What vitamin deficiency is most likely causing an 80-year-old woman's bleeding gums, given her limited diet of tea and toast for 2 years?

Vitamin C Deficiency is the Cause of This Patient's Bleeding Gums and Other Symptoms

Vitamin C (ascorbic acid) supplementation would most likely have prevented this 80-year-old woman's condition, as she is displaying classic signs of scurvy.

Clinical Presentation Analysis

The patient presents with several hallmark features of vitamin C deficiency (scurvy):

• Bleeding gums with hypertrophy
• Ecchymoses (bruising) of inner thighs
• Perifollicular hemorrhages
• Thin and weak appearance
• Limited diet of "tea and toast" for 2 years

These findings strongly point to scurvy, which develops when dietary vitamin C intake is inadequate for prolonged periods.

Pathophysiology of Vitamin C Deficiency

Vitamin C is essential for:

• Collagen synthesis and proper formation
• Maintaining capillary integrity
• Wound healing
• Antioxidant functions

When vitamin C is deficient:

• Collagen becomes defective, leading to weakened blood vessel walls
• Capillary fragility increases, causing easy bruising and bleeding
• Gingival tissue becomes inflamed, swollen, and bleeds easily
• Perifollicular hemorrhages appear (pathognomonic for scurvy)

Differential Diagnosis of Vitamins

Let's examine why vitamin C is the most likely deficiency in this case:

1. Vitamin C: The patient's presentation with bleeding gums, ecchymoses, and perifollicular hemorrhages is classic for scurvy 1, 2. Her diet of only tea and toast for 2 years would be severely deficient in vitamin C.

2. Vitamin A: While deficiency can cause epithelial changes, it typically presents with night blindness, xerophthalmia, and hyperkeratosis, not bleeding manifestations.

3. Vitamin B12 (Cyanocobalamin): Deficiency primarily causes megaloblastic anemia, neurological symptoms, and glossitis, but not the hemorrhagic features seen in this patient 3.

4. Vitamin D: Deficiency leads to bone demineralization (rickets in children, osteomalacia in adults) without the mucocutaneous bleeding seen here.

5. Vitamin E: Deficiency is rare and primarily causes neurological symptoms, not bleeding gums or ecchymoses 3.

Why Vitamin C Deficiency is Most Likely

The patient's clinical presentation perfectly matches the hemorrhagic manifestations of scurvy:

• Bleeding gums with hypertrophy is a classic early mucosal symptom 2
• Ecchymoses (bruising) results from capillary fragility 4
• Perifollicular hemorrhages are pathognomonic for scurvy 2

Her diet of only tea and toast for 2 years would be severely deficient in vitamin C, as neither tea nor toast contains significant amounts of this vitamin. Fresh fruits and vegetables, the primary dietary sources of vitamin C, are completely absent from her diet 3.

Treatment Approach

For vitamin C deficiency:

1. Immediate oral vitamin C supplementation (typically 100-250 mg daily)
2. Dietary counseling to include vitamin C-rich foods
3. Monitoring for improvement of symptoms (usually begins within days)
4. Address underlying causes of poor nutrition

Prevention Considerations

Regular consumption of vitamin C-rich foods or supplementation would have prevented this condition. The recommended daily intake for older adults is 75-90 mg/day, with some guidelines suggesting higher intake for optimal health 3.

Vitamin C deficiency can be prevented by including:

• Citrus fruits
• Berries
• Green leafy vegetables
• Fortified foods
• Supplementation when diet is inadequate

Conclusion

Based on the clinical presentation and dietary history, this 80-year-old woman's condition is most consistent with scurvy. Vitamin C supplementation would have prevented the development of her symptoms, making option C (Vitamin C) the correct answer.