzymatic processes&#46; Anomalies in the collagen structure disrupt the integrity of the hair&#44; connective tissue&#44; and blood vessels&#44; leading to the characteristic skin manifestations of scurvy&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The initial complaints&#44; after one to three months of deficiency&#44; are usually weakness&#44; malaise&#44; arthralgia&#44; anorexia&#44; and emotional liability&#46; Capillary frailty predisposes to purpura&#44; more frequent in the lower limbs&#44; petechiae&#44; ecchymosis&#44; gingival bleeding&#44; epistaxis&#44; and bone hemorrhage&#46; <a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Other dermatological findings include follicular hyperkeratosis and subungual hemorrhages <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; Dermoscopy reveals whitish hair follicles with &#8220;corkscrew&#8221; hair surrounded by a violaceous-hemorrhagic halo&#44; with the whitish area corresponding to perifollicular fibrosis and the violet halo to the extravasation of red blood cells&#46; <a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis of scurvy is clinical&#44; confirmed by low serum levels of vitamin C&#46; Symptoms usually occur with plasma concentrations below 0&#46;2&#8239;mg&#47;dL&#46; <a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The blood count usually reveals anemia and the inflammatory markers may be elevated&#46; Biopsy mainly helps in distinguishing it from vasculitis&#44; since the purpura in scurvy is of a non-inflammatory character&#46; The classic histological pattern is perifollicular hemorrhage&#44; irregularly shaped hair follicles with hyperkeratosis&#44; and curved hair&#46; <a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The prognosis for scurvy is excellent&#46; <a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Ascorbic acid supplementation &#40;100&#8239;mg three times a day&#41; results in some symptomatic improvement on the first day and complete resolution of skin lesions within weeks <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Scurvy is probably underdiagnosed&#44; although its manifestations are relevant to various medical specialties&#46; It is remembered as a disease of ancient times&#44; studied in high school and in history books&#44; and not as a real diagnostic possibility&#46; Attention should be paid to those patients with risk factors for nutritional deficiency&#44; so that the classic findings of scurvy&#44; an easily treatable disease&#44; can be identified early&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010"><span class="elsevierStyleBold">Financial support</span></span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Paulo Ricardo Martins Souza&#58; Approval of the final version of the manuscript&#44; drafting and editing of the manuscript&#44; effective participation in research orientation&#44; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#44; critical review of the literature&#44; critical review of the manuscript&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Let&#237;cia Dupont&#58; Approval of the final version of the manuscript&#44; design and planning of the study&#44; drafting and editing of the manuscript&#44; critical review of the literature&#44; critical review of the manuscript&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Felipe Eduardo Rodrigues&#58; Drafting and editing of the manuscript&#44; critical review of the literature&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Letter
Scurvy: hard to remember, easy to diagnose and treat
Paulo Ricardo Martins Souza, Letícia Dupont
Autor para correspondência
dupont.leticia@gmail.com

Corresponding author.
, Felipe Eduardo Rodrigues
Dermatology Department, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, SR, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Currently&#44; scurvy is an uncommon disease&#44; but it still exists&#44; especially in groups at risk for hypovitaminosis&#46; <a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Due to low suspicion&#44; its clinical manifestations are often not well interpreted&#44; leading to an extensive search for differential diagnoses <a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; The dermatological findings are fundamental clues&#44; especially perifollicular purpura&#44; which appears to be found only in this disease <a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; There are usually associated systemic symptoms&#44; and bleeding is common <a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; The prognosis is excellent&#44; with clinical response in the first days of vitamin replacement <a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The authors report the case of a male patient&#44; 63 years&#44; hypertensive&#44; diabetic&#44; with chronic renal failure on hemodialysis for five years&#46; He complained of asymptomatic lesions with progressive increase in the last two months&#44; mainly in the lower limbs&#46; In addition&#44; he reported weakness&#44; episodes of epistaxis&#44; and reported food intake limited to sandwiches and other carbohydrates&#44; denying consumption of fruits and vegetables&#46; On physical examination&#44; he had purpuric areas&#44; plaques and isolated&#44; mostly punctiform with perifollicular location&#44; affecting the lower limbs &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#44; upper limbs&#44; and back&#46; Upon inspection of the oral cavity&#44; no alterations were observed&#46; Corkscrew hairs were observed at dermoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Extremely low plasma levels of ascorbic acid corroborated the diagnosis &#40;0&#46;08&#8239;mg&#47;dL&#59; reference value&#58; 0&#46;5&#8211;1&#46;5&#8239;mg&#47;dL&#41;&#46; The anatomopathological exam showed folliculitis&#44; perifolliculitis&#44; and infundibular keratosis&#44; common findings in scurvy&#46; Days after oral supplementation of vitamin C&#44; at a dose of 300&#8239;mg&#47;day&#44; resolution of the skin lesions was observed&#44; in addition to improvement in asthenia and nasal bleeding&#46; Gingival bleeding&#44; historically the most classic manifestation of scurvy&#44; was not observed in the present case&#44; emphasizing that its absence does not exclude the diagnosis of the disease&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Scurvy is caused by ascorbic acid &#40;vitamin C&#41; deficiency&#59; vitamin C is found in fresh fruits and vegetables&#46; <a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Throughout history&#44; scurvy was mostly diagnosed during the great Irish potato famine between 1845 and 1849&#44; when the population of that country was reduced by 20&#37; to 25&#37;&#44; the American civil war&#44; and more recently the Afghanistan war in 2002&#46; Although uncommon and remembered for its historical significance&#44; scurvy is not a non-existent disease&#44; especially in individuals with unusual diets&#44; the elderly&#44; alcoholics&#44; patients with neoplasms or intestinal absorption disorders&#44; and patients on hemodialysis&#46; The kidneys reabsorb vitamin C and excrete it in the urine only when it exceeds the serum level&#59; however&#44; in dialysis this clearance is indiscriminate&#44; increasing the risk of deficiency&#46; <a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Ascorbic acid plays an important role in the formation of collagen and extracellular matrix&#44; leukocyte function&#44; iron absorption&#44; folic acid metabolism&#44; and other enzymatic processes&#46; Anomalies in the collagen structure disrupt the integrity of the hair&#44; connective tissue&#44; and blood vessels&#44; leading to the characteristic skin manifestations of scurvy&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The initial complaints&#44; after one to three months of deficiency&#44; are usually weakness&#44; malaise&#44; arthralgia&#44; anorexia&#44; and emotional liability&#46; Capillary frailty predisposes to purpura&#44; more frequent in the lower limbs&#44; petechiae&#44; ecchymosis&#44; gingival bleeding&#44; epistaxis&#44; and bone hemorrhage&#46; <a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Other dermatological findings include follicular hyperkeratosis and subungual hemorrhages <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; Dermoscopy reveals whitish hair follicles with &#8220;corkscrew&#8221; hair surrounded by a violaceous-hemorrhagic halo&#44; with the whitish area corresponding to perifollicular fibrosis and the violet halo to the extravasation of red blood cells&#46; <a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis of scurvy is clinical&#44; confirmed by low serum levels of vitamin C&#46; Symptoms usually occur with plasma concentrations below 0&#46;2&#8239;mg&#47;dL&#46; <a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The blood count usually reveals anemia and the inflammatory markers may be elevated&#46; Biopsy mainly helps in distinguishing it from vasculitis&#44; since the purpura in scurvy is of a non-inflammatory character&#46; The classic histological pattern is perifollicular hemorrhage&#44; irregularly shaped hair follicles with hyperkeratosis&#44; and curved hair&#46; <a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The prognosis for scurvy is excellent&#46; <a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Ascorbic acid supplementation &#40;100&#8239;mg three times a day&#41; results in some symptomatic improvement on the first day and complete resolution of skin lesions within weeks <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Scurvy is probably underdiagnosed&#44; although its manifestations are relevant to various medical specialties&#46; It is remembered as a disease of ancient times&#44; studied in high school and in history books&#44; and not as a real diagnostic possibility&#46; Attention should be paid to those patients with risk factors for nutritional deficiency&#44; so that the classic findings of scurvy&#44; an easily treatable disease&#44; can be identified early&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010"><span class="elsevierStyleBold">Financial support</span></span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Paulo Ricardo Martins Souza&#58; Approval of the final version of the manuscript&#44; drafting and editing of the manuscript&#44; effective participation in research orientation&#44; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#44; critical review of the literature&#44; critical review of the manuscript&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Let&#237;cia Dupont&#58; Approval of the final version of the manuscript&#44; design and planning of the study&#44; drafting and editing of the manuscript&#44; critical review of the literature&#44; critical review of the manuscript&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Felipe Eduardo Rodrigues&#58; Drafting and editing of the manuscript&#44; critical review of the literature&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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