AB0783 “RICE AND SARDINES”: AN UNUSUAL CAUSE OF RASH AND JOINT SWELLING

Abstract

Background:Systemic vasculitis presents with numerous widespread manifestations. Various diseases can masquerade as systemic vasculitis (1). It is crucial to carefully evaluate patients with unusual presentations to look for vasculitis mimics. Scurvy, a disease caused by severe and prolonged vitamin C deficiency, still occurs in industrialized countries (2). Ascorbic acid is involved in various biologic processes including the synthesis of mature collagen. Lack of ascorbic acid especially affects blood vessel integrity leading to haemorrhagic manifestations characteristic of scurvy (3).Objectives:Case report highlighting that scurvy is still prevalent in the west and may present with features resembling vasculitis.Methods:Information was obtained from the patient’s medical records.Results:A 61 year old Caucasian female presented with a 3 weeks’ history of bilateral lower limb pain, rash and swelling. She was referred to acute medicine to exclude deep vein thrombosis suspected by her general practitioner. She was previously fit and well apart from diagnosis of coeliac disease and various food intolerances. She believed her symptoms started following a recent course of Metronidazole for suspected dental infection which manifested with gum bleeding.She was found to have purpuric spots and ecchymosis bilaterally in her legs, from the toes to the groin. The left knee was swollen with evidence of hematoma around the joint.She denied fever, weight loss, night sweats, arthralgia, myalgia, rash, Raynaud’s, alopecia, mouth or genital ulcers, ear-nose-throat manifestations. She denied chest pain, difficulty in breathing or symptoms of peripheral neuropathy. There was no history of asthma, inflammatory bowel disease or uveitis. She reported occasional alcohol intake, she did not smoke cigarettes nor use recreational drugs. Examination otherwise revealed no other major abnormalities with normal vital signs.Initial differential diagnosis included platelet or coagulation disorders or vasculitis. Initial blood tests revealed normal full blood count, coagulation screen, ESR, CRP, liver and renal biochemistry.Urine dip was positive for blood but not for protein. Knee aspiration was attempted but no fluid could be aspirated. Knee x-ray was unremarkable. ANA, ANCA and anti-GBM antibody tests were negative.On further review and enquiry into her symptoms and lifestyle she admitted having a diet exclusively of “rice and sardines” for nearly 2 years. This information along with clinical features led to the suspicion of Vitamin C deficiency that was subsequently confirmed. Ascorbic acid levels were <2.8micromol/l (normal range 26.1-84.6.micromol/l).Replenishment of vitamin C was followed by a rapid and sustained recovery. Detailed investigation for additional macro and micronutrient deficiencies were undertaken with referral to a dietician and to gastroenterology.Conclusion:This case illustrates scurvy can present in previously “well” individuals and should be considered as a possible differential diagnosis of vasculitic lesions in the appropriate clinical context. Detailed dietary history is invaluable.References:[1]A Review of Primary Vasculitis Mimickers Based on the Chapel Hill Consensus Classification. Zarka et al, Int J Rheumatol, 2020 Feb[2]Global Vitamin C Status and Prevalence of Deficiency: A Cause for Concern? Sam Rowe1,Anitra C. Carr, Nutrients 2020 July[3]Adult scurvy. Hirschmann et al, J Am Acad Dermatol 1999 DecDisclosure of Interests:None declared