Medical Mystery: Extensive Ecchymosis — The Answer
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《新英格兰医药杂志》
To the Editor: The Medical Mystery in the December 1 issue1 involved a 71-year-old man with lower-extremity ecchymosis (Figure 1) and gingivitis (Figure 2, arrows). He was a retired Army man living alone with a modest income. He had poor nutritional intake, had a history of 150 pack-years of smoking cigarettes, and consumed two glasses of red wine each day.
Figure 1. Ecchymosis on the Lower Extremities.
Figure 2. Severe Gingivitis.
Scurvy was suspected and confirmed by a low level of ascorbic acid (3.6 μmol per liter; normal range, 30 to 40). Other nutritional deficiencies that were identified included those of folic acid (1.37 ng per milliliter ; normal range, 3 to 17 ng per milliliter ); calcium (1.96 mmol per liter; normal range, 2.22 to 2.61); and 25-hydroxyvitamin D (7 mmol per liter; normal range, 27 to 175). Ascorbic acid was given orally at a dose of 500 mg per day. Eight days later, the patient was able to walk alone, the ecchymosis gradually disappeared, and the congestive periodontitis was notably improved.
Denis Mulleman, M.D.
Philippe Goupille, M.D.
Fran?ois Rabelais University
37032 Tours CEDEX 1, France
Editor's note: We received 2001 responses to this Medical Mystery, including 58 percent from physicians in practice, 23 percent from physicians in training, and 11 percent from medical students. Responses were received from 81 countries. Of those, 69 percent correctly identified this case as due to a deficiency of vitamin C, or scurvy. Other proposed diagnoses were leukemia (especially monocytic variants), suggested by 14 percent of respondents; a variety of other nutritional deficiencies, by 8 percent; and many other conditions (such as autoimmune diseases, an overdose of medication, amyloid, and sepsis), by the remaining 9 percent.
Scurvy is a disease of great historical interest, especially in mariners participating in long voyages. Ascorbic acid (vitamin C) has many biologic functions; the best understood is its role in collagen synthesis — the failure of which leads to many of the clinical manifestations of scurvy. A moderate consumption of fruits and vegetables is adequate to prevent this disease.
References
Mulleman D, Goupille P. A medical mystery -- extensive ecchymosis. N Engl J Med 2005;353:2384-2384.
Figure 1. Ecchymosis on the Lower Extremities.
Figure 2. Severe Gingivitis.
Scurvy was suspected and confirmed by a low level of ascorbic acid (3.6 μmol per liter; normal range, 30 to 40). Other nutritional deficiencies that were identified included those of folic acid (1.37 ng per milliliter ; normal range, 3 to 17 ng per milliliter ); calcium (1.96 mmol per liter; normal range, 2.22 to 2.61); and 25-hydroxyvitamin D (7 mmol per liter; normal range, 27 to 175). Ascorbic acid was given orally at a dose of 500 mg per day. Eight days later, the patient was able to walk alone, the ecchymosis gradually disappeared, and the congestive periodontitis was notably improved.
Denis Mulleman, M.D.
Philippe Goupille, M.D.
Fran?ois Rabelais University
37032 Tours CEDEX 1, France
Editor's note: We received 2001 responses to this Medical Mystery, including 58 percent from physicians in practice, 23 percent from physicians in training, and 11 percent from medical students. Responses were received from 81 countries. Of those, 69 percent correctly identified this case as due to a deficiency of vitamin C, or scurvy. Other proposed diagnoses were leukemia (especially monocytic variants), suggested by 14 percent of respondents; a variety of other nutritional deficiencies, by 8 percent; and many other conditions (such as autoimmune diseases, an overdose of medication, amyloid, and sepsis), by the remaining 9 percent.
Scurvy is a disease of great historical interest, especially in mariners participating in long voyages. Ascorbic acid (vitamin C) has many biologic functions; the best understood is its role in collagen synthesis — the failure of which leads to many of the clinical manifestations of scurvy. A moderate consumption of fruits and vegetables is adequate to prevent this disease.
References
Mulleman D, Goupille P. A medical mystery -- extensive ecchymosis. N Engl J Med 2005;353:2384-2384.