Scurvy or scorbutus is a deficiency disease (state of malnutrition) resulting from a lack of vitamin C (ascorbic acid). Early symptoms of deficiency include weakness, fatigue, and sore arms and legs. Without treatment, decreased red blood cells, gum disease, changes to hair, and bleeding from the skin may occur. As scurvy worsens, there can be poor wound healing, personality changes, and finally death from infection or bleeding. It takes at least a month of little to no vitamin C in the diet before symptoms occur. In modern times, scurvy occurs most commonly in neglected children, people with mental disorders, unusual eating habits such as ARFID, alcoholism, and older people who live alone. Other risk factors include intestinal malabsorption and dialysis. While almost all animals, plants, and other life forms produce their vitamin C, humans and a few others do not. Vitamin C, an antioxidant, is required to make the building blocks for collagen, carnitine, and catecholamines, and assists the intestines in the absorption of iron from foods. Diagnosis is typically based on outward appearance, X-rays, and improvement after treatment. Treatment is with vitamin C supplements taken by mouth, or intravenously for optimal resolution. Improvement often begins in a few days with complete recovery in a few weeks. Sources of vitamin C in the diet include raw citrus fruit and several raw vegetables, including red peppers, broccoli, and tomatoes. Cooking often decreases the residual amount of vitamin C in foods. Scurvy is rare compared to other nutritional deficiencies. It occurs more often in the developing world in association with malnutrition. Rates among refugees are reported at 5 to 45 percent. Scurvy was described as early as the time of ancient Egypt, and historically it was a limiting factor in long-distance sea travel, often killing large numbers of people. During the later Age of Sail, it was assumed that 50 percent of the sailors would die of scurvy on a major voyage of exploration. In long sea voyages, crews were isolated from land for extended periods and these voyages relied on large staples of a limited variety of foods; the lack of fruit, vegetables, and other foods containing vitamin C in diets of sailors resulted in scurvy.
Signs and symptoms Early symptoms are malaise and lethargy. After one to three months, patients develop shortness of breath and bone pain. Myalgias may occur because of reduced carnitine production. Other symptoms include skin changes with roughness, easy bruising, and petechiae, gum disease, loosening of teeth, poor wound healing, and emotional changes (which may appear before any physical changes). Dry mouth and dry eyes similar to Sjögren's syndrome may occur. In the late stages, jaundice, generalised edema, oliguria, neuropathy, fever, convulsions, and eventual death are frequently seen. Signs of scurvy also include hypotension, pulmonary hypertension, and an enlarged heart.
Cause Scurvy, including subclinical scurvy, is caused by a deficiency of dietary vitamin C since the human liver is unable to synthesize vitamin C. Provided the diet contains sufficient vitamin C, the lack of working L-gulonolactone oxidase (GULO) enzyme has no significance. In modern Western societies, scurvy is seldom present in average adults, although underfed people (drug users, the homeless, neglected children and geriatrics) are affected. Virtually all commercially available baby formulas contain added vitamin C, preventing infantile scurvy. Human breast milk contains sufficient vitamin C if the mother has an adequate intake. Commercial milk is pasteurized, a heating process that destroys the natural vitamin C content of the milk. Scurvy is one of the accompanying diseases of malnutrition (other such micronutrient deficiencies are beriberi and pellagra) and thus is still widespread in areas of the world dependent on external food aid. Although rare, there are also documented cases of scurvy due to poor dietary choices by people living in industrialized nations.
Pathogenesis
Vitamins are essential to the production and use of enzymes in ongoing processes throughout the human body. Vitamin C is needed for a variety of biosynthetic pathways, by accelerating hydroxylation and amidation reactions. It is involved in a wide range of biochemical and physiological processes, including the amidation of several peptide hormones and the synthesis of nitric oxide, norepinephrine, carnitine and collagen. In addition, vitamin C contributes to the modulation of gene expression through epigenetic mechanisms affecting more than a thousand genes. The early symptoms of malaise and lethargy may be due to either impaired fatty acid metabolism from a lack of carnitine and/or from a lack of catecholamines, which are needed for the cAMP-dependent pathway in both glycogen metabolism and fatty acid metabolism. Impairment of either fatty acid metabolism or glycogen metabolism leads to decreased ATP (energy) production. ATP is needed for cellular functions, including muscle contraction. (For low ATP within the muscle cell, see also Purine nucleotide cycle.) In the synthesis of collagen, ascorbic acid is required as a cofactor for prolyl hydroxylase and lysyl hydroxylase. These two enzymes are responsible for the hydroxylation of the proline and lysine amino acids in collagen. Hydroxyproline and hydroxylysine are important for stabilizing collagen by cross-linking the propeptides in collagen. Collagen is a primary structural protein in the human body, necessary for healthy blood vessels, muscle, skin, bone, cartilage, and other connective tissues. Defective connective tissue leads to fragile capillaries, resulting in abnormal bleeding, bruising, and internal hemorrhaging. Collagen is an important part of bone, so bone formation is also affected. Teeth loosen, bones break more easily, and once-healed breaks may recur. Defective collagen fibrillogenesis impairs wound healing. Untreated scurvy is invariably fatal. Vitamin C deficiency may cause pulmonary hypertension by several mechanisms. It participates in the synthesis of type IV collagen, which is required for basement membrane formation and endothelial cell adhesion. It also participates in the synthesis of NO and carnitine, and may increase prostacyclin levels. Vitamin C also participates in the hydroxylation of specific proline residues of HIF-1α and thereby increases its rate of degradation, leading to decreased HIF-1α levels.
… excerpt ends here. Continue reading the full article.
