What is the recommended treatment for scurvy?

Treatment of Scurvy

Patients with clinical scurvy should be treated with 250 mg of oral vitamin C twice daily for 3 weeks. 1

Treatment Protocol

Acute Treatment Regimen

• Administer 250 mg oral vitamin C twice daily (500 mg total per day) for 3 weeks 1
• This dosing is based on CDC/MMWR recommendations for clinical scurvy in refugee and displaced populations 1
• Alternative regimens reported in case literature include 1000 mg daily for 15 days, though this is not the guideline-based recommendation 2

Expected Clinical Response

• Rapid clinical improvement typically occurs within 2 weeks, with resolution of skin lesions, bleeding manifestations, and joint contractures 3
• Fatigue, myalgia, and arthralgia improve early in treatment 2
• Perifollicular hemorrhages and ecchymoses resolve progressively 3
• Dental manifestations and gingival bleeding improve but may require additional dental care 2

Clinical Recognition

Pathognomonic Features to Identify

• Perifollicular hemorrhages (bleeding around hair follicles) 3
• "Corkscrew" or coiled hairs on chest, abdomen, and legs 3, 4
• Spontaneous ecchymoses without trauma 3, 4
• Gingival bleeding and poor dentition 2, 4
• Bone pain and joint contractures from periosteal/intraarticular bleeding 3

High-Risk Populations Requiring Vigilance

• Alcoholics and tobacco smokers 3, 4
• Patients with severe psychiatric illness or restrictive eating habits 3, 5
• Low socioeconomic status with poor dietary intake 3
• Malabsorptive disorders (Crohn's disease, post-surgical states) 5
• Elderly, malnourished, or institutionalized patients 3

Diagnostic Considerations

Laboratory Testing

• Laboratory confirmation is NOT necessary to initiate treatment - clinical suspicion alone warrants immediate vitamin C administration 3
• Plasma ascorbic acid <2 mg/L (<11 μmol/L) confirms deficiency when measured 2, 5
• Critical pitfall: Vitamin C levels reflect recent dietary intake and are unreliable during acute inflammation (CRP >10 mg/L) 6, 7
• Associated findings include normocytic anemia, hypocholesterolemia, and hypoalbuminemia 2

When to Suspect Scurvy

• Any patient with unexplained bleeding manifestations (purpura, ecchymoses, epistaxis) plus risk factors 3, 2
• Fatigue and anemia not explained by other causes in at-risk populations 3
• Bone pain with bleeding diathesis and normal coagulation studies 3

Special Circumstances

Refractory Cases Requiring IV Therapy

• Most patients respond to oral supplementation, but some with severe malabsorption may require intravenous vitamin C 5
• Consider IV route if symptoms persist despite high-dose oral therapy (2000 mg daily) 5
• Oral absorption is limited at higher doses due to saturation of intestinal transporters 7

Patients with Renal Impairment

• Use caution with high-dose vitamin C in kidney disease due to oxalate accumulation risk 8
• For patients with CKD not on dialysis, limit total vitamin C to 100 mg/day after acute treatment 8
• Avoid vitamin C in patients with history of oxalate kidney stones 6

Additional Contraindications to Screen For

• Do not administer vitamin C to patients with:
  • Hemochromatosis (iron overload) 6
  • G6PD deficiency (risk of hemolysis) 6
  • Active oxalate stone disease 6

Prevention After Treatment

Long-Term Maintenance

• Minimum daily intake of 40-45 mg prevents scurvy recurrence 1, 7
• Standard RDA is 75 mg/day for women and 90 mg/day for men 7
• One medium orange provides ~60 mg vitamin C 3
• Encourage dietary sources: fresh fruits and vegetables 1, 2

Monitoring

• Clinical improvement confirms diagnosis retrospectively 3
• No routine laboratory monitoring needed after symptom resolution 3
• Address underlying risk factors (alcoholism, malnutrition, psychiatric illness) to prevent recurrence 3

Critical Pitfalls to Avoid

• Do not delay treatment waiting for laboratory confirmation - start vitamin C immediately when scurvy is suspected clinically 3
• Do not confuse with other bleeding disorders - normal platelet count and coagulation studies help distinguish scurvy 3
• Do not overlook scurvy in developed countries - it remains underrecognized despite being easily treatable 3, 4
• Do not use plasma vitamin C levels during acute illness - inflammation makes interpretation unreliable 6, 7