A 52-year-old male construction worker from Rajasthan presents with a 3-month history of painful, swollen gums with bleeding, poor wound healing, and follicular hyperkeratosis on his lower extremities. He reports a diet of rice, dal, and occasional vegetables but no fresh fruits for the past 8 months due to financial constraints. Hemoglobin is 10.8 g/dL (normocytic). What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis: Scurvy (Vitamin C Deficiency) This patient presents with **classic scurvy** — vitamin C deficiency with: - **Gingival manifestations:** swollen, bleeding gums (pathognomonic) - **Skin signs:** follicular hyperkeratosis (perifollicular hemorrhages, corkscrew hairs) - **Impaired wound healing** (collagen synthesis defect) - **Risk factor:** prolonged dietary deficiency (no fresh fruits × 8 months) **Key Point:** The clinical presentation is **diagnostic**. Serum ascorbic acid testing is confirmatory but NOT required to delay treatment. ## Pathophysiology ```mermaid flowchart TD A[Vitamin C deficiency]:::outcome --> B[Impaired hydroxylation of proline & lysine]:::outcome B --> C[Defective collagen synthesis]:::outcome C --> D[Fragile blood vessels]:::action C --> E[Poor wound healing]:::action D --> F[Bleeding gums, perifollicular hemorrhages]:::urgent E --> G[Follicular hyperkeratosis, poor fracture healing]:::urgent ``` ## Management Algorithm ```mermaid flowchart TD A[Clinical scurvy diagnosed]:::outcome --> B{Severity assessment}:::decision B -->|Mild-Moderate: No complications| C[Oral ascorbic acid 500 mg BD]:::action B -->|Severe: Complications or malabsorption| D[IV ascorbic acid 1000 mg daily]:::action C --> E[Dietary counseling: citrus, leafy greens]:::action D --> F[Transition to oral after stabilization]:::action E --> G[Clinical response in 2-4 weeks]:::outcome F --> G ``` ## Why Oral Therapy is Appropriate Here **High-Yield:** This patient has **uncomplicated scurvy** with: - No acute hemorrhage or life-threatening bleeding - Intact GI tract (no malabsorption mentioned) - Mild anemia (Hb 10.8, likely secondary to poor nutrition + bleeding) - Stable clinical status **Oral ascorbic acid 500 mg twice daily** is standard first-line therapy. Response is rapid: gingival bleeding resolves in 1–2 weeks, follicular hyperkeratosis in 2–4 weeks. ## Dosing & Dietary Intervention | Parameter | Recommendation | |-----------|----------------| | **Acute therapy** | 500 mg BD orally (1000 mg/day total) | | **Duration** | 2–4 weeks until clinical resolution | | **Maintenance** | Dietary sources: citrus, tomatoes, leafy greens, guava | | **RDA** | 90 mg/day (men); 75 mg/day (women) | **Clinical Pearl:** Dietary counseling is as important as supplementation. In resource-limited settings, teaching the patient to consume seasonal fruits (guava, citrus, papaya) and leafy vegetables prevents recurrence. ## Why Serum Testing is NOT the Next Step **Warning:** Delaying treatment to await serum ascorbic acid levels is inappropriate. The clinical diagnosis is **pathognomonic** — bleeding gums + follicular hyperkeratosis + dietary history = scurvy. Serum levels are rarely measured in clinical practice; treatment is empirical based on clinical presentation. Testing delays symptom relief and risks progression of bleeding.