Internal Medicine Flashcard| Volume 44, e7-e8, October 2017

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Purpuric lesions in a 45-year old man


      • Scurvy is a rare issue but may not be overlooked as it can be severe.
      • Scurvy is often associated with inflammatory bowel diseases.
      • Purpuric lesions in scurvy can mimic cutaneous vasculitis.
      • Purple purpura of the palate as gingival inflammation are typical aspects of scurvy.
      • Supplementation has to be initiated before the diagnosis is confirmed.

      1. Case description

      A forty-five year-old man, with a tobacco and alcohol history, affected with Crohn's disease, was admitted for haemoptysis and abdominal pain. The clinical examination showed extensive cutaneous purpuric lesions (Fig. 1A ) and a purple-coloured palate with gingival inflammation (Fig. 1B). Biological analyses revealed an elevation of the C-reactive protein, at 15 mg/l, an icteric cholestasis with cytolysis and severe malnutrition demonstrated by a hypoalbuminemia of 21 g/l. The chest CT-scan showed slight ground glass opacity in the apex, and the abdominal CT-scan showed a non-specific and moderate colitis. What is the diagnosis?
      Fig. 1
      Fig. 1A. Purpuric lesions of the legs. B. Purple purpura of the palate, and gingival inflammation.

      2. Discussion section

      The cutaneous and mucosal purpuric lesions, in the context of alcohol intoxication and inflammatory bowel disease, called to mind the classical but rare diagnosis of scurvy. Our hypothesis was confirmed by low plasma ascorbic acid level: 0.3 mg/l (reference range 9.6–12.6). All the cutaneous and pulmonary lesions disappeared after vitamin C supplementation. Scurvy is a historical pathology described in situations of severe malnutrition []. It is often associated with inflammatory bowel diseases, although its incidence is underestimated because it is asymptomatic in most cases [
      ]. Furthermore, vasculitis associated with Crohn's disease has been described in rare cases, revealed by infiltrated purpuric lesions [
      ]. In our case, one of the purpuric lesions was biopsied and histological analysis showed a slight peri-vascular dermic infiltration with lymphohistiocytosic white cells, ectasic capillaries, and haemosiderine deposits with red cells extravasation. These particular aspects have been described in scurvy, but sometimes microscopic lesions can mimic small-vessels vasculitis [
      ], reminding us that clinical examination is essential. A purple purpura of the palate and a swollen gingival global inflammation are typical aspects of scurvy. The diagnosis can be confirmed by the plasma ascorbic acid level, but supplementation, which is cheap, has to be initiated as soon as the diagnosis is suspected. Indeed, scurvy can be severe and life-threatening due to the haemorrhagic consequences of vitamin C deficiency.

      Conflict of interest

      We have no conflict of interest related to this work.


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