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Early scurvy complicating anorexia nervosa.



ABSTRACT

Scurvy is an extremely rare complication of anorexia nervosa. Despite the poor intake of nutrients, anorexia nervosa is not commonly associated with vitamin deficiencies. We report a case of early scurvy complicating long-standing anorexia nervosa. Anorexia nervosa appears to be increasing in incidence. Although scurvy is unusual, this case shows the importance of its recognition as a nutritional consequence of anorexia nervosa.

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SCURVY develops after 1 to 3 months of ascorbic acid deficiency. The duration of the ascorbic acid deficiency determines the severity of the clinical manifestations. In general, anorexia nervosa is not characterized by vitamin deficiency. We describe a case of early scurvy complicating anorexia nervosa.

CASE REPORT

A 46-year-old 1-lispanic woman was admitted to the hospital because of cachexia cachexia /ca·chex·ia/ (kah-kek´se-ah) a profound and marked state of constitutional disorder; general ill health and malnutrition. . The patient had had a long history of early satiety, epigastric epigastric adjective Referring to the body region between the costal margins and the subcostal plane  pain, constipation, and progressive weight loss over the past several years. Two weeks before admission, the patient noticed easy bruising anti a nonpruritic rash on the lower extremities. Her medical history included nephrolithiasis, malnutrition, and normocytic anemia. The surgical history inclues a hysterectomy with bilateral salpingo-oophorectomy. On review of systems, the patient reported fatigue, lethargy, epigastric discomfort, and constipation. There was no history of trauma, fevers, chills, dyspnea, insomnia, or psychiatric illness.

On physical examination, the patient was withdrawn and cachectic cachectic /ca·chec·tic/ (kah-kek´tik) pertaining to or characterized by cachexia.

ca·chec·tic
adj.
Affected by or relating to cachexia.
. At presentation, the vital signs were normal. Weight was 85 lb, height 65 inches. Palpable perifollicular papules Papules
Firm bumps on the skin.

Mentioned in: Smallpox
 and nonpalpable purpuric macules and papules extended from the ankle to the knee bilaterally. Hemorrhages and ecchymoses Ecchymosis (plural, ecchymoses)
The medical term for a bruise. Ecchymoses may develop around the eyes following a nasal fracture.

Mentioned in: Nasal Trauma
 surrounded the knees and elbows bilaterally, but hemarthroses were absent. Lanugo lanugo /la·nu·go/ (lah-noo´go) the fine hair on the body of the fetus.

la·nu·go
n. pl. la·nu·gos
The fine, soft hair that grows on a fetus and is present on a newborn.
 was present over the arms. No lesions were noted on the hands, feet, nail beds, arms, or back. Petechiae Petechiae
Tiny purple or red spots on the skin associated with endocarditis, resulting from hemorrhages under the skin's surface.

Mentioned in: Endocarditis, Hantavirus Infections, Hemorrhagic Fevers, Idiopathic Thrombocytopenic Purpura

 were noted on the hard palate. The patient had few teeth, poor oral hygiene, and periodontal disease. Temporal wasting was present. No lymphadenopathy was noted. The neck, lungs, and heart were normal. Mild epigastric tenderness was elicited with palpation palpation /pal·pa·tion/ (pal-pa´shun) the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath in physical diagnosis. . There was no peripheral edema. Rectal examination showed scant occult blood. Psychomotor retardation was evident.

Laboratory data showed normocytic anemia with a reticulocyte index of 0.2, transthyretin value 5.2 mg/dL, morning cortisol level 4.7 [micro]g/dL, thyrotropin thyrotropin (thī'rätrō`pĭn) or thyroid-stimulating hormone (TSH), hormone released by the anterior pituitary gland that stimulates the thyroid gland to release thyroxine.  (TSH) value 7.49 [micro]U/mL, prothrombin time 12.1 sec, activated partial thromboplastin time Activated partial thromboplastin time
Partial thromboplastin time test that uses activators to shorten the clotting time, making it more useful for heparin monitoring.
 31 sec, and platelet count 140,000/[mm.sup.3]. Results of a cosyntropin stimulation test were normal, as were prolactin, thyroxine, liver enzyme and serum chemistry values, and erythrocyte sedimentation rate Erythrocyte Sedimentation Rate Definition

The erythrocyte sedimentation rate (ESR), or sedimentation rate (sed rate), is a measure of the settling of red blood cells in a tube of blood during one hour.
. A platelet ascorbic acid level was not obtained. Abdominal and pelvic CT scans showed small amounts of ascites, periportal edema, and a resolved left hydronephrosis. Findings on esophogastroduo-denoscopy and colonoscopy were normal. A skin punch biopsy of a perifollicular lesion showed hyperkeratotic perifollicular plugging, extravasation extravasation /ex·trav·a·sa·tion/ (ek-strav?ah-za´shun)
1. a discharge or escape, as of blood, from a vessel into the tissues; blood or other substance so discharged.

2. the process of being extravasated.
 of red blood cells Red blood cells
Cells that carry hemoglobin (the molecule that transports oxygen) and help remove wastes from tissues throughout the body.

Mentioned in: Bone Marrow Transplantation

red blood cells 
, hemosiderin hemosiderin /he·mo·sid·er·in/ (he?mo-sid´er-in) an insoluble form of tissue storage iron, visible microscopically both with and without the use of special stains.

he·mo·sid·er·in
n.
 in dermis, and lymphocytic inflammation.

Further dietary and social history revealed that the patient had lost 10 kg over the past 3 years. Her diet included small portions of boiled chicken and white rice. She ate canned vegetables rarely. She described herself as reclusive and fully dependent on family members for her care. While hospitalized, she refused house meals, liquid nutritional supplements, and the majority of oral medications. When questioned about her refusals, the patient was concerned about the size of her stomach and appeared fearful of weight gain. Each new medication or food was negotiated with the patient. She denied the seriousness of her weight loss. There was no evidence of binge eating, self-induced vomiting, or misuse of laxatives.

The patient was treated with ascorbic acid therapy via vitamin supplements and enteral supplements. The ecchymoses and petechiae resolved over the course of 7 days. The palpable perifollicular papules persisted. The patient was discharged to home but was readmitted 6 months later because of constipation and abdominal pain. Fever and leukopenia quickly developed, associated with hypotension. The patient died of refractory septic shock refractory septic shock Septic shock lasting > 1 hr, that does not respond to fluid resuscitation–IV therapy or pharmacologic–pressors. See Septic shock.  likely due to ischemic colitis.

DISCUSSION

We describe a malnourished patient with early scurvy and anorexia nervosa. Two other cases of scurvy associated with anorexia nervosa have been reported. (1,2) In our case, the early manifestations of scurvy were present in the form of petechiae and ecchymoses. Follicular hyperkeratosis hyperkeratosis /hy·per·ker·a·to·sis/ (-ker?ah-to´sis)
1. hypertrophy of the stratum corneum of the skin, or any disease so characterized.

2. hypertrophy of the cornea.
 on skin biopsy supports the clinical diagnosis of early scurvy. The patient met the DSMIV criteria for restricting type of anorexia nervosa.

Moderate deficiency of ascorbic acid is associated with petechial hemorrhage and ecchymosis ECCHYMOSIS, med. jur. Blackness. It is an extravasation of blood by rupture of capillary vessels, and hence it follows contusion; but it may exist, as in cases of scurvy, and other morbid conditions, without the latter. Ryan's Med. Jur. 172. . Severe ascorbic acid deficiency results in gingival gingival (jin´jv  hemorrhage, hemarthroses, and subperiosteal subperiosteal /sub·peri·os·te·al/ (-per-e-os´te-al) beneath the periosteum.
subperiosteal, (sub´perēos´tē
 hemorrhage. Follicular hyperkeratosis with corkscrew hairs is present on skin examination in moderate to severe cases. Nonspecific complaints include weakness, fatigue, dyspnea, and muscle aches. A normocytic anemia can develop, and poor wound healing develops due to decreased collagen synthesis. (3-6)

Ascorbic acid is required for the synthesis of collagen, dopamine, and carnitine. Unlike most mammals, humans cannot synthesize ascorbic acid. Without intake of ascorbic acid, body stores are depleted in 1 to 3 months. (5-7) In the United States, scurvy is most commonly observed in the homebound elderly, food faddists, and patients with malnutrition associated with malignancy.

According to dietary history in anorexic patients, intake of calcium, iron, niacin, riboflavin riboflavin: see coenzyme; vitamin.
riboflavin
 or vitamin B2

Yellow, water-soluble organic compound, abundant in whey and egg white. It has a complex structure incorporating three rings.
, and ascorbic acid is significantly lower than in normal subjects. (8) Despite near starvation, anorexia nervosa is not commonly associated with vitamin deficiencies. In a study comparing 20 anorexic female subjects with 20 control subjects, no significant differences were found in serum levels of thiamin thiamin
 or vitamin B1

Organic compound, part of the vitamin B complex, necessary in carbohydrate metabolism. It carries out these functions in its active form, as a component of the coenzyme thiamin pyrophosphate.
, pyridoxine pyridoxine: see coenzyme; vitamin. , ascorbic acid, folate, vitamin E, or vitamin D. (9)

Anorexia nervosa usually develops during adolescence, with a small percentage of cases developing after age 25. Multiple studies of anorexia nervosa confirm that 90% to 95% of the cases involve women. The lifetime prevalence rate of anorexia nervosa is 0.5%. An increase in the age-adjusted incidence rate of anorexia nervosa from 7.0 per 100,000 in 1950 to 1954 to 26.3 in 1980 to 1984 has been reported. (10) In females 15 to 24 years of age, a significant linear increase in age-adjusted incidence of anorexia nervosa between 1935 and 1984 is noted. (10) The mean annual increase of age-standardized rates of anorexia nervosa from 1965 to 1991 was 5.3%. (11) From these studies, it appears that the incidence of anorexia nervosa is increasing.

CONCLUSION

With the common use of nutritional supplementation of ascorbic acid, scurvy has gone from an omnipresent distemper at sea to a curiosity. In our case, early scurvy presented itself as a complication of anorexia nervosa, a common disease that appears to be increasing in incidence. Although scurvy is unusual, this case illustrates the importance of its recognition as a nutritional consequence of anorexia nervosa.

References

(1.) George GCW, Zabow T, Beaumont PJV: Scurvy in anorexia nervosa. S Afr Med J l975; 49:1420

(2.) Metha CL, Cripps D, Bridges AJ: Systemic pseudovasculitis from scurvy in anorexia nervosa. Arthritis Rheum 1996; 39:532-533

(3.) Barthelemy H, Chouvet B, Cambazard F: Skin and mucosal manifestations in vitamin deficiency. J Am Acad Dermatol 1986; 15:1263-1274

(4.) Hodges RE, Hood J, Canham JE, et al: Clinical manifestations of ascorbic acid deficiency in man. Am J Clin Nutr 1971; 24:432-443

(5.) Levine M: New concepts in the biology and biochemistry of ascorbic acid. N Engl J Med 1986; 314:892-902

(6.) Miller SJ: Nutritional deficiency and the skin. J Am Acad Dermatol 1989; 21:1-30

(7.) Greene HL, Hambidge KM, Schanler R, et al: Guidelines for the use of vitamins, trace elements, calcium, magnesium, and phosphorus in infants and children receiving total parenteral nutrition Total Parenteral Nutrition Definition

Total parenteral nutrition (TPN) is a way of supplying all the nutritional needs of the body by bypassing the digestive system and dripping nutrient solution directly into a vein.
. Am J Clin Nutr 1988; 48:1324-1342

(8.) Thibault L, Roberge AG: The nutritional status of subjects with anorexia nervosa. Int J Vitamin Nutr Res 1987; 57:447-452

(9.) Van Binsbergen CJ, Odink J, Van den Berg H, et al: Nutritional status in anorexia nervosa: clinical chemistry, vitamins, iron and zinc. Eur J Clin Nutr 1988; 42:929-937

(10.) Lucas AR, Beard CM, O'Fallon WM, et al: Fifty-year trends in the incidence of anorexia nervosa in Rochester, Minn. Am J Psychiatry 1991; 148:917-922

(11.) Eagles JM, Johnston MI, Hunter D, et al: Increasing incidence of anorexia nervosa in the female population of northeast Scotland. Am J Psychiatry 1995; 152:1266-1271

RELATED ARTICLE: KEY POINTS

* Anorexia nervosa is not commonly associated with vitamin deficiencies.

* Anorexia nervosa appears to be increasing in incidence.

* Stores of ascorbic acid deplete in 1 to 3 months.

* The duration of ascorbic acid deficiency determines the severity of scurvy.

* Scurvy is an unusual nutritional consequence of anorexia nervosa.

From the Division of Critical Care Medicine, Miriam Hospital; the Department of Medicine, Division of General Internal Medicine, Rhode Island Hospital; and Brown University School of Medicine, Providence, RI.

Reprint requests to Kenneth Christopher, MD, Miriam Hospital, Division of Critical Care Medicine, 164 Summit Ave, Providence, RI 02906.
COPYRIGHT 2002 Southern Medical Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2002, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Author:Wing, Edward J.
Publication:Southern Medical Journal
Geographic Code:1USA
Date:Sep 1, 2002
Words:1451
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