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      Recognising the return of nutritional deficiencies: a modern pellagra puzzle

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      BMJ Case Reports

      BMJ

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          Abstract

          A 34-year-old previously well woman presented with a 4-week history of diffuse erythema and crusting of skin affecting all four limbs. Examination revealed erythematous skin plaques associated with ulceration and fissuring affecting sun-exposed areas of all four limbs primarily on the dorsal surfaces, and a body mass index of 17 kg/m 2. She was admitted under the infectious diseases unit, and an autoimmune and infective screen was performed which returned unremarkable. Dietetic consultation led to the diagnosis of severe protein-energy malnutrition, consequent to a severely restricted, primarily vegan, diet. Analysis of the patient’s reported diet with nutritional software revealed grossly suboptimal caloric intake with risk of inadequacy for most micronutrients, vitamins and minerals, including niacin. Oral thiamine, multivitamin, iron supplementation and vitamin B complex were started, and a single intramuscular vitamin B 12 dose was administered. Marked improvement was seen after 6 weeks, with near-complete resolution of skin changes. These findings supported a diagnosis of pellagra.

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          An unexpected case of pellagra.

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            Old world meets modern: a case report of scurvy.

            Scurvy is a rarely seen disease resulting from a deficiency of vitamin C. We present a case of scurvy in a 65-year-old man. The patient reported heavy alcohol abuse over the last several years. He also reported that his diet consisted of cheese pizzas only. On physical examination, he was noted to have spontaneous ecchymosis of his lower extremities (denying any history of trauma); poor dentition; and corkscrew hairs on his chest, abdomen, and legs, with associated perifollicular petechia. Punch biopsy of his skin lesions revealed perivascular lymphohistiocytic inflammation, with some focal perifollicular erythrocyte extravasation. A serum ascorbic acid level was <0.12 mg/dL (normal range, 0.20-1.9 mg/dL). A diagnosis of vitamin C deficiency was made. The patient was successfully treated with 1 g/d vitamin C for the first 5 days, followed by a dose of 500 mg/d. Though scurvy is rarely seen in modern times, it is important to identify who is at risk and to recognize the clear and classic signs and symptoms associated with scurvy. Failure to diagnose this disease can potentially lead to expensive and unnecessary medical tests, as well as missing a very simple treatment that can prevent infection and even death.
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              Modern scurvy

              Scurvy is a disease that played an important role in ancient history and used to be a notorious cause of death in sailors. Nowadays, scurvy is not a common diagnosis in the civilized world, but this case report indicates that this old-fashioned disease is not extinct at all and still exists but in a different patient category.
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                Author and article information

                Journal
                BMJ Case Reports
                BMJ Case Rep
                BMJ
                1757-790X
                November 28 2018
                November 2018
                November 2018
                November 28 2018
                : 11
                : 1
                : e227454
                Article
                10.1136/bcr-2018-227454
                © 2018

                http://www.bmj.com/company/legal-information/terms-conditions/legal-information/tdm-licencepolicy

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