A 5-year-old boy from rural India presents with bleeding gums, poor wound healing, and perifollicular hemorrhages on the lower extremities. His mother reports that he has had a diet poor in fresh fruits and vegetables for the past 6 months due to financial constraints. Serum vitamin C level is 0.1 mg/dL (normal >0.6 mg/dL). What is the most appropriate immediate management?

Explanation

## Clinical Diagnosis: Scurvy (Vitamin C Deficiency) ### Pathophysiology of Scurvy **Key Point:** Vitamin C (ascorbic acid) is an essential cofactor for prolyl hydroxylase and lysyl hydroxylase, enzymes required for hydroxylation of proline and lysine residues in procollagen. Without hydroxylation, collagen cannot form stable triple helices or cross-links, resulting in defective connective tissue. **Mnemonic:** **SCURVY** = **S**evere **C**ollagen deficiency → **U**nstable **R**eparation of **V**essels and **Y**oung tissues ### Why Oral Vitamin C is the Correct Next Step **High-Yield:** Scurvy is a **preventable and reversible** disease. Oral vitamin C supplementation (100–200 mg/day) is the standard first-line treatment in mild-to-moderate cases with adequate oral intake capacity. Symptoms resolve within 2–4 weeks with appropriate dosing. **Clinical Pearl:** The patient is a child with adequate oral intake (no vomiting, dysphagia, or malabsorption reported). Oral supplementation is sufficient, cost-effective, and appropriate for the resource-limited setting. Dietary counselling on vitamin C–rich foods (citrus, tomatoes, leafy greens) is essential for long-term prevention. ### Clinical Features of Scurvy | Feature | Mechanism | |---------|----------| | Bleeding gums, loose teeth | Defective collagen in gingival connective tissue and periodontal ligament | | Perifollicular hemorrhages | Fragile capillaries around hair follicles; hair coils inward (corkscrew hairs) | | Poor wound healing | Impaired collagen synthesis and cross-linking | | Anemia (often present) | Iron malabsorption + chronic bleeding | | Bone pain, subperiosteal hemorrhages | Defective osteoid formation | ### Management Algorithm ```mermaid flowchart TD A[Suspected Scurvy<br/>Low serum vitamin C]:::outcome --> B{Severity assessment}:::decision B -->|Mild-moderate<br/>Oral intake OK| C[Oral Vitamin C<br/>100-200 mg/day]:::action B -->|Severe<br/>Malabsorption/vomiting| D[IV Ascorbic acid<br/>500 mg BD × 3 days]:::action C --> E[Dietary counselling<br/>Vitamin C-rich foods]:::action D --> E E --> F[Monitor: gum healing,<br/>hemorrhages, hemoglobin]:::action F --> G[Resolution in 2-4 weeks]:::outcome ``` ### Why Other Options Are Incorrect | Option | Why Wrong | |--------|----------| | IV ascorbic acid | Reserved for severe scurvy with malabsorption, vomiting, or inability to take oral medication. This child has no such contraindication. IV therapy is more expensive and unnecessary. | | Iron supplementation | While iron deficiency may coexist due to chronic bleeding, it is not the primary cause of scurvy. Iron supplementation alone will not correct collagen defects or resolve bleeding gums. Vitamin C must be given first. | | Antibiotics + topical dressing | Gum bleeding is due to defective collagen, not infection. Antibiotics are not indicated unless secondary infection develops. Topical measures do not address the underlying vitamin C deficiency. | **Clinical Pearl:** Scurvy is rare in developed countries but remains a concern in malnourished, elderly, and resource-limited populations. In India, it is seen in children with poor dietary diversity and in individuals with restricted diets (e.g., exclusive milk diet, boiled food). **Warning:** Do not confuse scurvy with **bleeding disorders** (hemophilia, thrombocytopenia) or **gingivitis** (bacterial infection). Scurvy presents with **perifollicular hemorrhages** and **corkscrew hairs**, which are pathognomonic. [cite:Harrison 21e Ch 91; KD Tripathi 8e Ch 12]