Severe Normocytic Anemia and Spontaneous Hematomas in Profound Vitamin C Deficiency

Scurvy is considered rare in developed countries but can occur in patients with a poor diet that lacks vitamin C. Risk factors include, but are not limited to, eating disorders such as anorexia nervosa, social isolation and dietary habits, and limited access to vegetables and produce due to low socioeconomic status. We describe a case of a middle-aged man who presented with bilateral thigh pain and inability to stand up or walk, skin rash, and swelling in his ankles. Initially, he thought he "pinched a nerve" during his daily exercise and that this caused his discomfort in his thighs. He was found to have severe anemia that required blood transfusion, gingival changes, multiple ecchymoses, perifollicular hemorrhage with corkscrew hairs, and an extensive lower extremity rash. His reticulocyte count was low, indicating insufficient bone marrow response. Imaging studies confirmed intramuscular bleeding and spontaneous hematomas. After a thorough investigation and detailed history, it was found that the patient had a very restricted diet due to poor socioeconomic status and neglect. Micronutrient deficiency was suspected, and testing for vitamin C, zinc, folate, and B12 levels was sent. Treatment for scurvy with vitamin C was started as soon as the diagnosis was suspected. Significant improvement was seen within three days after starting treatment, blood tests confirmed profound vitamin C deficiency, and the patient was eventually discharged to a rehabilitation center. Scurvy remains a challenging diagnosis due to its rarity and its symptoms that may mimic other, more common diseases. This case illustrates the importance of considering uncommon etiologies of severe anemia, especially in patients who have no significant past medical history or clear source of bleeding.