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\begin{document}

\title{Comment on: {[}Lost at Sea in Search of a Diagnosis: A Case of
Unexplained Bleeding{]} Subtitle: Scurvy from chemotherapy-induced
adverse effects in an adolescent oncology patient}



\author[1]{Michelle Toker}%
\author[1]{Benedict Wu}%
\affil[1]{Montefiore Medical Center}%


\vspace{-1em}



  
  \date{May 15, 2024}


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\textbf{Title} : Comment on: {[}Lost at Sea in Search of a Diagnosis: A
Case of Unexplained Bleeding{]}

\textbf{Subtitle} : Scurvy from chemotherapy-induced adverse effects in
an adolescent oncology patient

\textbf{Authors} : Michelle Toker, BS and Benedict Wu, DO, PhD

\textbf{Affiliation} : Division of Dermatology, Montefiore Medical
Center/Albert Einstein College of Medicine, Bronx, NY, USA

\textbf{Corresponding author} :

Michelle Toker

Albert Einstein College of Medicine, Montefiore Medical Center

Email: michelle.toker@einsteinmed.edu

Telephone: 516-946-4726

\textbf{Funding and support} : None

\textbf{Conflicts of Interest} : None

\textbf{Manuscript word count} : 452

\textbf{Reference count} : 6

\textbf{Figure count} : 1

\textbf{Table count} : 0

\textbf{Key words} : chemotherapy, oncology, pediatrics, nutritional
deficiency, vitamin C deficiency, scurvy

Dear Editor,

The brief report published by Amos et al in 2016 shed light on the
occurrence of scurvy in pediatric and adolescent patients with dietary
restrictions.\textsuperscript{1} Indeed, patients with
neurodevelopmental conditions are most commonly associated with the risk
of developing scurvy; other at-risk patients include those with
gastrointestinal disorders, alcoholism, and psychiatric
conditions.\textsuperscript{2, 3} We aim to expand upon the situations
when scurvy should be considered by presenting a case of an adolescent
male diagnosed with scurvy secondary to the adverse effects of his
chemotherapy.

A 19-year-old male with a 10-month history of high-risk pre-B-cell acute
lymphoblastic leukemia was consulted by the dermatology service for a
new diffuse rash present for four days. He was recently enrolled in
a~phase 3 randomized trial of inotuzumab ozogamicin and was receiving
methotrexate and vincristine. The chemotherapy regimen induced severe
dizziness, nausea, and vomiting refractory to anti-emetic medications.
His aversion to chemotherapy was so strong that it caused him to feel
nauseated between treatment sessions. He also endorsed painful oral and
pharyngeal sores that made it difficult to tolerate a regular diet. In
addition to oropharyngeal pain, he experienced marked arthralgia and
fatigue, which he also attributed to the chemotherapy. Additionally, the
patient reported that vincristine reduced his taste sensation, which led
to a poor appetite. These adverse symptoms culminated in a loss of 6.7
kg (9.1\%) in less than one month.

Physical examination revealed peri-follicular purpura on the back (Fig
1A), face, and bilateral upper and lower extremities. Upon closer
inspection, we noted prominent corkscrew (spiral and curly appearance)
hairs (Fig 1B). The lower mucosal lip had superficial erosions with
scalloped-borders and fine petechiae (Fig 1C). Laboratory evaluation
revealed pancytopenia with a platelet count of 42 k/UL and low serum
levels of vitamin C (\textless{}0.1 mg/dL), potassium (3.4 mEq/L),
magnesium (1.1 mg/dL), and albumin (2.8 g/dL). Serum vitamin A (35
mcg/dL) levels were within normal limits. The patient was diagnosed with
scurvy due to poor food intake from his chemotherapy-induced nausea,
emesis, and mucositis. It was thought that acidic foods, such as citrus,
exacerbated the mucosal erosions, which caused him to avoid vitamin
C-rich foods.

Scurvy, caused by a prolonged L-ascorbic acid (vitamin C) deficiency,
may manifest as pathognomonic corkscrew hairs with petechiae, gingival
pain and bleeding, vascular fragility, arthralgias, fatigue, and
numerous gastrointestinal symptoms.\textsuperscript{4,5, 6} Although
vitamin C deficiency was an indirect result of his chemotherapy, scurvy,
by itself, may have aggravated his symptoms, thereby creating a vicious
cycle of poor oral intake. Our case highlights the complex relationship
between chemotherapy-induced mucocutaneous adverse effects, a limited
diet, and vitamin C deficiency. We recommend clinicians to consider
scurvy in oncology patients, with or without thrombocytopenia,
presenting with peri-follicular purpura and corkscrew hairs.

\textbf{Ethics Statement:} Informed patient consent was obtained for
publication of the case details and photographs.

\textbf{References}

1. Amos LE, Carpenter SL, Hoeltzel MF. Lost at Sea in Search of a
Diagnosis: A Case of Unexplained Bleeding. \emph{Pediatr Blood Cancer} .
Jul 2016;63(7):1305-6. doi:10.1002/pbc.25980

2. Fortenberry M, Rucker H, Gaines K. Pediatric Scurvy: How an Old
Disease Is Becoming a New Problem. \emph{J Pediatr Pharmacol Ther} .
2020;25(8):735-741. doi:10.5863/1551-6776-25.8.735

3. Ho EY, Mathy C. Functional abdominal pain causing Scurvy, Pellagra,
and Hypovitaminosis A. \emph{F1000Res} . 2014;3:35.
doi:10.12688/f1000research.3-35.v1

4. Nguyen RT, Cowley DM, Muir JB. Scurvy: a cutaneous clinical
diagnosis. \emph{Australas J Dermatol} . Feb 2003;44(1):48-51.
doi:10.1046/j.1440-0960.2003.00637.x

5. Schuman RW, Rahmin M, Dannenberg AJ. Scurvy and the gastrointestinal
tract. \emph{Gastrointest Endosc} . Feb 1997;45(2):195-6.
doi:10.1016/s0016-5107(97)70250-5

6. Chaudhry SI, Newell EL, Lewis RR, Black MM. Scurvy: a forgotten
disease. \emph{Clin Exp Dermatol} . Nov 2005;30(6):735-6.
doi:10.1111/j.1365-2230.2005.01901.x

\textbf{Figure Legend}

Figure 1. A) Peri-follicular purpura on the back. B) Folliculocentric
heme-crusted papules with corkscrew hairs on the right shoulder C)
Superficial mucosal erosions and fine petechiae on the lower lip.\selectlanguage{english}
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