A 35-year-old male construction worker from rural Maharashtra presents with progressive joint pain, muscle weakness, and bleeding gums for 6 months. On examination, he has perifollicular haemorrhages, poor wound healing, and corkscrew hairs. Serum vitamin C level is 0.1 mg/dL (normal >0.6 mg/dL). A diagnosis of scurvy is made. What is the most appropriate immediate next step in management?

Explanation

## Clinical Context This patient presents with **scurvy** — vitamin C (ascorbic acid) deficiency. The clinical triad of perifollicular haemorrhages, poor wound healing, and bleeding gums is pathognomonic. The low serum vitamin C level (<0.2 mg/dL) confirms the diagnosis. ## Biochemistry of Vitamin C and Collagen **Key Point:** Vitamin C (ascorbic acid) is a cofactor for **prolyl hydroxylase** and **lysyl hydroxylase**, enzymes essential for hydroxylation of proline and lysine residues in collagen. Without hydroxylation, collagen cannot form stable triple helix cross-links, resulting in structurally defective collagen. **Mnemonic:** **CHOP** — Collagen Hydroxylation Occurs with Prolyl/lysyl hydroxylase (requires vitamin C, α-ketoglutarate, Fe²⁺). ## Pathophysiology of Scurvy ```mermaid flowchart TD A[Vitamin C deficiency]:::outcome --> B[Impaired prolyl/lysyl hydroxylase activity]:::outcome B --> C[Defective collagen cross-linking]:::outcome C --> D[Weakened blood vessel walls]:::action C --> E[Poor wound healing]:::action C --> F[Bleeding gums, perifollicular haemorrhages]:::action D --> G[Spontaneous bleeding, haemarthrosis]:::action ``` ## Management Algorithm **High-Yield:** Scurvy is a **medical emergency** when severe (haemoptysis, intracranial bleeding, cardiac arrhythmias). However, this patient has uncomplicated scurvy with no acute life-threatening bleeding. | Severity | Management | |----------|------------| | **Mild–Moderate** (as in this case) | Oral ascorbic acid 500 mg–1 g daily; clinical improvement in 2–4 weeks | | **Severe with acute bleeding** | IV vitamin C 1 g daily × 3 days, then oral; ICU monitoring | | **Haemodynamic instability** | IV vitamin C + blood transfusion + ICU support | ## Why Oral Supplementation is Correct Here **Clinical Pearl:** Oral vitamin C 500 mg daily is sufficient for uncomplicated scurvy. IV therapy is reserved for: - Severe malabsorption (short bowel, Crohn's disease) - Acute life-threatening bleeding (haemoptysis, intracranial bleeding) - Inability to tolerate oral intake This patient has normal GI function and no acute bleeding crisis, so oral therapy is appropriate and cost-effective. **Key Point:** Clinical improvement occurs within 2 weeks (bleeding stops, wound healing improves). Serum vitamin C normalizes within 1–2 weeks of supplementation. ## Why Other Options Are Incorrect | Option | Why Wrong | |--------|----------| | IV vitamin C 1 g daily | Indicated only for severe scurvy with acute bleeding or malabsorption. This patient has uncomplicated disease with normal GI function; oral therapy is sufficient and preferred. | | Bone marrow biopsy | Scurvy does not cause primary haematologic malignancy. Bleeding and anaemia are secondary to vitamin C deficiency, not bone marrow pathology. Biopsy is unnecessary and delays treatment. | | Dental extraction + orthopedic surgery | Surgical intervention is contraindicated in active scurvy due to poor wound healing and bleeding risk. Surgery should be deferred until vitamin C is replenished (2–4 weeks). | [cite:KD Tripathi 8e Ch 12; Robbins 10e Ch 7]