Scurvy is a disease of the vitamin deficiency group that serves as a clinical manifestation of vitamin C deficiency. The main symptoms are bleeding and swelling of the gums, damage to the skin (dryness, petechiae on the extremities with a bluish tinge), bone and joint system (hemarthrosis, loosening of the teeth with their further loss) . The diagnosis is established on the basis of characteristic clinical signs, medical history, and X-ray examination. Treatment consists of replacement therapy with ascorbic acid, a diet with a sufficient content of this vitamin.
General information
Scurvy (mourn, Meller-Barlow disease ) occurs only with a lack of ascorbic acid. Its name comes from the Greek prefix “a”, denoting negation, and the Latin root ” scorbutus -” scurvy “. In 1932, the anti-zingotic effect of vitamin C was proven. Until the 20th century, millions of people died from this disease. Currently, scurvy is rare, mainly among extremely poor and disadvantaged segments of the population with an irrational food culture. Outbreaks are possible during long expeditions, military operations, in closed institutions. The frequency of development and severity do not depend on age and gender.
Causes of scurvy
Ascorbic acid, which has many biochemical functions, is not synthesized endogenously in the human body. The absorption of vitamin C occurs in the duodenum 12, then it accumulates in the glandular tissue (mainly in the adrenal medulla and thyroid gland). The necessary reserves of this substance in adults are about 1500 mg. The causes of scurvy can be:
- Impaired absorption of vitamin C. The absorption of ascorbic acid is directly related to the proper functioning of the gastrointestinal tract. In conditions of violation of parietal digestion (destructive changes in the intestinal epithelium, for example, with helminthic invasions ) and abdominal digestion ( pancreatitis , prolonged diarrhea ), vitamin absorption is reduced or completely stopped.
- Inadequate intake. This reason is realized if a daily varied diet is not followed, but it is unlikely, since ascorbic acid is found in almost all vegetables, fruits, berries. The daily requirement is 70-100 mg for adults and 30-70 mg for children. With an absolute deficiency of vitamin scurvy develops in the period from 4 to 12 weeks.
Risk factors
Risk factors for the development of scurvy include pregnancy and lactation, hard physical labor, and infectious diseases that lead to excessive activation of the sympathoadrenal system. In this state, the catabolism (decay) of all substances, including ascorbic acid, is enhanced. Alcoholism , smoking reduce the adaptive capacity of the body, which entails an increase in the need for vitamin C.
Pathogenesis
Vitamin C is involved in oxidation- reduction processes, is responsible for the synthesis and decomposition of many substances. When scurvy occurs, aberrations occur in the mechanism of collagen formation – the fibrillar protein that forms the basis of connective tissue. With its defect, the activity of osteoblasts is inhibited, the structuring of protein matrices is disrupted , and, as a result, ossification processes are reduced.
The endothelial lining of blood vessels is also represented by collagen, which ensures its morphofunctional integrity and is responsible for the processes of hemostasis. As a result of endothelial defects, the permeability of the vascular wall increases, which is clinically manifested by bleeding of various localization.
Ascorbic acid takes part in the formation of hemoglobin, carrying out the transition of ferric to ferrous iron, which becomes suitable for reabsorption (absorption). With iron deficiency, the heme formation cycle is disrupted , microcytic hyporegenerative anemia develops . Vitamin C deficiency leads to a decrease in the activity of the coenzyme tetrahydrofolate , which is responsible for folic acid metabolism. Against the background of such changes, laboratory signs of megaloblastic anemia are observed .
Classification
Systematization of scurvy forms is carried out according to clinical manifestations, etiological factor. It can be primary (exogenous) – arising against the background of nutritional deficiency of vitamin C, secondary (endogenous), caused by increased demand and malabsorption. According to the criterion of severity, 3 degrees are distinguished:
- Easy. Manifested by weakness, fatigue. On examination, the skin with a pale shade of the type of “goose” as a result of an increase in hair follicles. Damage to the oral mucosa is characteristic: there is hyperemia of the interdental papillae, bleeding. In the future, the swelling spreads to the entire surface of the gums, they become loosened.
- Medium. Clinically manifested by pain in the muscles, mainly of the lower extremities, inactivity . The skin becomes dirty blue, a huge number of ecchymoses are visualized around the hair follicles – hemorrhages with a diameter of more than 3 mm. The development of aphthous stomatitis is characteristic , the gums acquire a blue-purple hue, the teeth become loose and fall out.
- Heavy. A sharp weakness develops, adynamia. Hemorrhages in serous cavities (pericardium, pleura), joint cavity, muscles are observed. With this form, ulcerative stomatitis , gingivitis occur . Often there is arterial hypotension, weakness of the pulse.
Symptoms of scurvy
The clinical manifestation of scurvy begins with general weakness, fatigue. The decrease in the strength of the collagen of capillaries and venules causes petechiae on the extremities, often accompanied by perifollicular hyperkeratosis . There are hemorrhages in the mucous membranes ( hemorrhagic periodontitis ), the thickness of the muscles, which is clinically manifested by myalgia of varying degrees. When blood enters the joint cavity, hemarthrosis characteristic of scurvy develops , mainly knee. Bursting pains occur, the joint increases in volume, with a significant accumulation of hemorrhagic exudate, contour smoothing is observed.
As a result of Fe2 + deficiency, the level of iron-containing enzymes ( cytochrome , peroxidase ) in the body decreases , which is manifested by sideropenic syndrome: taste perversion, addiction to spicy, spicy foods. Dystrophic changes in the nails develop, they become thin, dull, striation appears ; hair thinning, easily broken. Reduced iron levels lead to anemia with its classic clinic: dizziness, malaise, tachycardia .
Changes in the endocrine system are represented by hypofunction of the adrenal medulla. Deficiency of catecholamines leads to arterial hypotension , impaired nerve conduction, increasing the manifestations of existing anemia. Frequent viral, bacterial infections occur against the background of immunosuppression , always present with scurvy. Due to the inhibition of osteogenesis , tooth fixation is weakened, which leads to their loss.
In early childhood, scurvy is manifested by Meller-Barlow disease . Observed violations of ossification are expressed by deformation of the chest , the places of transition of the cartilaginous tissue of the ribs to the bone thicken, forming a “rosary”. Curvatures of the tubular bones are noted, changes in them lead to damage to the bone marrow – this explains the inhibition of hematopoiesis and increased bleeding. As in adults, there are skin manifestations – hemorrhages in the skin, mucous membranes, nosebleeds .
Complications
As a rule, complications are associated with the attachment of a secondary infection, since foci of hemorrhage are a favorable environment for the multiplication of microorganisms. Purulent plaque forms on the tongue, tonsils, necrosis of the mucous membrane occurs. Collagen defects and hemorrhagic effusion in the joints are accompanied by contractures, ankyloses . In some cases, blood from the vessels flows into the pericardial cavity, hemorrhagic pericarditis is observed with a transition to cardiac tamponade . Hemorrhages in the bile of the daughter of the brain , inter – shell spaces are accompanied by an increase in intracranial pressure with a risk of developing a dislocation syndrome.
Diagnostics
Since the clinical manifestations of scurvy are quite specific, the diagnosis is not particularly difficult. The survey was conducted doctor- gastroenterologist , dentist and other specialists profiles depending on the picture of the disease. Complications of scurvy pose a real threat to the patient’s life, therefore, timely diagnosis is necessary, which has the following stages:
- Clinical survey and examination. Patients complain of manifestations of anemic and hemorrhagic syndromes: fatigue, weakness, bleeding of various localization. The anamnesis is characterized by the presence of chronic gastrointestinal diseases, the absence of foods with a high content of vitamin C in the diet. The skin is pale with many petechiae. The bleeding of the gums, loosening of the teeth, and deformations of the bones are determined.
- Instrumental research. In the absence of clear data indicating nutritional deficiency of vitamin C, FGDS , colonoscopy is performed . If pancreatitis is suspected, hepatitis requires abdominal ultrasound . To exclude or confirm hemorrhages in the serous and articular cavities, X-rays of the OGK and joints are used. An early radiological sign of scurvy is general osteoporosis of bone tissue.
- Laboratory research. In blood tests, changes characteristic of iron deficiency anemia are detected. In the coprogram – signs of maldigestion , malabsorption . Determining the concentration of ascorbic acid in plasma is an indispensable method in controversial cases. Reference values of vitamin C in the blood are 4-20 μg / ml.
Differential diagnosis
Differential diagnosis requires the exclusion of diseases represented by hemorrhagic diathesis syndrome:
- congenital forms of blood clotting factor deficiency ( hemophilia , the disease the Stewart Prauera ):
- acquired forms – with cirrhosis of the liver , hemorrhagic fevers ( Crimean , Ebola ).
Exudative pericarditis that occurs with scurvy must be differentiated from myocardial infarction .
Scurvy treatment
Therapeutic measures are determined by the severity of scurvy. Mild treatment is carried out under the supervision of a nutritionist on an outpatient basis in compliance with a balanced diet. Medium and severe degrees require mandatory hospitalization in a therapeutic hospital, the appointment of medical nutrition, bed rest, and the correction of concomitant disorders.
Diet therapy
The main non-drug treatment for scurvy is diet therapy. It includes the obligatory calculation of daily calories, the ratio of the main macro-, micronutrients, taking into account age-sex, professional characteristics and compliance with the diet. It is represented by foods rich in vitamin C, most of its plant origin: leafy vegetables (white and Brussels sprouts, broccoli), red fruits (tomatoes, peppers), citrus fruits. The record holder for the content of ascorbic acid is dry rosehip, 100 g of which contains 1200 mg of vitamin C.
Drug treatment
With moderate and severe severity, along with the diet, drug therapy is required, the purpose of which is to correct the metabolism of vitamins, relieve pain and emergency conditions. For this, drugs of various pharmacological groups are used. When scurvy, the following treatments are used:
- Etiotropic . The main drug exposure is aimed at treating gastrointestinal diseases. Enzyme preparations containing pancreatin, bile components and non-animal enzymes are prescribed. With helminthic invasions, deworming is carried out depending on the type of pathogen. In case of nutritional deficiency of vitamin C, ascorbic acid is prescribed in tablets and parenterally for 1 month.
- Symptomatic Therapy is aimed at stopping bleeding: for this purpose, calcium chloride, aminocaproic and tranexamic acid are used. In severe cases, it performed the transfusion of erythrocyte mass , plasma. Iron deficiency anemia is corrected with iron preparations. In myalgia, local and systemic NSAIDs are used, which have a sufficient analgesic effect.
Forecast
Timely started rational therapy of an uncomplicated form of vitamin deficiency C gives favorable prospects for life, recovery and working ability. The prognosis worsens with moderate to severe scurvy, becoming doubtful in the case of massive hemorrhages in the serous cavities and unfavorable in case of cerebral hemorrhage. Joining a secondary infection, exacerbation of concomitant diseases significantly worsens the prognosis.
Prevention
The main and main role in the prevention of hypo -, vitamin deficiency is diet. An important aspect is the educational work, which consists in promoting a healthy lifestyle, advising on a balanced and balanced diet. Compensation of the somatic pathology of the gastrointestinal tract, the rehabilitation of foci of chronic infection, the appointment of vitamin complexes for people at risk are the most important measures to prevent the development of scurvy.