Scurvy is largely a historical disease but there are signs it’s making a comeback

Scurvy is is often considered a historical ailment, conjuring images of sailors on long sea voyages suffering from a lack of fresh fruit and vegetables.

Yet doctors in developed countries have recently reported treating cases of scurvy, including Australian doctors who reported their findings today in the journal BMJ Case Reports.

What is scurvy?

Scurvy is a disease caused by a severe deficiency of vitamin C (ascorbic acid), which is essential for the production of collagen. This protein helps maintain the health of skin, blood vessels, bones and connective tissue.

Without enough vitamin C, the body cannot properly repair tissues, heal wounds, or fight infections. This can lead to a range of symptoms including:

• fatigue and weakness
• swollen, bleeding gums or loose teeth
• joint and muscle pain and tenderness
• bruising easily
• dry, rough or discoloured skin (reddish or purple spots due to bleeding under the skin)
• cuts and sores take longer to heal
• anaemia (a shortage of red blood cells, leading to further fatigue and weakness)
• increased susceptibility to infections.

It historically affected sailors

Scurvy was common from the 15th to 18th centuries, when naval sailors and other explorers lived on rations or went without fresh food for long periods. You might have heard some of these milestones in the history of the disease:

• in 1497-1499, Vasco da Gama’s crew suffered severely from scurvy during their expedition to India, with a large portion of the crew dying from it

• from the 16th to 18th centuries, scurvy was rampant among European navies and explorers, affecting notable figures such as Ferdinand Magellan and Sir Francis Drake. It was considered one of the greatest threats to sailors’ health during long voyages

• in 1747, British naval surgeon James Lind is thought to have conducted one of the first clinical trials, demonstrating that citrus fruit could prevent and cure scurvy. However, it took several decades for his findings to be widely implemented

• in 1795, the British Royal Navy officially adopted the practice of providing lemon or lime juice to sailors, dramatically reducing the number of scurvy cases.

Evidence of scurvy re-emerging

In the new case report, doctors in Western Australia reported treating a middle-aged man with the condition. In a separate case report, doctors in Canada reported treating a 65-year old woman.

Both patients presented with leg weakness and compromised skin, yet the doctors didn’t initially consider scurvy. This was based on the premise that there is abundant vitamin C in our modern food supply, so deficiency should not occur.

On both occasions, treatment with high doses of vitamin C (1,000mg per day for at least seven days) resulted in improvements in symptoms and eventually a full recovery.

The authors of both case reports are concerned that if scurvy is left untreated, it could lead to inflamed blood vessels (vasculitis) and potentially cause fatal bleeding.

Last year, a major New South Wales hospital undertook a chart review, where patient records are reviewed to answer research questions.

This found vitamin C deficiency was common. More than 50% of patients who had their vitamin C levels tested had either a modest deficiency (29.9%) or significant deficiency (24.5%). Deficiencies were more common among patients from rural and lower socioeconomic areas.

Now clinicians are urged to consider vitamin C deficiency and scurvy as a potential diagnosis and involve the support of a dietitian.

Why might scurvy be re-emerging?

Sourcing and consuming nutritious foods with sufficient vitamin C is unfortunately still an issue for some people. Factors that increase the risk of vitamin C deficiency include:

• poor diet. People with restricted diets – due to poverty, food insecurity or dietary choices – may not get enough vitamin C. This includes those who rely heavily on processed, nutrient-poor foods rather than fresh produce

• food deserts. In areas where access to fresh, affordable fruits and vegetables is limited (often referred to as food deserts), people may unintentionally suffer from a vitamin C deficiency. In some parts of developing countries such as India, lack of access to fresh food is recognised as a risk for scurvy

• the cost-of-living crisis. With greater numbers of people unable to pay for fresh produce, people who limit their intake of fruits and vegetables may develop nutrient deficiencies, including scurvy

• weight loss procedures and medications. Restricted dietary intake due to weight loss surgery or weight loss medications may lead to nutrient deficiencies, such as in this case report of scurvy from Denmark

• mental illness and eating disorders. Conditions such as depression and anorexia nervosa can lead to severely restricted diets, increasing the risk of scurvy, such as in this case report from 2020 in Canada

• isolation. Older adults, especially those who live alone or in nursing homes, may have difficulty preparing balanced meals with sufficient vitamin C

• certain medical conditions. People with digestive disorders, malabsorption issues, or those on restrictive medical diets (due to severe allergies or intolerances) can develop scurvy if they are unable to absorb or consume enough vitamin C.

How much vitamin C do we need?

Australia’s dietary guidelines recommend adults consume 45mg of vitamin C (higher if pregnant or breastfeeding) each day. This is roughly the amount found in half an orange or half a cup of strawberries.

When more vitamin C is consumed than required, excess amounts leave the body through urine.

Signs of scurvy can appear as early as a month after a daily intake of less than 10 mg of vitamin C.

Eating vitamin C-rich foods – such as oranges, strawberries, kiwifruit, plums, pineapple, mango, capsicum, broccoli and Brussels sprouts – can resolve symptoms within a few weeks.

Vitamin C is also readily available as a supplement if there are reasons why intake through food may be compromised. Typically, the supplements contain 1,000mg per tablet, and the recommended upper limit for daily Vitamin C intake is 2,000mg.