Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2024;14(1):e2024030 1 A Case Series of Scurvy Presenting as Bruising Claire Quigley1, Helena Yhoo1, Liana Victory1, Stephanie Bowe1, Ciara Devenney1, Emma Shudell1 1 Mater Misercordiae University Hospital, Dublin, Ireland Key words: Atypical bruising, nutritional deficiency, scurvy Citation: Quigley C, Yhoo H, Victory L, Bowe S, Devenney C, Shudell E. A Case Series of Scurvy Presenting as Bruising. Dermatol Pract Concept. 2024;14(1):e2024030. DOI: https://doi.org/10.5826/dpc.1401a30 Accepted: June 29, 2023; Published: January 2024 Copyright: ©2024 Quigley et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Dr. Claire Quigley, Mater Misercordiae University Hospital, Dublin, Ireland. Email: clairequigley@mater.ie Introduction Vitamin C is essential in collagen formation, leukocyte function and other enzymatic processes. Defects in collagen disrupt the integrity of hair, connective tissue, and blood vessels, leading to characteristic cutaneous manifestations of scurvy [1]. Scurvy is often considered a historic disease, as- sociated with gingivitis, loose teeth and fatigue. A recent re- view showed that available evidence indicates that vitamin C deficiency is common in low- and middle-income countries and not uncommon in high income settings [2]. This case series describes scurvy manifesting as unexplained bruising, highlighting that although challenging to recognize due to a low index of suspicion, scurvy should remain within our dif- ferential as it is easy to diagnose and treat, once considered. Case Presentation Patient #1 is a 22-year-old female, with history of panproc- tocolectomy and end-ileostomy formation for Crohn. She was taking daily Vitamin B, C and D supplementation. She reported a 4 month history of widespread bruising. Physi- cal examination revealed extensive ecchymoses on her lower limbs (Figure 1), abdomen and flanks bilaterally. Laboratory investigations were grossly normal, except for a low level of vitamin C measuring 3 mg/L (reference range 4 – 15 mg/L). We increased the dose of her vitamin C supplementation to 2000 mg daily for 3 months and her ecchymoses resolved. This patients history of extensive bowel resection is likely responsible for her vitamin C deficiency. Patient #2 was an 81-year-old female with a background diagnosis of mycosis fungoides on treatment with bexaro- tene. On routine review she complained of nausea, diarrhea, bilateral swollen lower legs and ecchymoses. Bexarotene was held. Her nausea and diarrhea settled but a cause for her bruising and oedema remained elusive. Laboratory in- vestigations were normal except a vitamin C level returned as 3  mg/L (reference range 4 – 15 mg/L). We commenced 1000 mg/day of vitamin C and her ecchymoses and oedema resolved one month later. 2 Research Letter | Dermatol Pract Concept. 2024;14(1):e2024030 Patient #3 is a 77-year-old female with a history of lupus, Sjogren syndrome, pulmonary fibrosis and Crohn disease. Extensive facial ecchymoses (Figure 2) were noted at rou- tine review. A skin biopsy from her left cheek revealed red cell extravasation in the upper dermis but no vasculitis or features suggestive of lupus and a DIF was negative. Once again, investigations found a Vitamin C level of 3 mg/L (ref- erence range 4-15mg/L). Similarly, Vitamin C 1000 mg/day was started and her symptoms improved. Conclusions Clinical manifestations of scurvy typically occur within 12  weeks of inadequate intake. Risk factors include low socioeconomic status, alcoholism or illness predisposing pa- tients to poor oral intake [4]. Ecchymosis, perifollicular pur- pura, corkscrew hairs and easy wound breakdown are key cutaneous findings, however bruising in isolation, as in the case of our patients, may make the diagnosis more challeng- ing. Follicular hyperkeratosis and perifollicular hemorrhage are pathognomonic on examination [3]. Scurvy is often considered to have a relatively benign symptomatology but late stage deficiency can be severe; reported manifestations include generalized edema, jaundice, spontaneous bleeding, neuropathy, fever, convulsions, and death [4]. One published report discusses cardiac tamponade caused by scurvy  [5]. We recommend keeping scurvy within the differential when considering indistinct presentations. Patients typically see resolution of symptoms within weeks of commencing supplementation. References 1. Souza PRM, Dupont L, Rodrigues FE. Scurvy: hard to remember, easy to diagnose and treat. An Bras Dermatol. 2021;96(2):257- 258. DOI: 10.1016/j.abd.2020.03.024. PMID: 33622632. PMCID: PMC8007537. 2. Rowe S, Carr AC. Global Vitamin C Status and Prevalence of Deficiency: A Cause for Concern? Nutrients. 2020;12(7):2008. DOI: 10.3390/nu12072008. PMID: 32640674. PMCID: PMC7400810. 3. Fossitt DD, Kowalski TJ. Classic skin findings of scurvy. Mayo Clin Proc. 2014;89(7):e61. DOI: 10.1016/j.mayocp.2013.06.030. PMID: 24996243. 4. Léger D. Scurvy: reemergence of nutritional deficiencies. Can Fam Physician. 2008;54(10):1403-1406. PMID: 18854467; PMCID: PMC2567249. 5. Alnaimat S, Oseni A, Yang Y, et al. Missing Vitamin C: A Case of Scorbutic Cardiac Tamponade. JACC Case Rep. 2019;1(2):192- 196. DOI: 10.1016/j.jaccas.2019.07.006. PMID: 34316783. PMCID: PMC8301525. Figure 1. Patient #1. Bilateral perifollicular purpura on lower limbs. Figure 2. Patient #3. Facial ecchymoses.