scurvy scurvy scurvy is a disease resulting from a lack of vitamin c (ascorbic acid). early symptoms of deficiency include weakness, feeling tired and sore arms and legs. without treatment, decreased red blood cells, gum disease, changes to hair, and bleeding from the skin may occur. as scurvy worsens there can be poor wound healing, personality changes, and finally death from infection or bleeding. scurvyother namesmoeller's disease, cheadle's disease, scorbutus, barlow's disease, hypoascorbemia, vitamin c deficiencyscorbutic gums, a symptom of scurvy. the triangle-shaped areas between the teeth show redness of the gums.specialtyendocrinologysymptomsweakness, feeling tired, changes to hair, sore arms and legs, gum disease, easy bleedingcauseslack of vitamin crisk factorsmental disorders, unusual eating habits, homelessness, alcoholism, substance use disorder, intestinal malabsorption, dialysis, voyages at sea (historic)diagnostic methodbased on symptomstreatmentvitamin c supplements, diet that contains fruit and vegetables (notably citrus)frequencyrare (contemporary) it takes at least a month of little to no vitamin c in the diet before symptoms occur. in modern times, scurvy occurs most commonly in people with mental disorders, unusual eating habits, alcoholism, and older people who live alone. other risk factors include intestinal malabsorption and dialysis. while many animals produce their own vitamin c, humans and a few others do not. vitamin c is required to make the building blocks for collagen. diagnosis is typically based on physical signs, x-rays, and improvement after treatment. treatment is with vitamin c supplements taken by mouth. improvement often begins in a few days with complete recovery in a few weeks. sources of vitamin c in the diet include citrus fruit and a number of vegetables, including red peppers, broccoli, and tomatoes. cooking often decreases the residual amount of vitamin c in foods. scurvy is rare compared to other nutritional deficiencies. it occurs more often in the developing world in association with malnutrition. rates among refugees are reported at 5 to 45 percent. scurvy was described as early as the time of ancient egypt. it was a limiting factor in long-distance sea travel, often killing large numbers of people. during the age of sail, it was assumed that 50 percent of the sailors would die of scurvy on a major trip. a scottish surgeon in the royal navy, james lind, is generally credited with proving that scurvy can be successfully treated with citrus fruit in 1753. nevertheless, it was not until 1795 that health reformers such as gilbert blane persuaded the royal navy to routinely give lemon juice to its sailors. signs and symptoms early symptoms are malaise and lethargy. after one to three months, patients develop shortness of breath and bone pain. myalgias may occur because of reduced carnitine production. other symptoms include skin changes with roughness, easy bruising and petechiae, gum disease, loosening of teeth, poor wound healing, and emotional changes (which may appear before any physical changes). dry mouth and dry eyes similar to sjögren's syndrome may occur. in the late stages, jaundice, generalised edema, oliguria, neuropathy, fever, convulsions, and eventual death are frequently seen. a child presenting a "scorbutic tongue" due to vitamin c deficiency. a child with scurvy in flexion posture. photo of the chest cage with scorbutic rosaries. cause scurvy, including subclinical scurvy, is caused by a deficiency of dietary vitamin c since humans are unable to metabolically synthesize vitamin c. provided the diet contains sufficient vitamin c, the lack of working l-gulonolactone oxidase (gulo) enzyme has no significance, and in modern western societies, scurvy is rarely present in adults, although infants and elderly people are affected. virtually all commercially available baby formulas contain added vitamin c, preventing infantile scurvy. human breast milk contains sufficient vitamin c, if the mother has an adequate intake. commercial milk is pasteurized, a heating process that destroys the natural vitamin c content of the milk. scurvy is one of the accompanying diseases of malnutrition (other such micronutrient deficiencies are beriberi and pellagra) and thus is still widespread in areas of the world depending on external food aid. although rare, there are also documented cases of scurvy due to poor dietary choices by people living in industrialized nations. pathogenesis x-ray of the knee joint (arrow indicates scurvy line). vitamins are essential to the production and use of enzymes that are involved in ongoing processes throughout the human body. ascorbic acid is needed for a variety of biosynthetic pathways, by accelerating hydroxylation and amidation reactions. in the synthesis of collagen, ascorbic acid is required as a cofactor for prolyl hydroxylase and lysyl hydroxylase. these two enzymes are responsible for the hydroxylation of the proline and lysine amino acids in collagen. hydroxyproline and hydroxylysine are important for stabilizing collagen by cross-linking the propeptides in collagen. collagen is a primary structural protein in the human body, necessary for healthy blood vessels, muscle, skin, bone, cartilage, and other connective tissues. defective connective tissue leads to fragile capillaries, resulting in abnormal bleeding, bruising, and internal hemorrhaging. collagen is an important part of bone, so bone formation is also affected. teeth loosen, bones break more easily, and once-healed breaks may recur. defective collagen fibrillogenesis impairs wound healing. untreated scurvy is invariably fatal. diagnosis diagnosis is typically based on physical signs, x-rays, and improvement after treatment. differential diagnosis various childhood onset disorders can mimic the clinical and x-ray picture of scurvy such as: rickets osteochondrodysplasias especially osteogenesis imperfecta blount's disease osteomyelitis prevention foods and their vitamin c content per 100 grams item vitamin ccontents(mg) camu camu2000.00 amla610.00 urtica333.00 guava228.30 blackcurrant181.00 kiwifruit161.30 chili pepper144.00 parsley133.00 green kiwifruit92.70 broccoli89.20 brussels sprout85.00 bell pepper80.40 papaya62.00 strawberry58.80 orange53.20 lemon53.00 cabbage36.60 spinach28.00 turnip27.40 potato19.70 scurvy can be prevented by a diet that includes uncooked vitamin c-rich foods such as amla, bell peppers (sweet peppers), blackcurrants, broccoli, chili peppers, guava, kiwifruit, and parsley. other sources rich in vitamin c are fruits such as lemons, limes, oranges, papaya, and strawberries. it is also found in vegetables, such as brussels sprouts, cabbage, potatoes, and spinach. some fruits and vegetables not high in vitamin c may be pickled in lemon juice, which is high in vitamin c. nutritional supplements which provide ascorbic acid well in excess of what is required to prevent scurvy may cause adverse health effects. some animal products, including liver, muktuk (whale skin), oysters, and parts of the central nervous system, including the adrenal medulla, brain, and spinal cord, contain large amounts of vitamin c, and can even be used to treat scurvy. fresh meat from animals, notably internal organs, contains enough vitamin c to prevent scurvy, and even partly treat it. scott's 1902 antarctic expedition used lightly fried seal meat and liver, whereby complete recovery from incipient scurvy was reported to have taken less than two weeks. treatment scurvy will improve with doses of vitamin c as low as 10 mg per day though doses of around 100 mg per day are typically recommended. most people make a full recovery within 2 weeks. history symptoms of scurvy have been recorded in ancient egypt as early as 1550 bce. in ancient greece, the physician hippocrates (460-370 bce) described symptoms of scurvy, specifically a "swelling and obstruction of the spleen." in 406 ce, the chinese monk faxian wrote that ginger was carried on chinese ships to prevent scurvy. the knowledge that consuming foods containing vitamin c is a cure for scurvy has been repeatedly forgotten and rediscovered into the early 20th century. early modern era in the 13th century, the crusaders frequently developed scurvy. in the 1497 expedition of vasco da gama, the curative effects of citrus fruit were already known and confirmed by pedro álvares cabral and his crew in 1507. the portuguese planted fruit trees and vegetables in saint helena, a stopping point for homebound voyages from asia, and left their sick, who had scurvy and other ailments, to be taken home by the next ship if they recovered. in 1500, one of the pilots of cabral's fleet bound for india noted that in malindi, its king offered the expedition fresh supplies such as lambs, chickens, and ducks, along with lemons and oranges, due to which "some of our ill were cured of scurvy". unfortunately, these travel accounts did not stop further maritime tragedies caused by scurvy, first because of the lack of communication between travelers and those responsible for their health, and because fruits and vegetables could not be kept for long on ships. in 1536, the french explorer jacques cartier, exploring the st. lawrence river, used the local st. lawrence iroquoians' knowledge to save his men who were dying of scurvy. he boiled the needles of the arbor vitae tree (eastern white cedar) to make a tea that was later shown to contain 50 mg of vitamin c per 100 grams. such treatments were not available aboard ship, where the disease was most common. later, possibly inspired by this incident, several european countries experimented with preparations of various conifers, such as spruce beer, as cures for scurvy. in february 1601, captain james lancaster, while sailing to sumatra, landed on the northern coast of madagascar specifically to obtain lemons and oranges for his crew to stop scurvy. captain lancaster conducted an experiment using four ships under his command. one ship's crew received routine doses of lemon juice while the other three ships did not receive any such treatment. as a result, members of the non-treated ships started to contract scurvy, with many dying as a result. during the age of exploration (between 1500 and 1800), it has been estimated that scurvy killed at least two million sailors. jonathan lamb wrote: "in 1499, vasco da gama lost 116 of his crew of 170; in 1520, magellan lost 208 out of 230;...all mainly to scurvy." in 1579, the spanish friar and physician agustin farfán published a book in which he recommended oranges and lemons for scurvy, a remedy that was already known in the spanish navy. in 1593, admiral sir richard hawkins advocated drinking orange and lemon juice as a means of preventing scurvy. a 1609 book by bartolomé leonardo de argensola recorded a number of different remedies for scurvy known at this time in the moluccas, including a kind of wine mixed with cloves and ginger, and "certain herbs." the dutch sailors in the area were said to cure the same disease by drinking lime juice. in 1614, john woodall, surgeon general of the east india company, published the surgion's mate as a handbook for apprentice surgeons aboard the company's ships. he repeated the experience of mariners that the cure for scurvy was fresh food or, if not available, oranges, lemons, limes, and tamarinds. he was, however, unable to explain the reason why, and his assertion had no impact on the prevailing opinion of the influential physicians of the age, that scurvy was a digestive complaint. apart from ocean travel, even in europe, until the late middle ages, scurvy was common in late winter, when few green vegetables, fruits and root vegetables were available. this gradually improved with the introduction from the americas of potatoes; by 1800, scurvy was virtually unheard of in scotland, where it had previously been endemic.: 11 18th century james lind, a pioneer in the field of scurvy prevention in 2009, a handwritten household book authored by a cornishwoman in 1707 was discovered in a house in hasfield, gloucestershire, containing a "recp.t for the scurvy" amongst other largely medicinal and herbal recipes. the recipe consisted of extracts from various plants mixed with a plentiful supply of orange juice, white wine or beer. in 1734, leiden-based physician johann bachstrom published a book on scurvy in which he stated, "scurvy is solely owing to a total abstinence from fresh vegetable food, and greens; which is alone the primary cause of the disease", and urged the use of fresh fruit and vegetables as a cure. it was not until 1747 that james lind formally demonstrated that scurvy could be treated by supplementing the diet with citrus fruit, in one of the first controlled clinical experiments reported in the history of medicine. as a naval surgeon on hms salisbury, lind had compared several suggested scurvy cures: hard cider, vitriol, vinegar, seawater, oranges, lemons, and a mixture of balsam of peru, garlic, myrrh, mustard seed and radish root. in a treatise on the scurvy (1753) lind explained the details of his clinical trial and concluded "the results of all my experiments was, that