A Clinician’s Quick Guide to Scurvy: Risk Factors, Signs, and Treatment
Scurvy is rare.
It’s one of those “test question” diseases you learn about in medical school. Sure, you can memorize the signs and symptoms, but seeing it in practice? Does that actually happen?
Actually…Yes!
Historically, ascorbic acid deficiency was associated with certain professions–like those sailing on ships for months at a time without access to citrus–but more recently, it’s been making a comeback. A recent study actually estimated that the prevalence of vitamin C deficiency is about 5-7% in the United States. [1]
Not all people who have ascorbic acid deficiency are symptomatic. But, awareness of scurvy is important, as it can be deadly if left untreated.
On top of it all, scurvy may mimic other diseases, particularly those of rheumatologic and even oncologic nature.
Scurvy is such a good mimic that in fact, when I plugged in some of the symptoms (joint pain, swelling, refusal to bear weight, bruising) to ChatGPT, it spit out differential diagnoses like septic arthritis, juvenile idiopathic arthritis, leukemia, etc. However, scurvy didn’t even meet the list!
At least we can still beat AI at something, am I right?
So you can catch and treat scurvy, we’ll review this condition, including:
History & Risk Factors
Symptoms
Physical Exam & Signs
Evaluation
Treatment
So with that, let’s dive in.
History & Risk Factors
This goes without saying, but taking a good dietary history is paramount. Ask about fresh fruit and vegetables, with special interest in vitamin C rich foods like oranges and grapefruit.
Even if the patient takes a multivitamin, be sure to clarify its composition. Remember, not all supplements are created equally. Unfortunately, not all patients are aware of this.
Risk factors for developing ascorbic acid deficiency also come into play. I’m speaking from a pediatric perspective, but a history of restrictive eating and developmental disorder are risk factors. [2] Other risk factors include conditions with a proclivity to malabsorption, particularly of the small intestine.
In addition, a recent study published out of France showed that the incidence of scurvy can be increased in populations at risk for socioeconomic instability, particularly in times of economic inflation. [3]
Symptoms
The most common symptoms of scurvy are:
Fatigue or malaise
Gingival swelling and bleeding
Easy bruising
Arthralgias or back pain
Poor wound healing
Abdominal pain
On top of the arthralgias, some patients may even refuse to walk because of the pain. Depending on the patient, they may even complain of joint swelling, which is tied closely to the pathophysiology of scurvy–which is discussed in the next section.
Signs & Physical Exam
As a rheumatologist, I often find it helpful to try and tie signs and symptoms back to the pathophysiology, as it helps me remember them.
A Quick Note On Pathophysiology of Scurvy
In ascorbic acid deficiency, there is impaired collagen synthesis. This can lead to fragile collagen fibers in capillaries and decreased integrity of connective tissue.
These collagen structural dysfunctions lead to the clinical symptoms of perifollicular petechiae, gingival bleeding, easy bruising, and even hard palate petechiae.
In addition, this fragility can lead to subperiosteal hemorrhages and even intra-articular hemorrhages. Hence, the bone pain and even joint swelling.
Common Physical Exam Findings
Not every patient will have all of the signs of scurvy, but it is important to keep them in mind.
The top findings on physical exam you should look for include [4]:
Ecchymosis or purpura: secondary to capillary fragility; this can also occur on the hard palate, so be sure to check
Gingival bleeding and/or swelling: again, secondary to capillary fragility and defective connective tissue synthesis
Perifollicular petechiae with hyperkeratosis: this will feel like a small “bump” as you palpate
Cork-screw hairs: these may be small and short; interspersed among “normal” hair
Joint swelling: patients may have tenderness to palpation of some joints, in addition to effusion and limited range of motion
Pallor: anemia can also be associated with vitamin C deficiency
In addition, some patients may have lower limb edema.
Evaluation
Scurvy is diagnosed using laboratory studies. Patients may end up getting imaging as part of their work-up, given the propensity for scurvy to mimic infections, rheumatic diseases, and oncologic conditions.
Low Vitamin C and Other Laboratory Findings
Laboratory studies used to work-up for scurvy include, of course, ascorbic acid level. For some institutions, this may be a special send out lab. To diagnose scurvy, serum vitamin C level must be < 0.2 mg/dL.
Other lab findings can include [5]:
Anemia
Leukopenia
Elevated inflammatory markers, including sedimentation rate (ESR) and C-reactive protein (CRP)
As a result of easy bruising and bleeding, coagulation studies may also be checked, but these tend to be normal.
Imaging
While imaging is not required to make the diagnosis of scurvy, patients may get imaging during their evaluation given the signs and symptoms.
Plain radiography of painful or swollen areas may reveal findings consistent with subperiosteal hemorrhages. More dedicated musculoskeletal imaging may also reveal findings of hemarthrosis. While true synovitis is rare, it has been reported in the literature. [4]
I’ll also add that synovitis can sometimes develop in the setting of hemarthrosis, but it’s more of a reactive process to the presence of blood in the joint.
Treatment
The human body depends on exogenous forms of vitamin C. If vitamin C is not available in the diet, a person will develop deficiency in about 3 months.
So if we’re trying to replace a patient’s vitamin C stores, we need to keep this tidbit in mind.
Vitamin C Replacement Therapy
Treatment for scurvy requires vitamin C replacement therapy. Vitamin C can be replaced via PO or IV. We typically reserve IV for people who are unable to tolerate PO.
Dosing can vary from pediatric to adult patients. One extensive literature review showed pediatric dosing that ranged from 100-300 mg daily, which could be given in divided doses. [6] Another study in adults showed dosing between 500-1000 mg daily. [4]
When thinking about dosing, it’s also good to keep in mind that vitamin C is a water soluble vitamin.
Dietary Intake
The human body doesn’t synthesize vitamin C, and relies on exogenous intake. The daily recommended intake ranges from 15 mg to 120 mg, depending on age, smoking status, pregnancy status, and certain malabsorptive diseases. [7]
The best sources of vitamin C are fruits and vegetables. But, if a patient tells you they exclusively eat potatoes, that may not be enough.
The foods and drinks that have the most vitamin C are:
Red and green pepper
Orange juice and oranges
Grapefruit juice and grapefruit
Kiwi fruit
Strawberries
Broccoli
Brussels sprouts
Patients can also take a daily vitamin C supplement. The different forms of vitamin C include ascorbic acid, sodium ascorbate, calcium ascorbate, and others. [7]
Scurvy–Putting It All Together
Scurvy can be tricky to diagnose as it can mimic so many diseases. It’s important to keep it in the back of your mind, especially when taking care of at-risk patients.
Taking a good dietary history is paramount–be sure to ask about certain foods and specify what supplements your patient is taking. Don’t forget to check for the tell-tale mucosal and skin findings. Once you see the rash once, it’s difficult to forget.
If anything about your evaluation makes you suspicious, remember, you can always send the vitamin C level!
FAQ
What are scurvy symptoms?
Symptoms of scurvy include bleeding gums, fatigue, easy bruising, joint pain, petechial rash, and corkscrew hairs.
What serum vitamin C level is considered deficient?
If the serum vitamin C level is < 0.2 mg/dL, that is considered deficient.
What is the dose of vitamin C replacement therapy?
Each patient has their own considerations, and it depends on age and other comorbid conditions, but usually 100 to 1000 mg of vitamin C daily supplementation is needed for replacement therapy.
Important Disclosure:
This website offers general information and does not provide medical advice. It is not a substitute for professional medical consultation, diagnosis, treatment, or prevention. No doctor-patient relationship is established through this website. The opinions expressed are solely those of the author and do not reflect their employer's views.
References
Allen LH. Micronutrients - Assessment, Requirements, Deficiencies, and Interventions. N Engl J Med. 2025;392(10):1006-1016. doi:10.1056/NEJMra2314150
van Heerden C, Cheng DR, McNab S, et al. Scurvy and vitamin C deficiency in an Australian tertiary children's hospital. J Paediatr Child Health. 2024;60(9):409-414. doi:10.1111/jpc.16594
Assad Z, Trad M, Valtuille Z, et al. Scurvy incidence trend among children hospitalised in France, 2015-2023: a population-based interrupted time-series analysis. Lancet Reg Health Eur. 2024;49:101159. Published 2024 Dec 6. doi:10.1016/j.lanepe.2024.101159
Mertens MT, Gertner E. Rheumatic manifestations of scurvy: a report of three recent cases in a major urban center and a review. Semin Arthritis Rheum. 2011;41(2):286-290. doi:10.1016/j.semarthrit.2010.10.005
Ueki M, Sakamoto K, Nishioka N, et al. Rheumatologic manifestations with elevated levels of IL-6, IL-17A, and IL-23 in a patient with scurvy. Mod Rheumatol Case Rep. 2023;7(1):302-306. doi:10.1093/mrcr/rxac059
Trapani S, Rubino C, Indolfi G, Lionetti P. A Narrative Review on Pediatric Scurvy: The Last Twenty Years. Nutrients. 2022;14(3):684. Published 2022 Feb 6. doi:10.3390/nu14030684
Vitamin C. National Institutes of Health. Published March 26, 2021. https://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/
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