What Is Scurvy?

Overview

Most people think of scurvy as an eradicated disease. However, this is sadly not the case.¹ Whilst scurvy was first identified more than 3500 years ago in Egypt, it became closely associated with pirates and sailors after the great navigations in the 15th and 16th centuries.¹ It was not until many years later, in the 18th century, that scientists could finally explain exactly what caused this disease. Scurvy is a vitamin deficiency and is caused by not having enough vitamin C (also known as ascorbic acid) in your diet for a prolonged period of time.² As more studies have been performed and efforts to include all vitamins and minerals in our diets have increased over the centuries, this vitamin deficiency has become much rarer. However, even now, it still persists. But how can you tell if you have a vitamin deficiency? What are the symptoms? And who is most at risk of developing scurvy?

Causes and risk factors

Scurvy is caused by a deficiency of Vitamin C, which is also known as ascorbic acid or ascorbate.² Unlike most animals, humans lack the ability to transform sugar (glucose) into ascorbic acid and therefore, need to obtain vitamin C through their diets.³ However, it is one of the rarest vitamins for a person to lack, as many foods - including fruits and vegetables - contain ascorbate.²

It was a British Royal Navy officer, James Lind, who made great progress in understanding scurvy. In 1753, he created the first-ever clinical trial by comparing healthy people with patients with scurvy treated with lemon and orange juice. He observed significant improvements in the second group, leading him to conclude that eating citrus fruits leads to the remission of scurvy.¹ This idea, however, would still take a long time to be implemented. Indeed, it was only in 1795 that the Scottish physician Gilbert Blane could convince the Royal Navy to offer lemon juice to sailors regularly.¹

After that, cases of scurvy decreased, but the disease didn’t quite disappear entirely. Although rare in adults, this disease still affects children and the elderly, and paediatric scurvy was a major problem in the 19th century.¹ Further, people with malnutrition are also more likely to develop scurvy, meaning that during famines and wars, the numbers of people affected by scurvy tend to rise. Scurvy, beriberi and pellagra are three vitamin deficiencies that most often affect victims of malnutrition.¹

Another problem has arisen in the modern age, with restrictive diets often limiting people’s nutrition. Today, individuals at an increased risk of scurvy include:

• Patients who are institutionalised³
• Individuals who are on the autism spectrum³
• Homeless people³
• People of low socioeconomic status⁴
• Those with unusual eating habits, like those seen in patients with anorexia nervosa or avoidant/restrictive food intake disorder (ARFID)³
• Individuals with alcohol misuse disorder⁴
• Individuals with gastrointestinal disorders⁴

Vitamin C’s role in our health

Vitamin C is essential for the formation of collagen - the protein responsible for the formation of blood vessels, muscle, skin, bone and cartilage.⁴ Without vitamin C, the collagen produced by the body isn’t as strong and as stable as needed.⁴

Collagen deficiency can result in blood vessels becoming more fragile and likely to rupture, leading to bruises and bleeding.⁴ Similarly, the osteoid matrix (the organic compound of bone) is affected by poor collagen production, leading to bones that are brittle, fragile and prone to breaking.² Ascorbate is also essential for iron absorption, as it converts the iron in food from its ferric to more easily absorable ferrous form.³ As such, an ascorbate deficiency can cause iron deficiency anaemia. 

Signs and symptoms of scurvy

Symptoms of vitamin C deficiency can start appearing after 8 to 12 weeks.² These symptoms can affect several parts of the body, including:

• The skin: formation of petechiae (small red or purple freckle-like dots on the skin and mucosa), ecchymoses (bruises), hyperkeratosis (excess production of keratin, leading to a “thicker” appearance of the skin), corkscrew hairs and impaired healing of wounds.² 
• The blood: Increased haemorrhagia (bleeding) due to the fragility of the blood capillaries, anaemia, and epistaxis (nose bleeding).²
• The mouth: gum disease is a classic symptom, with gums that are swollen, red and bleed at the touch. In children, gum disease can lead to tooth loss or malformation.²
• Bone: scurvy can cause children’s bones to become brittle and fragile, mimicking rickets.² Other manifestations include altered posture (the “pithed frog” posture) and the formation of scorbutic rosary (bony lumps) over the belly.²
• Other non-specific symptoms include irritability, loss of appetite, low-grade fever and malaise.²

The following severe symptoms can occur, but these are rare:²

• Loss of skeletal muscle
• Complex regional pain syndrome (CRPS)
• Cardiac hypertrophy
• Pulmonary hypertension 
• Poor adrenal gland function
• Weakened bone marrow 
• Psychological changes
• Poor wound healing post-surgery
• Swelling (edema)
• Hair loss (alopecia) ²

If left untreated, scurvy can have deadly consequences. Increased susceptibility to infection, cerebral haemorrhage, or hemopericardium (the collection of blood in the lining of the heart) are some of the most severe consequences reported and are often fatal.²

Diagnosis

Providing a thorough history of your symptoms and dietary habits is important in diagnosing scurvy.² Levels of vitamin C in your blood plasma can be assessed by a blood test. This measures the vitamin C level in the blood and, if lower than a certain threshold, points to scurvy and can confirm a diagnosis.² Additional tests, such as X-rays, can be suggested by a medical professional to evaluate your bone health. This is especially important for children, as other diseases can also lead to brittle and fragile bones.²

Making a diagnosis of scurvy can be tricky, as it can mimic many other diseases, such as:² 

• Osteomyelitis
• Vitamin D deficiency
• Vasculitis
• Autoimmune diseases, like Sjögren syndrome and systemic lupus erythematosus
• Blood cancer (leukaemia)
• Necrotizing gingivitis
• Paediatric syphilis

Management and treatment

Scurvy responds well to treatment, and it is possible to recover completely from it.² Vitamin C supplementation is provided daily in variable doses, with infant doses varying between 100 and 300 mg/day and adult doses varying between 500 and 1000 mg/day. This is given for a month.² Although skin, blood and oral symptoms can be resolved rather quickly, bone issues take longer to heal. In severe cases, surgery may be required to correct abnormalities in bone growth.²

Prevention

An adequate diet can both cure and prevent scurvy.² The Recommended Dietary Allowance for adults is 90mg of vitamin C for individuals assigned males at birth (AMAB) and 75mg for individuals assigned females at birth (AFAB), increasing to 85mg during pregnancy and 120mg during lactation.⁵ Smokers are recommended to ingest 35mg more vitamin C on top of their recommended dosage, as smoking depletes vitamin C levels.⁵ The daily limit is 2000mg, a dosage well above average, as excess intake can cause gastrointestinal distress.⁵

Some of the best food sources of vitamin C are:⁵

• Citrus fruits, such as lemon, lime, orange, kiwi, and grapefruit
• Bell peppers
• Strawberries
• Tomatoes
• Potatoes
• Cruciferous vegetables, such as broccoli, cauliflower, Brussels sprouts, and cabbage

Vitamin C is very sensitive to light and heat, so it is best to ingest vitamin C-rich fruits and vegetables, either raw or lightly cooked (blanched or stir-fried).⁵ As vitamin C is water-soluble, it can also seep into the cooking liquid, so using excess water whilst cooking is not recommended.⁵

Summary

Scurvy is a disease caused by a deficiency of vitamin C (known as ascorbic acid or ascorbate). It is caused by a diet lacking in fruits and vegetables. Groups more at risk of developing scurvy include children, elderly people, homeless people, autistic people, people with a low income and those who have restricted diets like those seen in anorexia nervosa or ARFID. Common signs and symptoms of scurvy include red skin spots, bruises, gum disease, gum bleeding, anaemia, and blood loss. Scurvy can be diagnosed through a combination of clinical evaluation of symptoms, dietary history, and measuring levels of vitamin C in the blood, though X-rays can also be useful in diagnosing bone involvement. Treatment is simple and easy to follow, and with daily vitamin C supplementation, a complete recovery is possible. Prevention of scurvy involves a diet rich in citric fruits and vegetables such as cruciferous greens, tomatoes and potatoes, which are ideally raw or lightly cooked.