Page 232 - The Netter Collection of Medical Illustrations - Integumentary System_ Volume 4 ( PDFDrive )

Plate 8-9 Integumentary System

DIETARY SOURCES OF VITAMIN C AND CLASSIC CUTANEOUS MANIFESTATIONS OF SCURVY
SCURVY
Sources of vitamin C Major sites of concentration Normal and abnormal values
in body Serum:
Scurvy is a well-known nutritional disease that results Suprarenal Normal
from a lack of the water-soluble vitamin, ascorbic acid cortices 0.5 to 1.0
(vitamin C). Scurvy has a well-documented history. It mg/100 mL
was first recognized in the fourteenth century in sailors Scurvy
who spent long amounts of time at sea. The symptoms 0 to 0.1
were recognized as being related to a lack of fresh foods, Citrus Pituitary mg/100 mL
gland
especially citrus products. In 1753, James Lind, a British Breast milk fruits “Buffy“ coat: Urine:
surgeon aboard the HMS Salisbury, performed the first Normal Normal
documented clinical trial proving that scurvy was caused 15 to 25 15 to 30
by a lack of citrus fruit in the diet of sailors. After Lind’s mg/100 mL mg/24 hr
discovery, citrus fruits were included in ships’ provi- Scurvy Scurvy
sions, and the incidence of scurvy in sailors plummeted. Leukocytes <2 0
It was not until 1928 that ascorbic acid was isolated by Potatoes Fresh meats mg/100 mL
the Hungarian chemist, Albert von Szent-Grörgyi, who
was eventually awarded the Nobel Prize for this discov-
ery. Scurvy is still present in some areas of the world
due to inadequate dietary intake of vitamin C. Scurvy
is uncommon in North America but can be seen in
individuals with abnormal diets.
Clinical Findings: Scurvy is a disease that can affect Positive
a wide range of organ systems. The skin and mucous Rumpel-
membranes are always involved and may display the Leede test
initial symptoms of the disease. Recognition of these
symptoms is critical in diagnosing the disease and pre-
venting long-term illness. Scurvy is a rare disease in
regions of the world with access to proper dietary intake Multiple
of vitamin C. In North America and Europe, most cases perifollicular
are the result of abnormal dieting, psychiatric illness, hemorrhages
or alcoholism. Prompt recognition of the cutaneous
manifestations can lead to treatment and cure of the
disease. Scurvy has an insidious onset with nonspecific Corkscrew
constitutional symptoms such as generalized weakness, hairs Swollen, congested, bleeding gums
malaise, muscle and joint aches, and easy fatigability
with shortness of breath. These symptoms may be
related to the macrocytic anemia that is frequently seen
in patients with scurvy and is believed to be caused by
a coexisting folic acid deficiency.
The first clinical findings are often in the mucous
membranes and the skin. There are a multitude of cuta-
neous manifestations. Early in the course of disease,
skin becomes dry and rough, in association with a
dulling of the skin tone. Small, hyperkeratotic papules
may be noticed and resemble those of keratosis pilaris.
More specific and sensitive skin findings then develop,
including perifollicular hemorrhage and “corkscrew
hairs.” The corkscrew hairs are most noticeable on the
extremities. Swan-neck deformity of the extremity hair
may also occur due to abnormal bending of the hair;
this is less common than corkscrew hair. The nail bed
shows splinter hemorrhages. All cutaneous findings Typical “frog leg”
appear to be more common on the lower extremities. position, scorbutic
This is believed to be a result of increased hydrostatic rosary, multiple
pressure in the lower extremities while one is upright, ecchymoses
which leads to increased pressure on the small venules
in the follicular locations, resulting in the perifollicular
hemorrhages. These findings are also observed in areas
of pressure directly on the skin, such as around the waist
line. The Rumpel-Leede sign is positive: When a blood
pressure cuff is inflated for 1 minute to a value that is
greater than the diastolic pressure but less than the
systolic pressure, numerous petechial hemorrhages develop dental calculi at the base. This may result in variety of bony deformities. Scorbutic rosary is a term
occur distal to and underneath the blood pressure cuff. loose teeth and pain. Teeth eventually become dis- given to the prominence of the costochondral junctions.
This test is a sign of capillary fragility induced by rupted from their attachments and fall out. Infants with scurvy develop “frog legs” due to subperi-
increased hydrostatic pressure. Compared with scurvy in adults, congenital scurvy osteal hemorrhage. This form of hemorrhage is painful,
The mucous membranes may show the first sign of and scurvy during early childhood have unique manifes- and the infant naturally relaxes the lower limbs in this
the disease. The main finding is edematous, bleeding tations related to bony development. Vitamin C is criti- pattern to relieve the pain. Healing of the subperiosteal
gums. As the disease progresses, the gums become cally important for the development of collagen and hemorrhage often involves abnormal calcification of the
friable and peel away from the teeth. The teeth may cartilage, and abnormalities at a young age result in a region and the formation of a more club-shaped bone.

218 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS